HospitalInspections.org

Based on observation, interview, guideline review, and policy review, the provider failed to:
*Ensure medications (med) stored in multiple Sharps containers in the ambulance garage area had been properly monitored and secured to prevent unauthorized access to them.
*Have a consistent process for med disposal and documentation for staff to follow.
Findings include:

1. Interview on 12/3/19 at 8:15 a.m. with pharmacist C regarding med disposal revealed she:*Was unsure how the nurses disposed of partially used or refused patient medications.
*Thought they probably flushed them down the toilet, but she was uncertain.
*Indicated controlled meds should have been disposed of with a witness.
-That disposal should have been documented.
*Was not aware of the disposal and documentation process of non-controlled meds by nursing.

Interview on 12/3/19 at 8:35 a.m. with registered nurse (RN) A regarding med disposal revealed:*She would have put refused or partially used patient meds into the Sharps containers.
*Liquid meds were disposed of down the sink drain.
*If a med was controlled there should have been another nurse to witness that disposal.
-If only a partial dose of a controlled med was needed then two nurses documented the amount that was disposed of.
*There was no documentation to support how non-controlled meds were disposed of when they were partially used or refused.
-They would have only documented in the electronic medical record (EMR) the patient refused the meds.
*She was not sure what the process should have been for documentation of med disposal.

Observation and interview on 12/3/19 at 8:50 a.m. with RN B regarding med disposal revealed:
*She put refused or partially used patient meds into the Sharps containers for disposal.
-That included used fentanyl patches.
*The Sharps containers were in each patient room and the emergency room.
*When the Sharps containers were full they were taken to the ambulance garage and put into large plastic biohazard containers.
-Those containers were kept in that garage area until they were picked up by the biohazard disposal company.
*In that ambulance garage the biohazard containers were sitting unsecured near an ambulance by the wall.
*All staff and visitors had access to that unlocked ambulance garage.
*While we were observing the storage area an unidentified biohazard disposal staff person was loading up those full containers into his truck.
-He stated he usually picked up two to four full containers every month from the facility.
*She agreed the Sharps containers held disposed of meds including controlled meds such as fentanyl patches.
-Unauthorized individuals should not have had access to those.
*She stated in the past they had flushed fentanyl patches down the toilet, but they had stopped doing that quite awhile ago.
*There was no process to document the disposal of those used fentanyl patches or when patients refused meds other than the refusal in the EMR.
*They did not specifically document the quantity, dose, or how the meds were disposed of.

Interview on 12/3/19 at 9:25 a.m. with the director of nursing (DON) regarding the above revealed:*She confirmed meds should have been secured from unauthorized individuals at all times.
*The full Sharps containers holding disposed of meds kept in the ambulance garage would not have been secured.
*Medications such as fentanyl patches were a high risk for diversion and should have been disposed of and secured properly.
*She confirmed there was no consistent process for staff to follow for the disposal and documentation of disposal for all meds, and there should have been.
*She was aware the med disposal process needed to be done differently.
-A pharmacy survey done several months ago had also identified the issue.
*She had been looking into potential options for med disposal but had not gotten anything implemented yet.

Review of the provider's revised March 2009 pharmacy policy for Inspection, Removal and Storing of Outdated Medications policy revealed: "Patient medications (Excluding Narcotic drugs) that are outdated or otherwise unusable shall be disposed per sewer systems by (2) licensed professionals."
Review of the provider's revised July 2018 nursing guidelines for Medication Storage and Handling revealed:
*"...To dispose of duragesic patches after they are removed from a patient, fold it in half - sticky sides together - and place in sharps container. Do not toss in wastebasket. PCA [patient-controlled analgesia] syringes with narcotics left in them are wasted per pharmacist and nurse and documented in the Narcotic Record..."
*There was no mention of a process for disposal and documentation of other meds including refused or partially used meds.

Further interview and record review on 12/3/19 at 10:50 a.m. with RN B revealed:*She brought in the above policies and stated:
-The nurses were not following the pharmacy policy for med disposal.
-The nurses had been following the nursing policy for putting the used fentanyl patches into the Sharps containers.
--That policy had not included how those Sharps containers should have been stored securely from unauthorized individuals.
-Neither policy addressed the documentation process for med disposal.
*She brought in another reference from the quality director which was an FDA Drug Safety Communication printed on 12/3/19 that stated:
-"...Used fentanyl patches require proper disposal after use - fold the patch, sticky sides together, and flush it down the toilet right away..."
--She indicated they were not flushing the patches since they had been told meds should not be flushed down the sewer.
*She confirmed the current processes for med disposal were not consistent or secure.

