HospitalInspections.org

Based on review of documents and interview with staff, the facility failed to verify state licensure and CPR certification per hospital policies and procedures for 2 of 2 agency nurses who provided services to the hospital. This could potentially result in patients receiving care from unqualified nursing staff.

Findings were:

Facility policy 1000.55 entitled USE OF AGENCY PERSONNEL, last revised in June of 2011, states that when the hospital utilizes agency personnel to work in the facility "The Unit Manager and/or Director of Nursing Services will be responsible for assuring that a copy of all required licenses, certifications, evidence of current CPR training and other documentation is current ... "

Review of the personnel documentation of Staff #6 and Staff #8 revealed that both RNs worked at the facility with no verification of nursing licensure or CPR certification.

An in-person interview was conducted the morning of 2/21/13 with Staff #17, the facility Director of Nursing (DON), in a facility conference room. The DON acknowledged that current CPR training and nursing licensure was not verified prior to the nurses working in the facility.

Based on review of documents and interviews with facility staff, the facility failed to ensure that nursing staff described patient response to medications in accordance with facility policies and procedures. The responses to medications given on a PRN (as needed) basis were not documented in 3 of 31 patients whose records were reviewed. This potentially caused a decrease in communication regarding patient response to medications to the patients' healthcare providers.

Findings were:

Facility policy 1000.30 entitled MEDICATION ADMINISTRATION, last revised 6/11, states that the nurse who administers PRN medication must document in the MAR (medication administration record) or Progress Notes the time of administration; reason for PRN use; and the response to the medication, i.e. effectiveness of pain relief or other symptoms.

Review of the medical record of patient # 16 revealed entries on the PRN and One-Time Medication Record dated 2/1/13 at 1610, and 2/2/13 at 0400 for Vistaril 50 mg po (by mouth) for anxiety. There were no results documented on the MAR.

The record of patient # 19 contained the following entries on the PRN and One-Time Medication Record with no patient response recorded:
1. 1/25/13 at 0500, 1/26/13 at 2320, and 1/28/13 at 1700 for Unstell 1 capsule po for bladder pain.
2. 1/28/13 at 1622 for Nucynta 100 mg po for pain.
3. 1/29/13 at 0200 for Benadryl 50 mg po for insomnia.
4. 1/29/13 at 0515 for Tylenol 625 mg po for headache.

The record of patient #31 contained entries on the PRN and One-Time Medication Record dated 1/11/13 at 1350, and 1/15/13 at 0545, for Thorazine 25 mg po for anxiety with no patient response documented.

In an interview conducted 2/21/13 at 1:00 pm in a conference room, the above findings in the records of patients # 16, 19, and 31 were reviewed with staff # 17. Staff # 17 acknowledged there were no patient responses to the above listed PRN medications documented in the records.

Based on observation, review of documents, and interviews with facility staff, the hospital failed to ensure that outdated medications were removed and were unavailable for patient use. Expired medications and supplies were found in the medication storage area of the pharmacy and in the treatment rooms of 3 residence buildings on the facility campus. These items were available for patient use in violation of facility policy. This potentially could have resulted in patients receiving ineffective or unsafe medications and supplies.

Findings were:

Facility policy 1700.2 entitled EXPIRATION DATING, last reviewed in December of 2010, states "Cedar Crest Hospital & RTC Pharmacy will monitor and maintain a drug inventory, which is within dating as indicated by the manufacturer... The Pharmacist/Pharmacy Technician will remove all medications which expire that month, at the end of each month ...The Pharmacist/Pharmacy Technician will inspect the Pharmacy and all medication areas in the process."

Facility policy 1000.100 entitled MEDICAL SUPPLIES PROCUREMENT, last revised in January of 2013, states that the Unit's RN Manager is responsible for maintaining the stock of general medical supplies.

During a tour of the pharmacy in the company of staff # 25 on 2/19/13 starting at 11:40 am, the following expired medications were found in the medication storage area of the pharmacy available for patient use: Amox/clav pot, 250/125 mg, 7 capsules, expired 1/31/13; Azithromycin 250 mg, 1 capsule, expired 11/12; Phenazopyridine HCL 200 mg, 49 capsules, expired 12/12; Silver sulfadiazine cream 1%, 1 jar, expired 1/13; and Prochlorperazine suppositories, 25 mg, 8, expired 12/12.

During a tour of 3 residential units on the facility campus in the company of staff #17 on 2/19/13 starting at 11:40 am, the following expired lab and medical supplies were found in treatment rooms and available for patient use: 98 lab vacutainers and culture tubes which expired in 2012, and 50 steri-strip bandage packages that expired in 2011 and 2012.

In an interview conducted during the tour of the pharmacy on 2/19/13 starting at 1140 am, staff # 25 confirmed that the above medications were expired. During the tour of the residental units on 2/19/13 starting at 1140 am, staff #17 confirmed that the above medical supplies were expired.

Based on review of documents and interview with staff, the facility failed to meet nutritional needs in accordance with the orders of the practitioner responsible for the patient as a dietary consult ordered for a patient was not done in 1 out of 31 patient records reviewed. This potentially resulted in the nutritional needs of the patient not being adequately addressed.

Findings were:

Review of the medical record of patient # 31 revealed that an order for a dietary consult was written at the time of admission on 1/11/13 by physician staff # 13. The record of patient #31 also contained a form entitled "Consultation Request and Report" with the specialty line reflecting "Dietary," and was signed by physician staff # 12. The "Report of Findings" section of the form was blank, indicating that a dietary consult by the dietician had not been done. Patient # 31 was discharged on 1/18/13.

In an interview conducted on 2/21/13 at 1:00 pm in a conference room, staff # 17 reviewed the record of patient # 31. Staff #17 acknowledged that the dietary consult had not been done and should have been completed within 72 hours of being ordered.