HospitalInspections.org

Based on record review and interview the facility failed to ensure all medication adverse events (unforeseen or erroneous events that impact patient care) are reported to internal reporting mechanisms (computer reporting program to track such events) for 1(P (patient) #1) out of 10 patients sampled. This failed deficiency is likely to lead to under reporting of deficient practices and poor identification of quality improvement areas.
The findings are:

A. Record Review of facility's "Medication Errors" policy, dated 3/22/2021, revealed:

"1. Medication errors are defined as follows:
a. Wrong patient
b. Wrong medication
c. Wrong time or frequency
d. Wrong route
e. Omitted medication"

"2. Reporting Mechanism:
a. Error must be reported to Nursing Directors/Clinical Nurse leads and guests' attending physician as indicated.
b. Medication errors are placed in the event reporting system (ERS)
c. Person discovering medication error must complete an event report."

B. Record Review of P#1's medical chart from 8/13/2021 revealed:

1. On 8/13/2021 at 7:00 am Staff S#8 (Intensive Care Unit Registered Nurse) documented in P#1 medical chart, "Heparin (medication used to prevent or treat certain blood vessel, hear, and lung conditions) currently infusing, turned off this morning by this RN, OR (operating room) team at bedside and notified that heparin gtt (drip) was not paused overnight. (Provider) contacted plan to reschedule surgery for this afternoon."

2. On 8/13/2021 at 2:24 pm provider documented in P#1 medical chart, "Patient was supposed to go for tracheostomy (a surgical opening created through the neck into the trachea (windpipe) to allow direct access to the breathing tube and is commonly done in an operating room under general anesthesia) and PEG (percutaneous endoscopic gastronomy a procedure where a flexible feeding tube is placed through the abdominal wall and into the stomach, it allows nutrition fluids and/or medication to be put directly into the stomach), but the heparin drip was not discontinued at night, so they will be taking [patient] this afternoon."

C. Record Review of facility's "Medication Variance Occurrence Log," dated 08/08/2021 through 08/27/2021 revealed:
1. No report of failing to discontinue P#1's Heparin drip on 8/13/2021 documented on "Medication Variance Occurrence Log."

D. On 2/2/2022 at 9:15 am during interview with S#2 (Critical Care Director) replied, "yes" when they were asked if an incidence of not discontinuing a Heparin drip prior to surgery be a reportable incident.

Based on observation, interview, and record review, the facility failed to maintain an ongoing infection control program that would prevent, identify, and manage infections, screening (the evaluation or investigation of temperature, symptoms, risk factors. as part of a methodical survey to assess suitability for entrance into the facility for COVID-19 (upper respiratory infection) symptoms (to include temperature above 100 degrees, exposure or traveled out of the state), to ensure items utilized for direct patient care are furnished appropriately by not using items past expiration dates and not identified as being under an extended use authorization by the United States Food and Drug Administration. Certain expired medications are at risk of bacterial growth and antibiotics can fail to treat infections, leading to more serious illnesses and antibiotic resistance. Also, failed to ensure single use care items are not reused. This failed practice is likely to spread COVID-19 infection to anyone entering the facility, lead to poor treatment and delayed progression to goals and bacterial growth due to using expired medical supplies and lead to cross contamination and increased spread of potentially infectious organisms; and places patients at risk for infections while receiving treatment.

The findings are:

A. On 01/31/2022 at 3:45 pm, during observation in the main lobby toward the back of the lobby, surveyors were greeted by a woman who gave us a vendor badge after asking where we needed to go. We checked our temperature on the monitor without being asked and no questions regarding Covid-19 status, symptoms, travel or exposure were asked. While waiting for all to screen, observed 2 visitors/patients enter the facility and bypassed the screening station and was not screened in any way.

B. On 1/31/2022 at 4:35 pm, during tour of the ICU (Intensive Care Unit), observed the following expired (exp) medical supplies In the Medical Supply room:
1. Foley Catheters (flexible tube that a clinician passes through the urethra and into the bladder to drain urine) 2 sized 28 French (measurement of diameter) exp 07-31-2021, 1 sized 28 French, exp 10-31-2019.

