HospitalInspections.org

Based on review of facility documentation, facility tour, and employee interviews (EMP), it was determined that the facility failed to ensure drugs and biologicals were properly locked in all storage areas.

Findings Include:

Review, at approximately 8:30 AM on December 28, 2021, of "Radioactive Waste Disposal," revision dated March 19, 2021, revealed, "... 2. Used doses syringes/needles are placed in the individual "pig" container which they arrive in and returned to the from which it was ordered for disposal. The "pigs" are returned the following day to the Radiopharmacy; 2. All other radioactive syringes, needles, set-ups, etc. are disposed of in the sharps container. The sharps container is kept in the department until they have decayed through 10 half-lives and are monitored to insure they are at background before disposal. When the containers are at background they are disposed of with the regular trash. ..."

Review, at approximately 8:34 AM on December 28, 2021, of "Personal Protective Equipment," revision dated July 1, 2021, revealed, "... Procedure - Department Specific: ... B. End of each exam: 1. The technologist must wear gloves while cleaning the syringes, needles and other contaminated supplies from the tray. Plastic syringes and needles should be disposed of into an appropriate "Sharps" container. ..."

Review, at approximately 8:39 AM on December 28, 2021, of "Pulmonary Scintigraphy," revision dated October 27, 2021, revealed, "... Procedure: 1. Aerosol Imaging is done before perfusion imaging because it is more difficult to deliver a larger dose of the Tc99m DTPA aerosol than it is to deliver a larger dose of Tc99m MAA. ... Post-Procedural Clean-Up: The technologist must wear gloves while clearing the syringe, needle, and other used supplies from the room. Syringes and needles should be disposed of into a "sharps" container in the Hot Lab. ..."

1. At approximately 12:00 PM on November 29, 2021, in the Nuclear Medicine Suite, one syringe with no labeling and liquid was located inside the syringe on the counter.

EMP4 confirmed the above observation.

When asked, at approximately 12:05 PM on November 29, 2021, what was located inside of the syringe and if it should be left on the counter, EMP5 stated, "It's MAA. Obviously, they should be put back after use. ..."

The following policies were revised to describe proper use and handling of multi-use vials/syringes:

A. Multiple Use of Medication Vials or Syringes
B. System for Monitoring Anesthesia Medication & Supply Carts
C. Anesthesia Pack Policy and Procedure
D. Safe Handling of Syringes, Needles, and Vials Intended for Injection

Discussion with the Department Nurse Manager, the CRNA, the Pharmacist, and Director of Patient Care Services took place on 2/1/2022 which pertained to the general use of multi-dose vials and proper handling and disposing of opened vials. Additionally, proper labeling practices were reviewed for multi-use vials including date/time opened and/or removed from refrigerator; date/time of expiration, and initials of the person placing the label on the vial.

It was decided that multi-dose vials will be single patient use except for those medications that are accessed in a controlled clean area such as the Pharmacy clean room or a medication room. If an open vial is discovered in an area outside of the clean room/medication room, it will be properly disposed of. If any vial/syringe is not properly labeled, it will be disposed of.

In the event that a medication is difficult to obtain and the hospital would be at risk of not having a medication available due to wasting doses, the Pharmacy will pre-package unit doses of the medication with proper labeling and will place in the Pyxis medication dispensing unit. Certain medications that are used in the OR suites may be packaged in the anesthesia packs by the Pharmacist with proper labeling and stored in the Pyxis unit.

The Pharmacist and Surgery Nurse Manager will provide training for all nursing staff in the department and the CRNA's on the policies above. This will be completed by February 18, 2022.

The Surgery Department Nurse Manager will monitor that daily checks of the anesthesia carts are completed and the Pharmacist will conduct monthly monitoring rounds of medications in all areas of the Surgery Department. Monthly reporting to the Quality Improvement Committee will be done for the next 2 quarters (January 2022-June 2022) by the Surgery Department Nurse Manager and the Pharmacist. If improvement is noted, reporting will be quarterly for the last 2 calendar quarters for the year (July 2022-December 2022).

The following staff will be responsible for monitoring the continued implementation of the plan of correction:

Emergency Department Unit Manager,
Director of Patient Care Services, and
President/CEO.

Based on review of facility documentation, medical record review (MR), as well as employee interview (EMP), it was determined that the facility failed to follow its policy to ensure that the patient will be monitored visually at least every fifteen minutes and neurovascular checks will be completed every 30 minutes for one of one restraint record reviewed (MR14).

Findings Include:

Review, at approximately 10:10 AM on December 28, 2021, of "Subject: Restraints," review dated November 2021, revealed, "... It is the policy of Corry Memorial Hospital that all patients and associates have the right to a safe environment. ... 3. Unit Staff responsibilities while a patient is in restraints: ... b. The patient will be monitored visually at least every fifteen minutes; c. Neurovascular checks will be completed every 30 minutes; ..."

1. Review, at approximately 3:44 PM on December 13, 2021, of MR14 "Restraint Activity Record," dated July 10, 2021, revealed, "Soft extremity restraints ... 07/10/21 @ 0410 [Upward Arrow] ... [Downward Arrow] @ 0454 ..."

EMP8 confirmed the above finding, and further indicated, "... The restraint paper [Restraint Activity Record] is all that we have. ..."

2. Review, at approximately 3:50 PM on December 13, 2021, of MR14 "ED Nursing Triage," dated July 10, 2021, revealed, "... [He/She] was placed in four point soft restraints per MD order ..."

4. Review, at approximately 3:55 PM on December 13, 2021, of MR14 revealed no documentation of monitored visual checks completed every 15 minutes and neurovascular checks completed every 30 minutes after four-point soft extremity restraints were implemented on July 10, 2021 at 4:10 AM.

EMP8 confirmed the above finding at approximately 8:54 PM on December 15, 2021.