HospitalInspections.org

The Condition of Participation for Patient's Rights is not met, the hospital failed to protect patient's rights to receive care in a safe manner.


Findings included:


A facility nurse (Staff #8) did not follow basic infection control policies and standards of practice. Staff #8 re-used single-use Normal Saline Flush syringes on multiple patients throughout Staff #8's 18 months of employment at the facility. This practice exposed over 550 former patients to infectious disease. The facility did not complete the required retraining of all nurses concerning the reuse of saline flushes. Cross refer Tag A 144.

Based on interview and record review the facility failed to protect patient's right to receive care in a safe manner when 2% the nursing staff had not received training on the re-use of saline flushes.

Findings included:

During an interview on 11/24/15 at 10:00 a.m., in the conference room, Staff #1, Senior Director of Nursing, stated that 65% of the nursing staff had completed a mandatory online training in-service on the Policy and Practice Review of IV maintenance. Staff #1 stated the completion date for all staff is 11/27/15. Staff #1 stated no staff will be allowed to work until they have completed the training, including agency staff. Staff #1 stated even a nurse on leave returning after 11/27/15 came in, prior to her return to work date, to complete the mandatory in-service.

Review on 11/24/15 of the facility provided training material, Policy and Practice Review-IV maintenance procedures reflected:
Adult intermittent medication administration flush sequence (hub should be scrubbed for 15 seconds, with alcohol, before connection):
-Flush with at least 3 ml from 10 ml prefilled syringe and discard
-Administer medication as ordered and discard
-Flush with at least 3 ml from a second 10 ml prefilled syringe and discard

Review of the facility provided statistics for in-service completion reflected the Medical Surgical Units were 98% completed. A total of 311 nurses had completed the in-service in a two week time period, 4 nurses were still in progress and 165 nurses were registered to take the mandatory training.

During an interview on 11/24/15, in the conference room, at 10:30 a.m. Staff #2, Quality Director for South Market, stated the facility was conducting IV practice/flushing survey audits.
She stated there was confusion the first two days of the audit as to how many audits were to be conducted but it was quickly resolved.

Review on 11/24/15 of the facility IV practice/flushing audits reflected 5 audits per unit/ per shift for 11/20, 11/21, 11/22, and 11/23/15; including 34 instances where staffs received review on infection control practices and documentation.

Based on interview, and record review, the facility failed to implement a systemic plan to ensure that all staff nurses were retrained on the use of single-use syringes appropriately.


Cross refer Tag A 749.

Based on interview and record review the facility failed to provide care in a sanitary environment when 2% the nursing staff had not received training on the re-use of saline flushes.

Findings included:

During an interview on 11/24/15 at 10:00 a.m., in the conference room, Staff #1, Senior Director of Nursing, stated that 65% of the nursing staff had completed a mandatory online training in-service on the Policy and Practice Review of IV maintenance. Staff #1 stated the completion date for all staff is 11/27/15. Staff #1 stated no staff will be allowed to work until they have completed the training, including agency staff. Staff #1 stated even a nurse on leave returning after 11/27/15 came in, prior to her return to work date, to complete the mandatory in-service.

Review on 11/24/15 of the facility provided training material, Policy and Practice Review-IV maintenance procedures reflected:
Adult intermittent medication administration flush sequence (hub should be scrubbed for 15 seconds, with alcohol, before connection):
-Flush with at least 3 ml from 10 ml prefilled syringe and discard
-Administer medication as ordered and discard
-Flush with at least 3 ml from a second 10 ml prefilled syringe and discard

Review of the facility provided statistics for in-service completion reflected the Medical Surgical Units were 98% completed. A total of 311 nurses had completed the in-service in a two week time period, 4 nurses were still in progress and 165 nurses were registered to take the mandatory training.

During an interview on 11/24/15, in the conference room, at 10:30 a.m. Staff #2, Quality Director for South Market, stated the facility was conducting IV practice/flushing survey audits.
She stated there was confusion the first two days of the audit as to how many audits were to be conducted but it was quickly resolved.

Review on 11/24/15 of the facility IV practice/flushing audits reflected 5 audits per unit/ per shift for 11/20, 11/21, 11/22, and 11/23/15; including 34 instances where staffs received review on infection control practices and documentation.

Review of the facility provided IV practice/flushing survey reflected:
VISUAL INSPECTION:
IV type
IV hub scrubbed at least 15 seconds with each access?
IV flushed with proper volume of normal saline for device?
If medication given, was proper protocol (flush, discard, med, discard, flush, discard) followed?
DOCUMENTATION:
IV flush documented where?
Is there any re-use of single-use devices noted, or any deviance from policy (with the exception of incremental dosing)? (If yes, explain in comments)
Review of the facility provided CDC Injection Safety Guidelines reflected; one needle, one syringe, only one time; once they are used, both the needle and syringe are contaminated and must be discarded; a new sterile needle and a new sterile syringe should always be used for each patient and to access medication vials.