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Based on observation and interview, it was determined the facility failed to procure and maintain 36 vials of the Dantrolene to treat a Malignant Hypothermia Emergency as Succinylcholine was present and available for patient use. By not adhering to the acceptable standards of practice as set forth by the Malignant Hyperthermia Association of the United States (MHAUS), the facility could not assure they were prepared for a Malignant Hyperthermia Emergency. The failed practice had the potential to affect all patients admitted for surgical procedures. Findings follow:

A. A tour of the Pharmacy Department on 05/23/13 at 1020 revealed the Malignant Hyperthermia treatment kit contained only 18 vials of the emergency medication Dantrolene. MHAUS recommends 36, unless you can obtain within 5 minutes. The Director of Pharmacy stated they could not obtain Dantrolene from another source within 5 minutes.
B. Findings were verified, through interview, on 05/23/13 at 1040, with the Director of Pharmacy.

Based on observation, review of policy and interview, it was determined the Multiple Dose Vials (MDV's) were not labeled with information required per policy (dated with the date of initial puncture and initials of person opening vial) to ensure the product was disposed of in 28 days once punctured in one (Surgery) of four (Surgery, Pre-Operative/Post-Operative, Emergency Department, Medical/Surgical Floor) areas toured. By not labeling MDV's properly, the facility could not assure the disposal of the vials in a timely manner to assure they were not available for patient use beyond the 28 days (United States Pharmacopeia Chapter 51), once punctured. The failed practice had the potential to affect all patients admitted for surgical procedures. Findings follow:

A. A tour of the facility on 05/21/13 from 1330 through 1455 revealed the following mislabeled MDV's in Surgery:
1) One Labetalol 200 mg (milligram)/ 40 ml (milliliter) MDV, opened, not dated;
2) One Dexamethasone 4 mg/ml MDV, opened, not dated;
3) One Flumazenil 0.5 mg/ 5 ml, opened, not dated; and
4) One Influenza Virus Vaccine, opened, not dated.
B. A review of pharmacy policy titled "Multi-Dose Vials, Use/Labeling" stated "At the time of first opening a new MDV, it will be dated and initialed by the person opening that vial."
C. Findings were verified, through interview, on 05/21/13 at 1420 with the Operating Room Manager.

Based on observation, review of policy and interview, it was determined the facility failed to ensure floor stock was properly controlled in that they were unlocked in one (Surgery) of four (Surgery, Pre-Operative/Post-Operative, Emergency Department, Medical/Surgical Floor) areas toured. By not securing medications, the facility could not assure access was limited to licensed personnel and could not ensure the integrity of the products for patient use. The failed practice had the potential to affect all patients admitted for surgical procedures. Findings follow:
A. A tour of the facility on 05/21/13 from 1330 through 1455 revealed the following unsecured medications in Surgery:
1) Eight Xylocaine/Epinephrine 1% 10 mg (milligram)/ ml (milliliter) 50 ml vials;
2) Five Lidocaine 10 mg/ml 30 ml vials;
3) One Ropivicaine 5 mg/ml 30 ml vial;
4) Nine Sensorcaine/Epinephrine 0.5% 50 ml vials;
5) Four Sensorcaine 0.5% 50 ml vials;
6) Seven Marcaine 0.25% 50 ml vials;
7) One Sensorcaine 0.25% 50 ml vial;
8) Three Marcaine 0.25% 50 ml vials;
9) 12 Heparin Lock 5 ml 100 Unit/ml;
10) One Omnipaque 350 mg/ml 50 ml vial;
11) Three Vancomycin 1 gram vials; and
12) 15 Balanced Salt Solutions 500 ml bottle.
B. A review of pharmacy policy titled "Drug Procurement/Inventory Control" stated "Medications are stored in a secure manner."
C. Findings were verified, through interview, on 05/21/13 at 1430 with the Operating Room Manager.

