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Based on Emergency Department (ED) record review, staff interview, typed statement review, staff documentation review, policy review, and attempted patient interview, the hospital failed to ensure that each patient receives care in an environment that a reasonable person would consider to be safe. Patient #1, one (1) of 10 patients reviewed, received an intramuscular medication that had been retreived from a biohazard waste container.


Findings include:


Cross Refer to A0405 for the facility's failure to ensure that Patient #1 received care in an environment that a reasonable person would consider to be safe.

Based on Emergency Department (ED) record review, staff interview, staff documentation review, typed statement review, policy review, and attempted patient interview, the hospital failed to ensure that all medications given to Patient #1, one (1) of 10 patients reviewed, were prepared and administered in accordance with accepted standards of practice.


Findings include:


On 12/22/16 the State Complaint Hotline received a complaint from Patient #1 regarding an ED visit made on Saturday 12/17/16 between 10:00 p.m. and 11:59 p.m. Patient #1 stated the ER visit was for complaints of a severe headache. Patient #1 stated that a male nurse took her vital signs, the ED physician did his examination and prescribed three medications, oral Benadryl and two (2) injections. A female nurse (Registered Nurse [RN] #1) came into the room and gave Patient #1 the oral Benadryl and one (1) of the injections. The nurse fumbled around at the tray she had set up the medications on and then stated that she had thrown the wrong medicine vial into the red biohazard container on the wall. The nurse left the room, returned to the room, unlocked the biohazard container from the wall, and removed it. Patient #1 stated that Nurse #1 could not get the biohazard container open so she got a male nurse (RN #2) to help her open it. When the container was open RN #1 reached into the biohazard container and retreived the vial of medication. Patient #1 told RN #1 that she did not want that medication that had been thrown into and retrieved from the biohazard container. RN #1 stated, "The vial was never opened so it's ok if I give this to you." The nurse gave Patient #1 the injection with the medication from the vial retreived from the biohazard container.


On 1/4/17 an unannounced visit was made to the hospital to investigate the complaint made by Patient #1. During the entrance conference with the Chief Executive Officer (CEO) at 9:10 a.m. and with the Chief Nursing Officer (CNO) the Director of Quality Management and the Director of Risk Management at 9:20 a.m. the nature of the investigation was discussed.


Review of Patient #1's ED record revealed that she arrived at the ED on 12/17/16 at 11:03 p.m. with the complaint of a headache which began one (1) day ago. Triage was completed at 11:15 p.m. The ED physician examined the patient and ordered: Toradol 60 mg (milligrams) IM (Intramuscular); Compazine 10 mg IM; and Benadryl 50 mg orally. The patient's diagnosis was Migraine Headache. RN #1 was the primary nurse and documented giving the patient Benadryl 50 mg orally at 11:40 p.m. She gave the patient Toradol 60 mg IM in the right gluteus at 11:41 p.m. and Compazine 10 mg IM in the left gluteus at 11:41 p.m. The pain had decreased on 12/18/16 at 12:04 a.m. and the patient was discharged home at that time.


On 1/4/17 at 1:11 p.m. a call was placed to the complainant. A message was left on voice mail requesting she return the call. The complainant failed to return the call.


In an interview on 1/4/17 at 12:40 p.m. the hospital CEO stated that he was aware of the incident where two (2) ED nurses removed a vial of Toradol from a biohazard container and gave the medication in an injection to the patient.


On 1/4/17 at 3:10 p.m. an interview was held with the ED Director to discuss the incident. She stated that she was aware of the incident and that ED procedures had been changed since the incident had occurred.


Review of a typed statement signed by the ED Director on 1/4/17 revealed, "On 12/29/16 ...Clinical Director and I spoke with (RN #1) related to a complaint that Risk Management received from (Patient #1) on 12/21/16. (Patient #1) reported that she felt she was given medication that had been accidently dropped in the sharps container and then retrieved and given to her by (RN #1).
I questioned (RN #1) if she knew why (Patient #1) would be complaining about her care on 12/17/16. She couldn't remember the patient. I informed (RN #1) that (Patient #1) felt she had been given medication that might have been removed from the sharps container and asked if she knew anything about it.
(RN #1) stated that she had accidentally dropped the vial of Toradol in the sharps container and that she did retrieve the unopened vial from the container and gave the medication to the patient. She stated that the vial was unopened in the container and was sealed. (RN #1) stated she removed the sharps container from the wall with the key from the accu dose and took the container into the hall to retrieve the medication.
I informed (RN #1) that this was unacceptable practice and it was a safety risk to her and it also made the patient feel unsafe in her care. I informed (RN #1) that this corrective action would serve as a written warning and this type of behavior must not continue or I would have to precede and escalate to further corrective action which could result up to suspension or termination. (RN #1) was told to always follow policy and procedure for wasting of medications and for infection control."

