HospitalInspections.org

Based on interview and document review, it was determined the facility staff failed to ensure the medical records for two (2) of eight (8) patients were complete and accurate. (Patients #2 and #7)

1. Patient #2's medical record had scanned documents with no identifying information as to what patient the information belonged to; and

2. Patient #7 had an order for a consult that was not performed prior to discharge.

The findings include:

1. Patient #2's EMR (Electronic Medical Record) was reviewed on 5/11/16 with Staff Member #1. Patient #2's EMR contained two pages of hand written progress notes dated 5/3/16. Neither of the two pages had any information that would indicate to what patient the information belonged to. Staff Member #1 stated, "They should have placed a label with the patient's name and medical record number on the pages.


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2. A review of Patient #7's electronic medical record (EMR) was conducted on 05/11/16 with Staff #10 and Staff #22. Patient #7 was admitted to the facility on 05/05/16 and discharged on 05/10/16. Documentation in Patient #7's EMR revealed a consult for a plastic surgeon on 05/10/16. Patient #7's EMR did not show evidence the consult was conducted. The surveyor inquired to Staff #10 the reason the consult was not conducted. Staff #10 informed the surveyor he/she would clarify. At approximately 3:10 p.m., Staff #10 reported to the surveyor, "The consult was canceled, but the physician did not cancel it in the system (EMR) and it should have been."

On 05/11/16 at approximately 4:30 p.m., the medical record review was discussed during the exit conference with the administrative team.







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Based on observation, staff interview and document review, it was determined the facility staff failed to:
1. Clean the septum of medication vials with alcohol before inserting the needle;
2. Practice and implement proper infection control procedures regarding utilizing proper use of PPE (personal protective equipment) prior to entering a patient's room on isolation for 1 of 2 isolation observations.

The findings include:

1. The surveyor observed Staff #17, a registered nurse (RN) preparing medications for Patient #11 at 10:45 a.m. on 05/11/16, and noted the following:
Staff #17 prepared three (3) syringes to administer Solu-Medrol 125 milligrams (mg) IVP (intravenous push) to Patient #11. Staff #17 performed hand hygiene and donned gloves and drew up ten (10) cubic centimeters (cc) of sodium chloride from a single dose vial. Staff #17 did not disinfect/clean the rubber septum of the vial prior to inserting the syringe's needle to withdraw the patient's diluent dose. Staff #17 then took two (2) one (1) millimeter (ml) syringes and drew up the patient's prescribed dose of Solu-Medrol, but did not clean the rubber septum of the vial prior to inserting the syringe's needle and when he/she re-entered the vial with a new syringe. Staff #17 inserted the Solu-Medrol from the two (2) one (1) ml syringes into the ten (10) cc syringe of sodium chloride prior to administering to Patient #11.

The surveyor interviewed Staff #17 after Patient #11 was administered his/her medications. Staff #17 was asked what the protocol was for cleaning the septum of the vial with an antiseptic prior to inserting a syringe needle. Staff #17 stated, "You don't need to because once you remove the cover top off the new vial, they are sterile."

The facility's policy titled "Medication Administration Methods" read in part: "Injections (includes subcutaneous, intramuscular, and intradermal) 1. e. Disinfect the vial's rubber septum before piercing by wiping (and using friction) with a sterile 70 percent isopropyl alcohol, ethyl/ethanol alcohol, iodophor, or other approved antiseptic swab. Allow the septum to dry before inserting a needle or other device into the vial.

The surveyor conducted an interview on 05/11/16 at 3:08 p.m. with Staff #9, whom was present during the observation. Staff #9 stated, "The staff member should have cleaned the vials with alcohol prior to inserting the needle into a new vial of mediation and when he/she re-enters the vial. This is what is expected and taught at (facility's name). You pop the top, wipe it because it is not sterile."


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2. An observation was conducted on 05/11/2016 at 8:55 a.m., in the presence of Staff #9 and Staff #25. The observation revealed Staff #21 failed to don personal protective equipment (PPE) in the correct manner prior to entering a patient's room clearly designated with "Contact Precaution" signage. Staff #21 slipped his/her arms into the isolation gown, without placing his/her head through the opening of the gown or properly tying his/her PPE. Staff #21 entered the contact isolation/precaution room without being fully dressed in his/her PPE. The facility's isolation gowns are made in a way that once the wearer's head fits through the opening, the wearer's neck and shoulders are provided protection and the gown can be properly tied.

An interview was conducted on 05/11/2016 at 8:59 a.m., with Staff #25. Staff #25 verified the observation and acknowledged Staff #21 failed to don the isolation gown as it was meant to be worn. Staff #9 directed Staff #21 to discard the gown he/she had put on and properly don an isolation gown.

Review of the "Contact Precautions" signage read in part: "Wear a gown when entering patient room if you anticipate contact with patient or environment ..." The picture included on the "Contact Precautions" sign displays the proper way to wear the gown, with the wearer's head through the opening and the gown protecting the wearer's neck and shoulders. The picture also displays the isolation gown properly tied to provide further protection.

Review of Staff #21's education file indicated he/she had received education related to the proper donning of PPE. Staff #21 failed to comply with established infection control practices.


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