C. On 1/31/2022 at 4:37 pm interview with Staff (S)#5 (Manager of Intensive Care Unit) confirmed the items were expired and should have been removed from the supply room.

D. On 01/31/2022 at 4:45 pm, during tour of the ICU (Intensive Care Unit), observed the following expired medical supplies In the Medical Supply room:
1. Five packages of Cook Medical (product name) Percutaneous Entry Thinwall Needle (helpful for vascular veins to carry blood throughout the body) access; Supplied sterile in peel-open packages; Designed for 1-time use for savings and infection prevention.) exp 01-09-2022.

E. On 01/31/2022 at 4:47 pm, during tour of the ICU (Intensive Care Unit), observed the following:
1. In exam room 5, a green plastic Christmas tree adapter (CTA) also known as Universal Oxygen Nut and Nipple Connection (used in a hospital setting, to secure oxygen tubing to an oxygen delivery source mounted on the wall in each patient treatment room, specified for one patient use.) mounted on the wall. The CTAs per manufacturer's recommendation are single-use (one time) and should be discarded (throw away) after every patient.

F. On 01/31/2022 at 4:50 pm, during an interview S#2 (ICU (Intensive Care Unit) Director) and S#5 (ICU Manager) confirmed the expired medical supplies in the medical supply room. S#2 and S#5 confirmed, nursing staff is responsible to stock, rotate (move older supplies forward), and validate if medical supplies are not expired prior to using in patient care.

G. On 01/31/2022 at 4:55 pm, during an interview, S#2 confirmed, the green plastic CTA are not changed out after each patient, the adapters are only wiped down by staff. S#2 stated, "Since oxygen flows outward there is no chance of another patient being affected by re-using."

H. On 02/01/2022 at 8:30 am, during observation in the main lobby, surveyor was given a visitor sticker and asked to read temperature of all surveyors. No questions about Covid status, symptoms, travel or exposure asked. Same day at 11:00 am while observing the lobby, unescorted, observed 2 separate individuals enter the facility, approach the reception person, were given a visitor sticker and continued into the facility. No temperature scan, no questions about Covid status, symptoms, travel or exposure asked.

I. On 02/01/2022 at 3:30 pm during interview with S#3 (Quality Coordinator) who confirmed, "the current policy on Covid-19 screenings is being revised and should be completed in the next few weeks, the facility has not followed the written policy completely for a while now."

J. On 02/02/2022 at 8:30 am, during observation in the main lobby, surveyor was given a visitor sticker and asked to read temperature of all surveyors. No questions about Covid status, symptoms, travel or exposure asked.

K. On 02/02/2022 at 9:45 pm, during an interview, S#1 (Chief Quality Officer) confirmed there isn't a written policy on CTAs usage or disposing after single-use. S#1 confirmed the facility goes by the manufacturer's recommendation and asked S#2 to provide a copy of the label for the manufacturer.

L. Record review of a label for Vyaire (manufacturer) for the Airlife (product name) green plastic Christmas tree adapter also known as Universal Oxygen Nut and Nipple Connection 001840 (model number), undated, revealed, "Do not re-use", as the recommendation. No other information to reflect possible reusage.

M. Record review of facility policy titled, "Symptom Screening Covid-19-Interim Guidance" last revised 02/23/21 confirms, Under section labeled:
Symptom Screen Includes:
-Temperature check less than 100.0
-Unprotected exposure to a known or suspect COVID-19 patient
-Symptoms of COVID-19 as defined by current CDC Guidelines
-COVID-19 test pending results
"Patients, visitors, and essential support staff will be screened for COVID-19 symptoms before being allowed entry. If a patient, visitor or essential support staff member has a negative symptom screen, a color coded, adhesive badge or wrist band will be provided to indicate screening completed and cleared for entry. If the symptom screen indicates a positive screen, the individual is denied entry."


42995




45267