HospitalInspections.org

Based on observations, interviews and records reviewed the Hospital failed to adhere to their policy for handling of Intravenous solutions and insulin administration.

1.) The Surveyor toured the pre-holding area of the Surgical Suite at 8:10 A.M. on 12/30/2020 and interviewed the Nurse Manager. The Surveyor observed an intravenous solution spiked (prepared) and hanging in a vacant pre-operative holding bay. The Nurse Manager said that the intravenous solutions were prepared by one of the unit's medical assistants however the solution would be administered by the Registered Nurse after the IV was placed.

According to the State Board of Registration of Nursing Advisory Ruling #9204, date of review 5/13/2015, the nurse is not to administer an infusion solution that the nurse has not procured, removed from the sealed container, and prepared.

2.) According to the policy titled "Bedside Medication Verification and EMR Administration Record, when insulin needs to be drawn up from a multi-dose vial the bar code label is placed on the syringe and the single dose is brought to the patient.

The Surveyor toured the pre-holding area of the Surgical Suite at 8:15 A.M. on 12/30/2020 and interviewed RN #3. RN#3 said that if she needed to deliver a dose of insulin in the pre-holding area that she would draw up the medication, check the dosage with another nurse before delivering the insulin to the patient. When asked, RN#3 said that she would need to bring the multi-dose insulin vial to the patient's bedside in order to scan the vial. RN #3 was unaware of how to use the insulin bar code labels that were attached to each multi-dose insulin vial. Because of infection prevention concerns and repeated infections related to multi-dose vials, they are not to be brought to a patient's bedside and then returned to the medication storage area.