Based on clinical record and policy and procedure review, it was determined the facility failed to develop a plan of care for two (#1 and #4) of nine (#1-9) patients; failed to develop individualized care plans indicating the care required, the methods and approaches necessary, and modifications needed for seven (#2, #3, #4-9) of nine (#1-9) patients. Failure to develop individualized care plans did not allow the staff to ensure the care for the patients was planned, implemented and achieved. Findings follow:

A. Review of the policy and procedure titled "Care Planning" received from the Chief Nursing Officer (CNO) at 1145 on 05/24/13 revealed "... Within eight (8) hours of admission all patients shall have a pre-printed plan of care generated by the Registered Nurse (RN) or Licensed Practical/Vocational Nurse under the direct supervision of a RN ....The plan of care shall be individualized, based on the diagnosis and patient assessment. The plan of care shall address the learning needs of the patient and/or family. After the initiation of the plan of care by nursing, those disciplines consulting in the care shall contribute to the plan as appropriate to the patient's assessed needs.
B. Review of the clinical record of Patients #1, admitted on 05/20/13 at 2200 revealed no care plan had been developed.
C. Review of the clinical record of Patient #4, admitted 04/18/13 at 15:30 revealed no care plan had been developed.
D. Review of the clinical records of Patients #2, #3, #4-#9 revealed computer generated Nursing Care Plans which listed a nursing diagnosis, outcome and interventions but were not specific as to what interventions were to be utilized, did not address patient and family teaching methods, and modifications necessary to achieve optimum patient care. Examples follow:
1) Patient #2's nursing care plan revealed under" Name of Care Plan" was Impaired Gas Exchange. Under "Outcomes" was Respiratory status: Gas Exchange, Vital Signs. Under "Interventions" was Medication Administration, Oxygen Therapy. The interventions did not define what medication was to be administered and how much oxygen was required. Review Patient #2's clinical record revealed he received Accucheks four times a day to monitor blood sugars, was on a mechanical soft diet with nectar thickened liquids for aspiration/reflux, was in soft wrist restraints on 05/22/13, was incontinent and had a wound on the left foot which the physician prescribed medication for treatment. None of the above was care planned.
2) Patient #7's nursing care plan revealed under "Name of Care Plan" was Acute Pain. Under "Outcomes" was Pain Control. Under "Interventions" was incision site care. The intervention did not define what the site care consisted of. Review of the clinical record revealed Patient #7 received insulin, oral antihyperglycemics and Accuchek monitoring twice daily, was receiving anticoagulant medications and anti-embolic measures (thromboembolism-deterrent hose and sequential compression devices), and had an order for Oxygen to keep oxygen saturation levels above 97 percent. Review of the Nursing Notes authored by Registered Nurse (RN) #3 at 1131 on 04/29/13 revealed the following: "...Respiratory Dyspnea, Cough - non-productive, short of breath upon ambulation. Skin-extremities coccyx area two small pea size area open, bright red. Hematological Anticoagulant use..." None of the above was care planned.
E. During an interview with Registered Nurse #2 at 1135 on 05/24/13, she was asked how nurses knew what specific techniques or teaching had/was/would be utilized for patients. RN #2 stated it was passed word of mouth during report.
F. The above findings were verified by the CNO at 1210 on 05/24/13.

Based on clinical record review and interview, it was determined the facility failed to ensure the time of surgery was documented on the operative report for 12 of 12 (#5, #7, and #10-#19) surgical patients. The failed practice did not allow knowledge of which surgical procedure was performed in what order in the event of multiple surgeries in one day. Findings follow.

A. Review of clinical records revealed the time of surgery was not documented on the operative report for Surgical Patient #5, #7, and #10-#19.
B. Findings were confirmed by the Chief Nursing Officer at 1224 on 05/24/13.

Based on Emergency Room clinical record review, it was determined nine of nine clinical records had undated physician's orders and seven (#21,#22, #24-27, and #30) of nine (#20-22, #24-27, #29 and #30) had untimed physician's orders. Failure to date and time physician ' s orders did not allow an establishment of future actions, assessments or timeline of events. The failed practice affected nine of nine Emergency Room patients selected for review. Findings follow:

A. Review of Emergency Room clinical records revealed Patient #20-22, #24-27, #29 and #30 had undated physician's orders.
B. Review of Emergency Room clinical records revealed Patient #21,#22, #24-#27, and #30 had untimed physician's orders.
C. The above finding were verified by the Chief Nursing Officer at 1155 on 05/24/13.