Review of the provider's 11/6/19 Safety Committee notes revealed:
*"[DON] reported that there was a State Pharmacy survey completed 5-29-19. One issue brought up was disposing of liquids, medications, and patches. Investigating what process would work for us that meets the state regulations and is cost effective. 11-6-19 [DON] reports that still investigating what would work best for AWMH [Avera Weskota Memorial Hospital]. [Quality director] will check with some other facilities as to what they are using at her upcoming meeting."
*The drug disposal concern had been identified approximately six months ago and had not been corrected.

Review of the provider's October 2019 Disposal of Sharps policy revealed:
*"Take full container to Oxygen storage room and place in red containers marked Bio-Hazard."
*There was no mention of the ambulance garage or how those biohazard containers would have been secured.

Review of the provider's October 2019 Pharmacy Services policy revealed: "A licensed Pharmacist directs pharmaceutical services including methods and procedures for ordering, storage, administration, disposal and record keeping of drugs and biologicals."

Based on observation, record review, interview, and policy review, the provider failed to ensure the medical records were complete to ensure:
*Interventions for discharge planning had been put in place for two of two sampled acute care inpatients (1 and 10).
*The care plans had included problems not related to the admission diagnosis for one of one sampled acute care inpatient (3).
*Interventions had been documented for one of one sampled acute care inpatient (8) with a low blood glucose level.
Findings include:

1. Observation and interview on 12/2/19 at 3:00 p.m. with patient 1 revealed there was a small glass of thickened water on her overbed table. She stated she:
*Was in the hospital, because she was weak and dehydrated.
*Lived in the attached apartments.
*Had been trying to puree her foods with a chopper, but it did not get the food smooth enough.
*Had not thickened her liquids at home.
*Had been working with physical therapy (PT) and speech therapy (ST).
*Was being discharged on 12/3/19.
*Had not received education on how to puree her food and thicken her liquids at home.
*Knew there was a powder used to thicken her liquids but did not know how much to use or where to buy that powder.

Review of patient 1's practitioner notes on:
*11/30/19 included:
-She had been seen in the emergency department, and then admitted to acute inpatient status on 11/30/19. She had difficulty swallowing, acute dehydration, and weakness.
-She was given intravenous hydration and started on a pureed diet.
-PT and ST consultations had been ordered.
-She also had Parkinson's disease and had been struggling with eating and drinking for the past year.
-Over the past week her ability to swallow had worsened significantly.
*12/1/19 included:
-She had been able to eat 100% of her pureed breakfast.
-She had been feeling anxious as she thought she would have to go to the nursing home.
-She was reassured the plan was to utilize ST, PT, family, and neurology to improve her dysphagia and weakness.
-Was started on a low dose of Xanax for her anxiety as needed once a day.
*12/2/19 included:
-She had been able to drink nectar thick consistency fluids well and consume 100% of her pureed food.
-Her anticipated discharged date was 12/2/19.
*12/3/19 included:
-"Assessment & Plan:
(1) Parkinson disease:
Her hydration and difficulty swallowing were caused by this. This is better. Will discharge and will have Home Health Evaluation. Change diet to nectar thick liquids and Pureed diet.
(2) Anxiety:
Alprazolam prn [as needed] was started. This is because of her Parkinson's. She anxious about eventually going to the nursing home.
(3) Difficulty swallowing:
Due to Parkinson's. So far, changes in diet/consistency of food should help.
(4) Muscle spasm:
I suspect this is also due to Parkinson's. She states this is pretty painful. I will start cyclobenzaprine but I told her about the potential side effects of this too."

Review of patient 1's ST 12/2/19 evaluation treatment diagnosis information revealed: "The patient is a pleasant 82 year old female who was referred for a BSE [bedside swallowing evaluation] secondary to reduced nutritive intake along with history of dysphagia and PD [Parkinson's disease]; patient participated in skilled ST this past spring in which she upgraded to mechanical soft textures and thin liquids; however at this point in time patient reports her swallowing has regressed and she has difficulty with meats; patient reports pureed foods go the best. patient also prefers nectar-thickened liquids."

