HospitalInspections.org

Based on facility tour, observation, staff interview and policy review, it was determined that the facility failed to ensure that all drugs and biological are kept in a secure area, and locked when appropriate.


Findings include:


Initial facility tour beginning at 12:00 p.m. on 12/19/2011 with the Chief Nursing Officer (CNO), revealed medication on top of the medication carts in the nursing work rooms on floors 3 West, Room #373 and 1 West, Room #169. The CNO confirmed that the medications should be secured and not left on top of the medication carts. Two (2) of three (3) nursing work rooms medication carts inspected during the initial tour had medications not secured as follows:


1. 3 West, Room #373 - The door was open and four (4) multi-dose vials of insulin and three (3) vials of heparin were on top of the medication cart.


2. 1 West, Room #169 - The door was closed but not locked and a multi-dose vial of Lovenoxon was top of the medication cart.


Review of the facility's Pharmacy Policy #5.3 - Security of Medication Areas revealed, "All drug storage areas shall be locked unless under the personal and immediate supervision of personnel authorized to administer or dispense medications.
a) Drugs shall be accessible only to personnel authorized to administer or dispense or personnel under their supervision authorized to transport, restock, or prepare medications for dispensing.


Review of the Department Safety Officers' (DSO) Internal Audit tool Group 7: Medication Management #59 revealed, "Medication storage: Med cart locked.." Management #68 stated, "Medication room and medications are secure."

Based on facility tour, observation, staff interview, in-service review and policy review, it was determined the facility failed to implement the hospitals policies that govern the control of infections and communicable diseases.


Findings include:


Initial facility tour on 12/19/2011, beginning at 12:00 p.m. with the Chief Nursing Officer (CNO), revealed patient rooms on floors 3 West and 1 West had signs posted on the doors noting for anyone to go to the nursing station prior to entering the patient room. When the Chief Nursing Officer (CNO) was asked what was the purpose of the signs, the CNO stated that they were used to indicate patient isolation (isolation precautions). When asked what type of isolation per room was in use, the CNO stated that she was uncertain without reviewing the medical record and that it was a violation of Health Insurance Portability and Accountability Act (HIPAA) to denote the type of isolation.


Review of the Transmission-Based Precautions policy and procedure, IFC 2009.10.20, revealed that when Transmission-based precautions are in use, a precaution sign will be placed on the door to the patient's room by nursing personnel. This sign will indicate what type of precaution has been initiated and directs all health-care personnel as well as directs visitors, if the individual should enter the room and what protection is needed.


Review of the Patient Safety Module for isolation training for all new clinical employees during orientation revealed:
a) Door Signs noting: Another method of patient communication is door signs. Information such as nothing by mouth (NPO), Fall Risk, various isolation signs, and others are used to alert all that enter the patient's room of general information. None of these signs violate the HIPAA regulations regarding confidentiality.
b) The facility has 3 types of transmission-based precautions: Contact, Droplet, and Airborne. For each of these, a door sign would be used stating the type of isolation and appropriate Personal Protective Equipment (PPE) to be used. This alerts all who enter if specific actions must be taken prior to entering. This does not violate HIPAA because no confidential information is given. If an employee from another department, visitor, or family member wishes to enter the patient's isolation room, he/she will need the same protection as the nursing staff. The nurse will be responsible for educating those who enter on the safety precautions to use.


Review of the Annual Requirements November and December 2011 for isolation training for all employees revealed, "Standard Precautions - take notice of signs before you enter a patient's room." The signs in the training material are the 3 types of transmission-based precautions: Contact, Droplet, and Airborne.


On 12/20/2011, at 10:00 a.m., an Infection Prevention Action Plan dated Tuesday, December 20, 2011 was given to the surveyor with a completion date of Monday, December 19, 2011. The plan was signed by the Chief Nursing Office.


At 10:30 a.m. on 12/20/2011, 1 West, 2 West, and 3 West floors were toured with the Chief Nursing Officer (CNO), and the correct type of isolation precaution signs were noted on all doors with isolation patients.