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Based on records review and interviews, the facility failed to ensure all inpatient records documented reports of treatment, medication administration, and other information necessary to monitor the patient's condition for four of thirty-one patients records reviewed (#4, #7, #8 and #14). As a result, nursing staff failed to accurately document medication administration in accordance with the practitioners' orders and the facility's medication administration policy for patients #4, #7, #8 and #14.

This deficient practice could affect the care of all patients in accordance to the practitioners' orders and interventions.

Findings included:


Patient #4

Record review of Patient #4's Physician Admission Orders dated 10/11/14, at 1640, revealed ordered medications included in part, DuoNeb (a sterile inhalation solution containing a combination of albuterol and ipratropium medications) 1 unit dose HHN every (Q) 6 hours while awake.

Record review of Patient #4's Medication Administration Record (MAR) dated 10/11/14, at 1645 to 10/12/14 at 0700 revealed Duoneb 1 unit dose Q 6 hours while awake was handwritten as a Scheduled Medication for 1830, 2400, and 0600.

Further review of Patient #4's MAR revealed the dose for 1830 was lined out and initialed, the dose for 2400 was circled and written as administered at 0235 and initialed, and the 0600 dose was overwritten as 0800 from 0600 but was not documented as given or not given; by crossing out, circling or initialing.

Record review of Patient #4's Nurses notes for 10/12/14, from 0620 to 0930, revealed Patient #4 was awake with no documentation that Patient #4 received her DuoNeb treatment, or the reason she did not receive the DuoNeb treatment.

Patient #7

Record review of Patient #7's Physician Admission Orders dated 01/12/15, at 1330, revealed ordered medications included Home medication; Losartan 100mg (milligrams) PO (by mouth) once daily.

Record review of Patient #7's MAR dated 01/13/15, at 0701, to 01/14/15 at 0700, revealed handwritten Scheduled Medication Losartan 100mg PO daily at 0900. Further review revealed no documentation on 01/13/15, at 1010, to indicate whether Patient #7 received her Losartan at 0900. Registered Nurse (RN) - M documented administration of Aspirin 81mg and Protonix 40mg at 0900; with no documentation as to the reason Losartan was not administered according to the physician orders.

Patient #8

Record review of Patient #8's Physician Admission Orders dated 12/26/14, at1855, revealed ordered medications included in part, Solumedrol (an anti-inflammatory glucocorticoid) 80 milligrams (mg) IV (intravenous) Q 8 hours and home medications included in part, Norvasc 5mg PO Q HS.

Record review of Patient #8's MAR dated 12/27/14, at 0701, to 12/28/14, at 0700, revealed Solumedrol 80gm was handwritten for scheduled administration at 1000, 1800, and 0200. RN-K drew a line through and initialed for the scheduled dose for 1000 and 1800. The scheduled dose for 0200 had no documentation as being administered; by crossing out, circling, or initialing.

Record review of Patient #8's Nurses notes for 12/28/14, at 0130, revealed her right forearm was IV infiltrated. There was no documentation that Patient #8 received her Solumedrol 80 gm, or the reason she did not receive the physician ordered medication Solumedrol IV at 0200.

Record review of Patient #8's MAR dated 12/26/14, at 0701 to 12/27/14, at 0700, revealed Norvasc 5mg PO Q HS at 2030. Further review revealed Norvasc at 2030 had a line through it; but was not initialed by nursing staff as administered. Review of Patient #8's MAR for 12/27/14, at 2100, revealed Norvasc was circled with a low blood pressure documented of 123/45.

Record review of Patient #8's Nurses notes for 12/27/14, revealed no documentation that the physician was notified of Patient #8's low blood pressure or that her Norvasc was held from administration.

Patient #14

Record review of Patient #14's Physician Admission Orders dated 12/31/14, at 0513, revealed ordered medications included in part, Flagyl 500mg IV Q 8 hours; and home medication, Carvedilol 6.25mg 1 tab BID (twice daily).

Record review of Patient #14's MAR dated 12/31/14, at 0545, revealed handwritten Scheduled Medications included: Carvedilol 6.25 mg po BID at 0900 and 1700, and Flagyl 500mg IV Q 8 hours at 0600, 1400, and 2200. Further review of the MAR revealed no documentation that Carvedilol was administered at 0900, or the reason the medication was not administered. There was no documentation that Flagyl was administered at 1400, or the reason it was not administered. The only documentation was that Flagyl 500 mg IV was administered at 0600 when the RN-L crossed it out and initialed.

Record review of Patient #14's Nurses notes revealed Patient #14 was discharged 12/31/14, at 1610.

During an interview on 01/13/15, at 10:10 AM, with RN-B revealed Patients' MAR should be documented by nursing staff during administration of scheduled medications according to the physician orders.

RN-B stated that most nursing staff would draw a line through the times and initial next to the scheduled time; as administered. RN-B stated that if a medication was not given in accordance with the physician orders, then nursing staff was supposed to circle it as held, or not given; with an explanation in the nurses' notes or directly on the MAR.

