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1500 AVENUE H

ELY, NV 89301

No Description Available

Tag No.: C0276

Based on observation, interview and record review, the facility failed to properly label 3 opened vials of medications and failed to dispose of 1 single dose medication vial placing the vial, back into the medication room for the next staff to use.

Findings include:

The facility policy titled Single/Multi Dose Medication Vials in Clinical Areas dated 8/2008, documented:

"...Multi Dose:

Upon first access of a multi-dose vial, the vial must be given an expiration date of 28 days or the manufacturer's expiration date, whichever is less ..."

On 8/19/14 at 3:15 pm, the Director of Pharmacy reviewed the medications in the automated medication dispenser that was located in the medication room in the medical surgical unit. The Director of Pharmacy indicated multiple dose vials could be used multiple times for different patients. When the vials were initially opened a label was placed on the vial to document the expiration date which would be 28 days after opening the vial or the manufacturer expiration date depending what date came first. The Director indicated the staff needed to use the stick-on labels to hand write the expiration date on the vials.

The automated medication dispenser in the medical surgical unit had one 3 ml (milliliters) Humulin N vial and one Humulin R vial that were open, no expiration labels were placed on the vials. The Director of Pharmacy confirmed the stick-on labels were missing and the vials needed to be discarded.

The Emergency Room medication room had two vials of Humolog medications with no stick-on labels. The manufacturer's label documented an expiration date of January 2014. The Director of Pharmacy indicated the vials needed to be discarded.

The facility policy titled Single/Multi Dose Medication Vials in Clinical Areas dated 8/2008, documented:

"...The medication in a single-dose vial must not be used for more than one patient ...A single-dose vial, including, any remaining medications in the vial after its use, must be discarded ..."

The automated medication dispenser in the medical surgical unit had an open 10 ml Diltiazem vial. The manufacturer's label documented the medication was a single dose vial. The vial had a stick-on label which had the date of 9/5/14, hand written on the expiration section of the label.

The Director of Pharmacy confirmed the single dose vial of Diltiazem should not have been returned to the medication dispenser and should have been thrown away. The Director indicated the single-dose vial should only be used for one patient and then discarded.

No Description Available

Tag No.: C0295

The facility did not ensure appropriate bowel movements were monitored for 1 of 22 sampled patients (Patient #10).

Findings include:

Patient #10 was admitted to the facility on 8/4/14, with diagnoses that included left lower leg wound, tachycardia, and dysphagia.

On 8/4/14 at 9:00 PM, Patient #10's Nurse documented the gastrointestinal assessment: Patient #10's date of last bowel movement (BM) was "Yesterday? Patient unsure".

On 8/8/14 at 2:35 PM, Patient #10 was transferred to another facility. Patient #10's Nurse documented, "PT (Patient) discharged to (name of facility) via Ely Ambulance. Report is called to (name of Nurse at receiving facility). She is made aware that PT has not had a BM for several days".

On 8/21/14, a Registered Nurse (RN) was interviewed. The RN stated the policy should be found under the subjects of "Bowel Monitoring" or "Intake and Output". The RN was unable to locate a policy that explained the procedure for bowel monitoring. The RN stated that he would report no bowel movement to a Physician based on the patient's normal bowel movement pattern. The RN acknowledged no bowel movement for a couple of days would be a concern and should be reported to the Physician.

On 8/21/14, The Chief Nursing Officer (CNO), was interviewed. The CNO stated the facility did not have a policy related to bowel monitoring. The CNO acknowledged Patient #10's lack of a bowel movement from 8/4/14 through 8/8/14 should have been reported to the Physician.

No Description Available

Tag No.: C0297

Based on observation and interview, the facility failed to follow State Hospital regulations for prevention, control and investigating infections by not washing hands after performing patient care for 1 of 22 patients (Patient #1).

Findings include:

NAC (Nevada Administrative Code) 449.325 Prevention, control and investigation of infections and communicable diseases. (NRS 449.0302 )
1. A hospital shall:
(a) Provide a sanitary environment to avoid sources and transmission of infections and communicable diseases.

Patient #1

Patient #1 was admitted on 8/8/14, with diagnoses including hypertension, pneumonia and respiratory insufficiency.

On 8/21/14 at 8:55 am, the Registered Nurse (RN) prepared Patient #1's morning medications. The RN prepared six different oral medications and one intravenous medication. After administering the oral medications to Patient #1, the RN prepped Patient #1's left lower forearm saline lock site. Using bare hands, the RN flushed the saline lock port with normal saline solution and connected the antibiotic intravenous bag and started the intravenous pump.

The RN gathered the old antibiotic intravenous solution bag that was hanging on the intravenous pole and walked out of the patient's room. The RN walked back to the nursing station, opened the medication room door and discarded the old antibiotic intravenous solution bag into the trash.

