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Based on policy review, fall log review, medical record review, and staff interview, facility staff failed to document per policy after a patient fell in 1 of 3 patients (Patient #8) that experienced a fall.

Review of facility policy titled "Risk for Falls" review/revised 03/01/2016 revealed, "...All staff members are responsible for implementing the intent and directives contained within this policy ... If a client experiences a fall ... Document what occurred in the nurse's progress notes including: client appearance at time of discovery, client response to event, evidence of any injury, location, medical provider notification, family notification, medical/nursing actions ..."

Findings included:

Review of a fall log revealed Patient (PT) #8 experienced a fall on 10/21/2018 at 1835, after being evaluated at an area emergency room (ER) earlier in the day for an unrelated issue.

Closed medical record review conducted on 11/07/2018 revealed Patient (PT) #8 was a 77-year-old male admitted on 10/02/2018, with a diagnosis of "Bipolar disorder, current manic state with psychotic features." Review of a nursing note written by Registered Nurse (RN) #1 on 10/22/2018 at 0315 revealed, "...Pt in bed at beginning of shift. Pt fell previous shift (dayshift). See fall paperwork. Pt took meds (medications) without issue. Alert and oriented x1. (Symbol for no) complaints or issues ..." Review of a nursing note written by RN #2 on 10/21/2018 at 1145 revealed, "Pt transported, via (named transport service), to (named ER) ..." Review of a nursing note written by RN #2 on 10/21/2018 at 1540 revealed, "Pt returned from (named ER). Appears brighter seemed to ambulate better. (sic) ..." Revealed no other documentation regarding a fall on 10/21/2018.

RN #2 was unavailable for interview.

Interview conducted on 11/07/2018 at 1330 with the Director of Quality revealed the patient record revealed no documented evidence of PT #8's fall including client appearance at time of discovery, client response to event, evidence of any injury, location, medical provider notification, family notification, or medical/nursing actions. Interview revealed facility policy was not followed.

Based on observations, reviews of policies, review of manufacturer's recommendations, list of patients receiving insulin, medical record review and interviews with staff, the facility failed to follow policy and manufacturer's recommendations in storage of insulin by failing to discard an expired vial of insulin in 1 of 1 insulin vials on nursing care unit.

The findings include:

Observation on 11/06/2018 at 1350 of nursing unit A revealed a Lantus (type of insulin) vial with a handwritten opened date of 09/23/2018 and expiration date of 10/19/2018, 44 days after vial was opened for use.

Review on 11/07/2018 of policy, titled "Vials and Ampules of Injectable Medications" with revision date of 01/23/2018, revealed "...Medication in multi dose vials may be used for 28 days from the date opened if inspection revealed no problems, unless stated otherwise by manufacturer..."

Review on 11/07/2018 of manufacturer's package insert of Lantus insulin revealed "...Do not use Lantus after the expiration date stamped on the label or 28 days after you first use it....."

Review on 11/07/2018 of a list of patients requiring Lantus insulin between 10/19/2018 and 11/06/2018 revealed one patient (Patient #11).

Interview on 11/07/2018 at 1400 with LPN #1 who signed MAR as administering Lantus insulin to Patient #11 revealed the expiration date was not checked before administering the insulin.

Interview on 11/06/2018 at 1350 with the assigned floor RN #3 revealed the insulin was expired and should have not be used.

Interview on 11/06/2018 at 1400 with the CNO revealed the expired vial of insulin should not have been available for use and should have been discarded.

Interview on 11/07/2018 at 1045 with the Pharmacist Director revealed all insulins expire in 28 days after opening and should be discarded.

NC00142957
NC00144448