RN-B confirmed that on 01/13/15, at 1010, Patient # 7's Losartan should have been circled at 0900 as not administered. RN-B stated that Patient #7 did not receive her Losartan because it was a home medication that was not brought in by the family after admission; and Patient #7 was being scheduled for discharge. RN-B circled Patient #7's Losartan during the interview; as not given, but no explanation.

RN-B reviewed Patient #8's records and indicated that he was not able to indicate whether or not Patient #8 received her Norvasc on 12/26/14 at 2030 according the recorded documentation.

RN-B indicated that the nurse administering the medication may have administered it, but failed to initial. RN-B stated that Patient #8's Norvasc was held on 12/27/14, at 2100, due to low blood pressure documented on the MAR and confirmed the nurses notes did not document notification to the physician regarding the low blood pressure or the Norvasc being held for administration.


Record review of the facility's Policy titled, Time Critical Medications, Reference #16001, undated, revealed " Medication administration will be documented at the time of administration."

Based on observations, interviews, and records review, the facility failed to make outdated/expired drugs and biologicals not available for patient use. The facility failed to follow its policy and procedure for using and labeling multi-dose medication vials for three of three medication and biological storage areas reviewed. As a result, expired medications and biologicals were found stored and readily available for patient use in the pharmacy medication storage departments, and emergency crash carts; which also was not in accordance with the facility's policy.


This deficient practice could result in ineffective or unsafe medications being used for any patient.


Findings included:


During an observation on 01/12/15, at 11:25 AM, with Staff #5 present, revealed expired 1% Lidocaine HCL 50 mg injections (numbing medication) with expiration dates of December 2014 were stored in a refrigerator in Hospital "A" Emergency Department (ED) medication room.


Observation on 01/13/15, at 9:20 AM, at one of the facility's satellite emergency department with the Hospital Administrator (HA- B) present revealed the emergency crash cart located at the inpatient area revealed the following expired medications and biologicals available for use in patient care:


1.) Dextrose (used for low blood sugar) 25% injections, 2 boxes expired 04/01/14. There were no other Dextrose injection boxes available for use.


2.) Arterial Blood Gas (ABG) kit (used for laboratory blood draws that contains heparin), 2 kits expired December 2014. During the observation, the HA-B stated that the new ABG kits "came in last week;" removed the expired ABG kits from the crash cart, and replaced them with the new unexpired kits.


Further observation on 01/13/15, at 9:30 AM, at the facility's satellite ED's Pharmacy medication storage area with the HA-B and Pharmacist-B present, revealed the following expired medications were found in the storage carts available for use in patient care:


1.) Digoxin (used to treat congestive heart failure), 6 vials expired 12/14. There were no other Digoxin vials available for use that was not expired.


2.) Atropine (used to treat extremely low heart rate) 20 ML, 2 bottles expired 12/14. There were no other Atropine bottles available for use that was not expired.


During an interview on 01/13/15, at 9:35 AM, with the HA-B, confirmed the above observed medications and biologicals had expired and were available for patient use. The HA-B stated that the Dextrose injections and Atropine medication were on back order for replacement. The HA-B further stated that the Digoxin had not been ordered. The HA-B stated the facility and Pharmacist were aware of the expired medications observed in the crash cart and the pharmacy medication storage area; but were left in the storage areas in the event of an "emergency." The HA-B indicated that it was better to have expired medications available to administer for patient use, than to not have the medication available to the patient at all.


During an interview on 01/13/15, at 9:40 AM, with the facility's Pharmacist-B confirmed the above observed medications were expired in the Pharmacy medication storage area. The Pharmacist stated that he was not aware when the facility would receive the medications that were on back order and thought it was best to keep expired medications available, rather than discard the medication and not have it available for patient use; if it was actually needed.


Record review of the facility's Policy titled, Inspection of Pharmacy Related Areas, Reference #16010, undated revealed that the Procedures included in part, Inspections shall include the main pharmacy, all nursing care units, drug storage units, emergency boxes, emergency carts, and all other areas of the facility where drugs are dispensed, administered or stored (including drugs in areas that do not obtain their stocks from the pharmacy). 4. Inspections shall verify that: "g. Outdated or otherwise unusable drugs are identified, removed from stock, and stored to prevent their distribution and administration."

Observation of the medication dispensing room of Hospital A (HA-A) on 1/12/15, at 11:30 PM, with staff member # 5 revealed 2 separate signs with competing directions for determining expiration dates for multi-dose medication vials. One sign indicated expiration dates should be 30 days from the opening and the other sign indicated 28 days should be the expiration date.

Observation of the medication refrigerator revealed staff members failed to use the provided medication labels correctly or not at all. The labels allow for documenting the date the medication was opened and the expiration date. Pneumococcal Vaccine labeled incorrectly (opened 1/3/15 - expire 2/3/15 versus 1/31/15). Humulin Insulin with only the expiration date on the vial no label was used.