The RN then opened the medication room door, stood in the nursing station and indicated morning medication administration was completed for Patient #1. The RN did not wash his hands after handling the patient's intravenous port, after leaving the patient's room with the old intravenous antibiotic bag and after discarding the bag in the medication room.

On 8/21/14 in the morning, the RN indicated hand washing should have been completed after administering the patient's intravenous medication, before leaving the patient's room and after holding and discarding the old intravenous solution.

On 8/21/14 in the morning the Chief Nursing Officer (CNO) confirmed hand washing should have been completed prior to leaving the patient's room and after handling the old intravenous solution.

No Description Available

Tag No.: C0320

Based on observation, interview and record review, the facility failed to maintain proper infection control technique in the operating room and failed to follow initial steps for cleaning and disinfecting surgical equipment and endoscopy scopes when manufacturers recommendations for cleaning solutions were not followed.

Findings include:

1) On 8/20/14 at 7:35 am, a patient was in operating room #2 having surgery to the right knee. During the surgery, the operating room nurse picked up dirty linen from the floor with bare hands. The operating room nurse lifted the cover to the dirty linen container with bare hands and discarded the dirty linen into the container. The dirty linen container had a foot pedal to open the container top. The nurse did not use the foot pedal and did not wash her hands immediately after touching the soiled linen and container top. The nurse proceeded to touch electronic monitoring equipment around the room and then used her keyboard before using a hand sanitizer.

After the procedure, the surgical technician who assisted in the procedure discarded dirty linen in the dirty linen container. The surgical technician used soiled gloves when opening the top of the soiled linen container. The surgical technician did not use the foot pedal to open the top of the container and continued to use soiled gloves to adjust the top to leave it continuously open for him to discard bulk linen items. The technician then closed the lid using the soiled gloves.

After the surgical technician had opened the soiled linen container with soiled gloves, the surgical nurse opened the soiled linen container, at times using bare hands and also gloved hands. Hand washing or the use of a hand sanitizer was not immediately done after touching the soiled container top. The staff touched other items in the room such as electronic medical equipment, a keyboard, the door leading into the supply area, tables and stools in the operating room prior to using a hand sanitizer.

On 8/21/14 in the morning, the Chief Nursing Officer (CNO) indicated when discarding soiled linen or trash using the containers with foot pedals, the foot pedals should be used instead of handling the top of the containers with gloved or bare hands to open the bin.

2) On 8/20/14 at 9:55 am, two surgical technicians (ST) were in the soiled utility room cleaning scopes used for endoscopy and colonoscopy procedures. ST #1 indicated he was teaching the newly hired ST #2. There was no information on how to soak and clean the soiled medical equipment readily visible for staff use in this room. Both staff members used plastic gowns and gloves during the cleaning.

ST #1 indicated soaking and flushing was performed before transferring the scopes to the next room to be placed in the Steri washer. The sink was filled with water and a scope was soaking in the water. The ST #1 indicated the solution Endozyme, was used to soak and clean the scope. The ST #1 indicated one squirt of the solution was used for every four gallons of water. There was no measuring device or indicator in the sink to verify the amount of water used. ST #1 indicated there was a water line from built up minerals in the sink but the ST was not able to give the amount of water used when the water was filled to the water marking. The ST #1 indicated he just made sure the water level was above the scope and was not sure how many gallons were actually being used.

After ST #1 flushed the ports in the sink and left the scope soaking in the water solution he removed his plastic gown and hung the gown on the small protruding access door which was the door to transfer equipment from the dirty soiled room into the next room where the Steri washer was located. A fluid filled Styrofoam cup was on top of the protruding door. While still inside the soiled utility room with soiled gowns beside him and soaking scopes just feet away, the ST #1 took the cup and started to drink from it and placed it back on top of the protruding transfer door.

On 8/20/14 at 3:05 pm, ST #3 measured one pump (squirt) from the Endozyme solution bottle was equivalent to one fluid ounce or 30 cc (cubic centimeters).

The Endozyme manufacturer instructions recommended for manual cleaning 10 to 15 parts of water should be added to 1 part of Endozyme solution.

On 8/20/14 in the afternoon, the CNO confirmed the wrong dilution ratio was being used when soaking the scopes used for endoscopy and colonoscopy procedures. The CNO indicated the staff should have been using a measuring device to measure the appropriate amount of water to soak and flush the scopes. Also, the CNO indicated the correct ratio, if the staff were using four gallons of water, would be 34 fluid ounces (34 squirts) to 51 fluid ounces of Endozyme solution mixed with four gallons of water. The CNO confirmed the solution was too diluted and not correct when 4 fluid ounces (4 squirts) were mixed with four gallons of water. The CNO also indicated food and drinks were not allowed in the soiled utility room at any time.