Review of an "Employee Counseling/Disciplinary Action Notice" for RN #1, signed by the ED Director and dated 12/28/16, revealed:
"Action Taken: Written Warning
Discussion: On December 21st we received a complaint from (Patient #1) who stated she had been given an injection from a vial that she felt was not safe for administration. She felt it had been removed from a sharps container.
Corrective Action Recommended: This practice is not acceptable and should not continue. Patient safety and security should always be the top focus. Always follow the policy for wasting and discarding any medication unable to be given.
This counseling or warning will be made part of your employee record. Continuation of behavior identified herein will subject you to further disciplinary action, up to and including termination."



Review of another typed statement signed by the ED Director on 1/4/17 revealed: "On 12/21/16, Risk Management received (a complaint) from (Patient #1) related to her visit on 12/17/16. (Patient #1) reported that she felt that she was given medication that had been accidently dropped in the sharps container and then retrieved and given to her by (RN #1). (Patient #1) also stated that a tall male nurse helped her get the sharps container off the wall.
(RN #2) a PRN (as needed) staff member, was the nurse involved. I was able to make phone contact with (RN #2) this morning, but related to his work schedule at his primary job have not had a formal meeting at this time to discuss the above incident. (RN #2) did state however that he and (RN #1) had removed the key to the sharps box from the accu dose and removed the sharps box from the patient's room. (RN #1) had retrieved the medication and then she went to administer the medication since the vial was closed and sealed.
I informed (RN #2) that the medication should have been wasted and he should have been a witness to the waste and not a participant in unacceptable behavior. He agreed that he did not make the best decision and that this would not happen again.
I informed (RN #2) that he would receive a written warning concerning this practice and we are scheduled to meet on Friday."


Review of an "Employee Counseling/Disciplinary Action Notice" for RN #2, signed by the ED Director and dated 12/28/16, revealed:
"Action Taken: Written Warning
Discussion: On December 21st we received a complaint from (Patient #1) who stated she had been given an injection from a vial that she felt was not safe for administration. She felt it had been removed from a sharps container.
Corrective Action Recommended: This practice is not acceptable and should not continue. Patient safety and security should always be the top focus. Always follow the policy for wasting and discarding any medication unable to be given.
This counseling or warning will be made part of your employee record. Continuation of behavior identified herein will subject you to further disciplinary action, up to and including termination."


Review of a memorandum sent to ED staff on 1/4/16 by the hospital's CEO regarding sharps container keys revealed, "Effective immediately the key to the sharps containers will no longer be kept in the Emergency Room. In the event a patient with suicidal intentions presents to the Emergency Room, the nursing supervisor should be notified to come to the Emergency room and remove the sharps container from the room."


On 1/5/17 at 9:15 a.m. an interview was held with RN #1 to discuss the incident. She stated that she had taken two (2) vials of medication into the patient's room and had inadvertently thrown the closed vial of Toradol into the biohazard container attached to the wall. She stated that she had gotten the key to the biohazard box from the charge nurse, but did not tell the charge nurse what she was going to do with it. (RN #2) helped her retreive the Toradol from the container. RN #1 stated that the vial of Toradol was sealed and sitting on top of the other contents in the container. "I felt the medication was not contaminated and I got it out." She cleaned the top of the vial and gave the medication to the patient. When asked what she would do if the same situation occurred in the furture RN #1 stated that she would administer the medication from a different vial.


On 1/5/17 at 9:20 a.m. an interview was held with RN #2. He confirmed that he had helped RN #1 retreive the medication from the biohazard container.


On 1/5/17 at 9:21 a.m. a video of the incident in the ED on 12/17/16 was viewed. The video showed that RN #1 entered Patient #1's room at 11:31 p.m. with medications. At 11:36 p.m. she left the room then returned to the room. At 11:37 p.m. RN #2 removed the biohazard container from the patient's room and was seen sitting in a chair at the nurses station at 11:38 p.m. At that time RN #1 removed an item from the biohazard container and returned to the patient's room. At 11:39 p.m. RN #2 returned to Patient #1's room and put the biohazard container back on the wall.



On 1/5/17 at 9:30 a.m. the Director of Risk Management stated that the key to biohazard containers was kept in the ED at the suggestion of Joint Commission for quick removal of the container in an ED room where patients had mental health issues.



Review of the facility's "Hazardous Materials and Waste Management Plan" (Revision Date 1/12/2016) revealed: ... II. Scope: The Hazardous Materials and Waste Management program is designated to address the risks the variety of substances addressed in this plan pose to the environment to (the hospital) and to patients, staff and visitors of the organization. The program is also designated to assure compliance with applicable codes and regulations.
III. Fundamentals: ... F: Segregation of hazardous waste at the point of generation is an effective means of controlling the potential for exposures or spills during collection, transport, storage and disposal.
IV. Objectives: ...C. The Hazardous waste program include... Bio hazardous waste, sharps and other physical hazards...
VI. Process for Managing The Risks: ...Patient Safety - The Safety Officer is responsible for working with the individual responsible for patient safety... Orientation, Training, and Education ....Employees also receive departmental safety orientation at their respective work areas regarding hazards and their responsibilities to patients, visitors, and co-workers..."



The Complaint that the hospital failed to ensure that all medications given to Patient #1 were prepared and administered in accordance with accepted standards of practice was substantiated.