Review of the hospital ' s policy and procedure entitled Inspection of Pharmacy Related Areas Reference # 16010 and interview with staff member # 5 revealed the hospital policy recommended 28 day expiration dates for multi-dose medication vials. Staff member # 5 could not provide evidence of compliance with the requirement.




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21560

Based on records review and interviews, the facility failed to ensure equipment (Pediatric Crash Cart #1 and Adult Crash Cart #2) was inspected and tested for performance, reliability and safety.


- Pediatric Crash Cart #1 was not inspected by staff on seven (12-hour) shifts in December 2014.


-Adult Crash Cart #2 was not inspected by staff on 15 (12-hour) shifts during November and December 2014.


This deficient practice could affect the safety and well-being of patients, staff and visitors.


Findings included:


Review of Pediatric Crash Cart (CC#1) Check List dated December 2014 indicated staff did not inspect crash cart emergency equipment including emergency medications on seven (12-hour) shifts.


Review of Adult Crash Cart (CC#2) Check List dated November 2014 and December 2014 indicated staff did not inspect crash cart emergency equipment and emergency medications on 15 (12-hour) shifts.


Review of the facility's Crash Cart undated policy Reference # 7054 required nursing personnel to verify emergency equipment was in good working order and to record/complete the Crash Cart Check List each shift.


Interview with Staff #6 on 01/13/15, at 9:30 a.m., confirmed that facility staff were required to inspect all crash carts at a minimum of once per 12-hours shift and to record/complete each Crash Cart Check List per facility policy.


During the Exit Conference on 01/13/15, the facility was given an opportunity to ask questions and provide additional information regarding deficient practice identified during the survey process. No additional information was given.

Based on observations, interviews and records review, the facility failed to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases.


- Facility stored infectious linen in permeable biohazard bags in close proximity of a clean emergency crash cart and a clean supply cart and potentially infected the crash cart while transferring the biohazard linen.


- Facility staff transferred a biohazard linen bag to the soiled linen room and contaminated staff uniform. The keyless entry pad and entry door handle were contaminated with the staff's soiled gloves. The keyless entry pad and entry door handle were not sanitized after the transfer.


- Facility staff did not thoroughly sanitize hands after biohazard linen transfer.


- Facility stored clean linen supplies on the floor in the clean linen room.


- Facility stored clean linen in the clean linen room on the shelves without plastic cover or drapes.


These deficient practices to provide a sanitary environment to avoid sources and transmission of infections and communicable disease could affect the health and safety of all patients and staff.


Findings included:


During an observation at Hospital "A" on 01/12/15, at approximately 12:30 p.m., revealed infectious linen in permeable bags were stored in close proximity (within a few inches) of an emergency crash cart and an equipment supply cart. Staff #10 was observed to manually remove a full biohazard linen bag from a portable linen bag holder. The biohazard linen bag came into contact with the adjacent emergency crash cart and the staff's uniform. Staff #10 transferred the biohazard bag to the soiled linen room and contaminated the keyless door entry pad and door entry handle with contaminated gloves. The keyless entry pad and door handle were not immediately sanitized after the transfer.


Interview with Staff #5 on 01/12/15, at approximately 12:45 p.m., confirmed the Surveyor's observations and the facility's deficient practices regarding the potential for the transmission of infections and communicable diseases. Staff #5 indicated the Infection Control Representative for each hospital facility was the primary facility site source to conduct week to week infection control audits to assist each facility in Infection Control compliance. Staff #5 stated the Infection Control Representative averaged "a few hours a week" to conduct "Environmental Rounds" while assigned to work "normal staffing duties."


Observation on 01/13/15, at Hospital "C" at approximately 11:00 a.m. revealed Staff #14 transferred infectious linen to the soiled linen room. Staff #14 did not thoroughly sanitize her hands after removing the gloves. Staff #14 washed hands for approximately 5 seconds.


Review of the facility's Hand Hygiene undated policy Reference # 4009 indicated in-part that staff were required to wash their hands thoroughly, using rigorous scrubbing action for at least 15 seconds and to always wash their hands after removing gloves.


An observation on 01/12/15, at 1:00 p.m., revealed Hospital "A" stored several packages of clean linen wrapped in plastic on the floor and a chair in the clean linen room. Clean linen was observed in the shelves without any plastic cover or drape. Several dark particles were observed on the uncovered clean linen.


Review of the facility's undated Infection Control Environmental Rounds form indicated staff were required to maintain adequate separation of clean and soiled materials; clean linen to be adequately covered; and no supplies to be stored on the floor in the Utility and Storage Rooms.


Interview on 01/13/15, at approximately 11:15 a.m., with Staff #6 revealed the Infection Control program at the facility required more input and feedback from the Quality Improvement Committee to have an effective program.


During the Exit Conference on 01/13/15, the facility was given an opportunity to ask questions and provide additional information regarding the deficient practices identified during the survey process. No additional information was given at that time.