HospitalInspections.org

Based on observation, policy review and staff interview, the facility failed to ensure patient care policies were followed during care for Patient #1 and Patient #3, two (2) of three (3) care patients with observed care.


Findings include:


On 2/04/14 at 9:30 a.m. Licensed Practical Nurse (LPN) #2 was observed administering Patient #3's insulin injection as ordered. After the injection the nurse gave the patient her ordered medications by mouth. The LPN failed to remove her gloves or wash her hands before proceeding with the administration of medications taken by mouth. After completing the medication pass the nurse removed her gloves, discarded them and washed her hands. It was noted that only one (1) nurse verified the insulin dosage prior to administration to Patient #3.


On 2/04/14 at 11:10 a.m. LPN #2 was observed performing Patient #1's ordered blood glucose check. She failed to remove her gloves or wash her hands before proceeding with other care.


On 2/04/14 at 3:10 p.m. the Director of Nursing (DON) and LPN #2 were asked what the facility's policy was on gloves and hand washing after possible exposure to body fluids, such as administering and injection or performing a blood glucose check. The DON stated, "You should change gloves and wash your hands before proceeding with further care." During the discussion LPN #2 stated that she did fail to follow the facility's hand washing policy during the 9:30 a.m. medication pass and 11:10 a.m. skill observation. "...I forgot to change my gloves and wash my hands after I was finished."


Review of facility's "Insulin Administration" policy (Date Originated: March 2008) revealed, "...Policy: ...8. All insulin doses shall be verified with regard to insulin type and dose by two licensed nurses ... ".


Review of facility's undated "Handwashing" policy revealed, "Policy: Hospital personnel shall wash their hands to prevent the spread of infections: ...2. Before applying and after removing gloves. ..5. Before contact about the face and mouth of patients. ...General Principles: ...F. Gloves: Gloves are to (be) used only once and then discarded in the appropriate waste container. New gloves should be put on after direct contact with the patient's secretions or excretions if care of that patient has not been completed...".


Findings were presented during exit conference on 2/05/14 at 4:15 p.m. During discussions the DON stated that they would have in-services and the Administrator stated that the hospital's staff had become too comfortable. No further documentation was provided for review.

Based on observation, staff interview and policy and procedure review, the facility failed to ensure the pharmacy checks and keeps current one (1) of one (1) crash cart observed two (2) of two (2) times and failed to ensure the pharmacy keeps refrigerator medications labeled per policy.

Findings include:

Observation of the facility's Medication Room, made with Licensed Practical Nurse (LPN) #1 on 2/4/14 at 2:45 p.m., revealed that the refrigerator contained an opened vial of Tuberculosis vaccine which was not dated or initialed and a vial of Regular Insulin which was dated 11/23/13. When asked what the facility's policy was on multidose vials the LPN stated, "Once opened it is good for 30 days."

Review of the facility's undated "Multiple Use Sterile Products" policy revealed, "Policy - Multiple use sterile products (e.g., vials) shall be used and disposed of in accordance with this policy... Length of use of multiple use sterile products - After initial entry, multiple use sterile products may be used up to time specified in the facility's infection control policies provided they are in date, contain a preservative, and show no evidence of contamination... Insulin - Insulin will have a 28 day expiration from the date the vial was opened."

Observation of the facility's crash cart with LPN #1 on 02/04/14 at 2:35 p.m. revealed the cart contained:
Calcium Chloride 10% (percent) 1 (one ) gram - four (4) boxes were labeled "expired 3/13" on a yellow sticky note;
Appressoline expired 2013 and the vial was empty;
Aminophyllline 250 milligram (mg)/10 milliliter (ml) - one vial was labeled "expired 2/13" on a yellow sticky note;
Verapimil 10mg/4ml - one vial was labeled "expired 2/13" on a yellow sticky note; and
A note in the cart which stated that Mannitol was unavailable.

Observation of the crash cart on 02/05/14 at 12:05 p.m. with LPN #2 revealed no Mannitol was in the cart. Interview with the Director of Nurses (DON) at 12:15 p.m. revealed, "Pharmacy said they were leaving the expired medications in the drawers because they haven't been able to obtain any more."

Review of the facility's undated "Emergency Drugs: Monitoring and Inspection" policy revealed, "Policy - The pharmacy shall establish a monitoring and inspection system to ensure the integrity of emergency drug supplies. .... Pharmacy Inspections - Emergency drug containers shall be checked by the pharmacy at least once a month and after each use to remove deteriorated and outdated drugs and assure completeness of content. The inspection shall assure that all items required for immediate availability are actually present and are in usable condition..."

During exit conference at 4:15 p.m. on 2/05/14 these findings were presented. No further documentation was provided for review.

Based on observation, staff interview and policy review, the hospital failed to ensure that the physician for Patient #2, one (1) of three (3) patients reviewed with blood sugars (BS or BG) above 170, was notified of high BS, failed to ensure the patient had physician's orders for Sliding Scale Insulin and failed to ensure the patient was given the insulin as was needed for high BS.

Findings include:

Record review revealed that Patient #2 was admitted for rehabilitation after shoulder surgery. She also had a diagnosis of Type 2 Diabetes and took oral agents. Review of the patient's recorded BSs revealed that documented BS on 02-03-14 and 02-04-14 ranged from 156 to 209. There was no documented evidence that the physician was being made aware of these high BS or that Sliding Scale Insulin had ever been ordered or given. On 02/05/2014, at exit conference, the Registered Nurse (RN) stated that she was not aware this patient did not have sliding scale orders.

Review of the facility's undated Sliding Scale Policy revealed:
"It is the policy of this facility that the following sliding scale for insulin will be utilized unless otherwise ordered:
Blood Glucose (BG) 0-60 sweetened juice;
BG 61-150 no insulin;
BG 151-200 3 (three) units (Humulin R insulin) SQ (subcutaneous);
BG 201-250 5 (five) units SQ;
BG 251-300 8 (eight) units SQ;
BG 301-350 10 units SQ;
BG 351-400 12 units SQ;
> (greater than) 400 give 12 units then call Provider (physician);
Do not administer under 5 (five) units"

During exit conference at 4:15 p.m. on 2/05/14 these findings were discussed. The Administrator stated, "We are so small that we have just gotten too comfortable." No further documentation was presented for review.

Based on observation, staff interview and policy review, the facility failed to ensure a Registered Nurse (RN) actively supervises and evaluates the care given by a Licensed Practical Nurse (LPN) regarding decisions made not to call the physician for high Blood Sugars (BS) requiring Sliding Scale insulin and the LPNs failure to follow the infection control policy regarding handwashing and changing gloves.

Findings include:

Cross Refer to C271 for the hospital's failure to ensure a RN supervised and evaluated the LPN regarding handwashing and glove changes.

Cross Refer to C294 for the hospital's failure to ensure a RN supervised and evaluated care given by an LPN to Patient #2 regarding failure to contact Patient #2's physician for high BS.