HospitalInspections.org

Based on findings from medical record (MR) review, facility document review, and interview, the corrective actions undertaken by the nursing service after a patient sustained a burn from a warm pack placed on her back (after being heated in a microwave) were only implemented on the hospital's medical/surgical nursing units versus on all nursing units.

Findings include:

--Per MR review, Patient A was admitted to the hospital for a surgical procedure. On day of discharge, 2 days later, Patient A developed a 2nd degree burn on her mid right back from a warm pack prepared by staff that consisted of a moist cloth that had been warmed in the microwave.

--Per interview of the Nurse Manager of the hospital's 3 medical / surgical nursing units on 9/17/14 at 10:15 am, a staff member applied a warm pack to Patient A's back made from moist towels that had been heated in the microwave. The patient developed a burn from the warm pack. After this event all medical / surgical nursing staff (registered nurses, licensed practical nurses, and nurse aids) were educated on appropriate process for applying a warm pack (obtain physician order to use a T-pump) and were instructed to not heat towels in microwave.

--Per interview of the hospital's Risk Manager/Patient Safety Officer on 9/17/14 at 10:25 am, the education to staff was not provided hospital-wide to the rest of the nursing units in the hospital, e.g., the mental health unit.

Based on findings from observation and facility document review, the nursing service did not ensure that staff practice in regards to checking emergency response boxes in the 3 birthing rooms was effective. Also, the hospital's policy and procedure (P&P) in this matter did not address how often the emergency boxes should be checked for currency and completeness.

Findings include:

--Per observation on 9/16/14 at 11:45 am, a "Black Emergency Box" was noted in each of 3 birthing rooms. The black emergency boxes contained medications, equipment and intravenous solutions for use in an emergency.

--Per interview with registered nurses (RNs) #1, #2, and #3 on 9/16/14 at 11:10 am, 11:45 am, and 12:20 pm, respectively, all indicated the black emergency boxes are opened at the beginning of each month and checked for outdated equipment.

--However, per review of the "Black Emergency Box" checklists for emergency boxes 1, 2, and 3, (one box in each birthing room) all were dated as last checked in April (4/24/14, 4/1/14, and 4/1/14, respectively). In addition, box #2 contained 3 items listed as expired, i.e., Naloxone expired on 3/1/14, betadine expired on 6/2014 and epinephrine expired 7/2014. Box #1 also contained 2 items listed as expired on the checklist.

--Per review of the hospital's P&P titled "Emergency Equipment, Checking of," dated 9/2011, it lacked specific instructions regarding a routine frequency at which the staff should be checking the black emergency boxes for currency and completeness.

--During interview with the Obstetrical Unit Nurse manager on 9/17/14 at 12:30 pm, these findings were acknowledged.