Review of patient 1's 12/3/19 case management/social services documentation included:
*The assessment and discharge planning had been started on 11/30/19 at 1:54 a.m.
*The only information that had been documented was on 12/3/19 at 10:55 a.m.
*It included:
-Durable medication equipment used-walker.
-Anticipated discharge plan included her anticipated discharge location-home health care.
-Continued discharge planning included additional information of: "Plans are for patient to return home with outpatient ST, Dakota at Home was notified for other services to help keep her at home. Home Health Eval [evaluation] ordered and faxed to Avera at Home. She will need help in planning her meals around pureed food and also will need assist with bathing services."

Review of patient 1's 12/3/19 discharge instructions included:
*Her new medications and her previous medications list.
*Information on her diagnoses of anxiety, dysphagia, and dysphagia diet.

Interview on 12/3/19 at 3:30 p.m. with registered nurses A and B and the director of nursing regarding patient 1 revealed:
*She had been discharged earlier on this day (12/3/19).
*They had reviewed her discharge instructions with her.
*They were unaware if she had any way to thicken her liquids or puree her food.
*There had been no education on how to do those things.
*A home health evaluation had been ordered.
*They anticipated home health would assist her with how to puree her food and thicken her liquids.
*They were not sure when home health had planned to do her evaluation.

2. Review of patient 10's medical record revealed:
*He had been admitted on 9/17/19 with acute pancreatitis and alcohol abuse.
*A 9/17/19 at 7:21 p.m. physician's progress note revealed the physician was going to talk to him about taking naltrexone as an outpatient.
*A 9/19/19 at 1:17 p.m. physician's progress note revealed the physician visited with him about his depression and ordered Prozac. Patient 10 had admitted he had some depression related to his alcoholism.
*Discharge instructions given to him included printed information on:
-Understanding pancreatitis.
-Amylase enzyme.
-Lipase enzyme.
-Discharge instructions for chronic pancreatitis.
*No information had been provided to him in regards to his alcoholism and treatment options.

Interview on 12/3/19 at 3:30 p.m. with registered nurses A and B and the director of nursing regarding patient 10 confirmed no written information had been provided to the patient on alcohol treatment options.

3. Review of patient 3's medical record revealed:
*She had been admitted on 9/17/19 with cellulitis of the right side of her face.
*She had recently, approximately one week ago, given birth.
*An abdominal computed tomography scan showed an enlarged uterus consistent with postpartum state.
*Nursing progress notes from 9/17/19 at 1:09 p.m. through 9/19/19 at 8:00 a.m. revealed:
-No information regarding the recent baby she had, if the baby was staying in the room with her, if the baby had been breastfed, if she had any needs related her postpartum state, and if there had been any side effects from the intravenous antibiotics she had received regarding the baby.
-That her abdomen was soft, non-tender, and flat.
*Her 9/17/19 care plan had problems that included:
-Impaired gas exchange.
-Altered tissue perfusion.
-Fluid volume deficit.
*There were no problems related to the infection, her antibiotic use, and if there had been any concerns in regards to her postpartum needs.

Interview on 12/3/19 at 3:30 p.m. with registered nurses A and B and the director of nursing regarding patient 3 confirmed no documentation had been found in the patient's medical record about her postpartum state. They agreed the care plan did not include any information about her cellulitis, pain, or her postpartum state.

4. Review of patient 8's medical record revealed:
*A blood glucose (BG) level of 52 on 9/24/19. It had been collected by the laboratory at 7:25 a.m.
*A bedside BG of 66 at 11:02 a.m. An intervention of orange juice and crackers with peanut butter was given to the resident.
*A repeat BG of 67 had been completed at 11:25 a.m.
*There was no documentation regarding any assessments, interventions, or response to interventions for her BG of 52, 66, and 67.

Interview on 12/3/19 at 3:30 p.m. with registered nurses A and B and the director of nursing regarding patient 8 confirmed no documentation had been completed for her low BG of 52. They agreed more documentation should have been completed to show the patient's entire assessment.

5. Review of the provider's December 2010 Discharge Planning policy included:
*"Within 24 hours of admission, a hospital must identify each patient's potential need for continuing care following discharge. The facility must initiate planning with applicable agencies to meet identified needs, and patients must be offered assistance to obtain needed services upon discharge."
*"The discharge planning process incorporates:
-A determination of the patient's post discharge hospital care needs.
-The patient's capacity for self-care.
-An assessment of the patient's living conditions.
-The identification of health or social care resources.
-The education of patient or family to prepare them for post hospital care."