3) On 8/20/14 in the morning, ST #3 stepped into the main soiled utility room where dirty surgical instruments and devices were soaked and cleaned prior to placing them into the washer or transferring them to the sterilization room. ST #3 indicated cleaning would be done by the main ST assigned to the area but indicated he may be called in to do cleaning of the devices when needed. ST #3 indicated he could not clarify how long an item was to be soaked in the Prolystica solution and had to ask the main ST #4 who handled the area. There was no signage posted around the room to instruct staff on how to soak and clean the instruments. Also there was no signage posted on how much Prolystica solution should be diluted with water.

On 8/20/14 the main ST #4 who was in charge of the main sterilization area indicated soiled surgical instruments were cleaned and soaked prior to transferring them into the washer. ST #4 indicated some items such as the camera, some types of scopes and light cords were not sent through the washer prior to entering the sterilization room. ST #4 indicated those items have to be manually washed and soaked with the Prolystica solution and then transferred to the sterilization area without being sent to the washer because they were fragile items.

ST #4 indicated 1 to 1 ½ squirts (30 to 45 cc's) of the Prolystica solution, used for cleaning and soaking the surgical instruments, was diluted into 1 gallon of water. There was no measuring device or indicator in the sink to determine if the correct amount of water was being used. ST #4 indicated she would " guess " how many gallons of water she would use and would squirt 1 squirt for each gallon of water. ST #4 indicated she would fill the sink until the instruments were covered with water.

The manufacturer's recommendations for the Prolystica solution documented to use 1/8 to ½ fluid ounces of the solution to 1 gallon of water.

On 8/20/14 in the afternoon, the CNO indicated a measuring device or an indicator in the sink should have been used to correctly measure the amount of water being mixed with the Prolystica solution. The CNO indicated all staff should be aware of the proper ratio to mix the Prolystica solution and the proper soak times for the solution. The CNO confirmed the Prolystica solution ratio to water was not followed. Too little may not be effective to properly clean and too much of the solution may be harmful to the instrument material causing premature deterioration.

PERIODIC EVALUATION

Tag No.: C0335

Based on interview and document review, the facility failed to follow the facility policy regarding quarterly quality assurance duties to identify opportunities to improve or resolve problem areas and to report the findings on a quarterly basis to the Governing Body, Medical staff and appropriate departments.

Findings include:

The facility policy titled Quality Improvement dated June 2010, documented:

" ...Do:
Data is collected to determine:
Whether design specifications for new processes were met
The level of performance and stability of existing processes
Priorities for possible improvement of existing processes

Check:
Assess care when benchmarks or thresholds are reached in order to identify opportunities to improve performance or resolve problem areas

Act:
Take actions to correct identified problem areas or improve performance
Evaluate the effectiveness of the actions taken and document the improvements in care
Communicate the results of the monitoring, assessment and evaluation process to relevant individuals, department or services.

Reporting Of Data:
The findings, conclusions, recommendations, actions taken to improve performance and the results of actions taken are documented and reported through established channels.

Results of the outcomes of performance improvement and patient safety activities identified through data collection and analysis, performed by all departments including medical staff will be reported to the Performance Improvement Committee on a quarterly basis as designated.

The Performance Improvement Committee will report, to the Medical Staff on a quarterly basis, their analysis of the quality of patient care and services provided throughout the facility. The report will include a review of the performance improvement process as it relates to patient care.

The Performance Improvement Committee will provide the Governing Body with a report of the relevant findings from all performance improvement activities performed throughout the institution at least on a quarterly basis ... "

On 8/21/14 at 8:30 am, the Chief Nursing Officer (CNO) indicated in April of 2014, the Quality Assurance (QA) Coordinator resigned from her position leaving her with all the QA responsibilities. The CNO indicated the previous QA Coordinator was coming in to assist with the program and to train her until a new QA Coordinator was hired on.

The CNO indicated when quarterly QA reviews were conducted at the end of the quarter the information would be gathered, evaluated and disseminated. The information gathered would determine if the issues would be carried to the next quarter, resolved or the need for in-services to be conducted with the staff.

On 8/21/14 in the morning, the CNO indicated the last QA meeting was performed sometime in January 2014, to review the quarterly data gathered from October, November and December 2013.

The CNO indicated the first quarterly QA review for 2014, which was January, February and March was not complete. The CNO indicated data for the 2014 first quarter had been gathered but not yet reviewed and evaluated. The CNO indicated there had been no QA meeting after the first quarter QA data had been gathered.

The CNO indicated the second quarterly QA review for 2014, which was April, May and June was not completed. The CNO indicated data for the 2014 first quarter had been gathered but not yet reviewed and evaluated. The CNO indicated there had been no QA meeting after the first quarter QA data had been gathered.