HospitalInspections.org

C-0914

485.623(b) Standard: Maintenance

Based on observation, interview and record review, the facility failed to provide ongoing preventive maintenance (PM) according to manufacturer's guidelines for 1 of 24 sampled pieces of medical equipment. This item was used for reprocessing of Endoscopy scopes (devices used to examine body cavities and organs). This had the potential to affect all individuals receiving scope exams.

Findings include:

Observation on tour of the surgical department on 7/14/21 at 2:30 PM revealed that the Medivator Reprocessing Machine did not have any type of inventory sticker indicating date of last PM. There was a green round sticker without any valid information on it.

Review of the PM care equipment log revealed that the Medivator Reprocessing Machine did not have a sheet available in the logging system.

Interview with Bio-electronic representative on 7/15/21 at 10:30 AM confirmed that there was no record of PM for the Medivator Reprocessing Machine.

C-1016

485.635(a) (3)

Based on staff interview and observation, the facility failed to ensure that drugs and biologicals were managed in a manner that is safe and appropriate, and to ensure that outdated drugs and biologicals were not available for patient use.

Findings are:

A. Observation during tour of anesthesia and surgical areas on 7/14/2021 at 2:00 PM and 7/15/21 at 8:14 AM revealed, the following items available for patient use:

*2 vials of Metoclopramide (anti-nausea medication) 10mg/2ml with expiration dates of 5/2021 in the Anesthesia medication cart.
*A King Airway Device with an expiration date of 5/10/2021
*An Insufflation Tubing Set with an expiration date of 5/16/2021 in a Gallbladder Surgical Case Kit.
*An Endopath verses needle with an expiration date of 7/2019 in the same Gallbladder Surgical Case Kit.

Staff Interviews on 7/14/21 at 1430 with CRNA (Certified Registered Nurse Anesthetist) and Surgical RN, and 7/15/21 at 8:15 AM with Central Supply Staff member confirmed that the above items were expired and available for patient use, and staff were uncertain who was responsible for the Anesthesia Cart supplies.

C-1049 Nursing Services

485.635 (d)(3)


Based on observation, staff interviews, policy review, employee file review and record review, the facility failed to have a policy that was written in accordance with State laws and Federal regulation, staff failed to administer Intravenous (IV) medication according to State law, the facility failed to competency test staff according to State law and the facility failed to have accurate medication administration in the Electronic Medication Administration Record (EMAR).

Findings include:

A. Observation of IV push medication administration on patient 14 by LPN on 7/13/2021 at 1:00 PM revealed the following: LPN had medication removed from Pyxis (locked medication delivery system) and had all supplies in a basket in a locked cupboard. Upon entering patient 14's room, the LPN asked the patient's name and date of birth. Two vials of Cefazolin (antibiotic medication) 1milligram (mg) each were removed from basket, both tops removed and tops scrubbed for 10 seconds with alcohol wipe, LPN did not apply gloves. LPN took blunt needle and placed on syringe. 10 milliliters (ml) of sterile water were drawn up into this syringe and put into first vial of Cefazolin to reconstitute (adding sterile diluent to a powder), another 10 ml of sterile water was drawn up and put into second vial of Cefazolin. LPN then scanned the patient bracelet, returned to computer and scanned one Cefazolin vial. LPN then withdrew contents of each Cefazolin vial into one 20 ml syringe. LPN then applied label to the 20 ml syringe and recapped the needle. At this point surveyor asked for a pause for LPN to review order as there were variances in the medication administration directions. Administration instructions read: "Give IV push over 3-5 minutes." Another area read: "For IV Administration reconstitute vial with 10ml of Sterile Water. Once completely dissolved withdraw entire contents for 1 gram dose and administer dose via slow IV push over 1 minutes." The back of the vial had Intra Muscular (IM) directions. LPN reviewed the EMAR and replied, "I know the 3-5 minutes is correct because I work part time in the pharmacy". Medication administration directions were not verified prior to administration. LPN went to patient's side and briefly looked at the Peripheral IV (intravenous line with a short catheter typically placed in a forearm) site on right wrist by pulling back the dressing. LPN cleaned IV port with alcohol wipe for 10 seconds and attached a 10 ml syringe filled with normal saline. LPN pulled back to check blood return and there was none. LPN stated, "This patient never has blood return, we all know that and it works fine", LPN then administered the IV normal saline into the Peripheral IV. LPN then attached the Cefazolin 20 ml syringe and administered over 3 minutes by IV push and removed the 20 ml syringe. LPN then attached another syringe with 10 ml of normal saline and administered over 20 seconds. LPN did not have gloves on at any time during this IV medication administration.

*Record Review of resident 14 order for Cefazolin intravenous antibiotic dated 7/10/21and printed on 7/14/21 read: Administration Instructions: "Give IV push over 3 - 5 minutes" "For IV Administration reconstitute vial with 10 ml of Sterile Water. Once completely dissolved withdraw entire contents for 1 gram dose and administer dose via slow IV push over 1 minutes".

*Review of Skills list for "Intravenous push with IV" received from Vice President (VP) of Patient Care Services (PCS) on 7/13/21 revealed that clean gloves were to be applied.

*Interview with Vice President of Direct Care Services on 7/13/21 at 4:45 PM confirms that LPN should have applied gloves.

B. Facility Policy review of "Medication Management-Administration and Verification" dated 7/2021 indicates under PRIOR TO MEDICATION ADMINISTRATION, Section D. (3) "Verify/Barcode Scanning that the medication and label is correct by comparing against the medication order". Another part of this policy under, PARENTAL (IV) MEDICATION ADMINISTRATION, Section F. (2a) "IVP will be administered utilizing the amount, rate of administration, diluent, and monitoring recommendations as published by the manufacturer and referenced literature. 1. A nurse shall only reconstitute IV push medications, when one of the following occurs: a. There is an emergent need for reconstitution, OR b. A "kit" is provided that includes the diluent, vial and instructions. 1. The instructions will be provided via the electronic medical record (EMR) whenever possible.

*Interview with VP of PCS on 7/14/21 at 12:15 PM confirmed that there were no further policies related to the procedure of IV push medication administration.

*The facility did not follow the protocol as stated above, for order verification or for reconstitution of the medication.

C. Facility Policy review of "RN/LPN Scope of Practice" dated 4/2021 indicates under Section D. "An LPN may provide intravenous (IV) therapy in accordance with their State Laws. 1. NE Nurse Practice Action Section 38-2237."


*LPN interview on 7/13/21 at 1:00 PM revealed that LPN admitted that no management staff member or another RN have observed this LPN administering an IV medication.

*Employee file review of "CHI Health Division competency Assessment Checklist Spring 2021, RN/LPN" dated 5/18/21 lacked any information that indicated IV medication administration competency.

*Interview with VP of PCS on 7/14/21 at 12:15 PM confirmed the facility was unable to locate Skills/competency testing for IV medication administration for LPN.



State Reference and Regulation Requirements below:

Regulation review of 38-227 reveals: 38-2237. Intravenous therapy; requirements. (1) A licensed practical nurse may provide intravenous therapy if he or she (a) holds a valid license issued before May 1, 2016, by the department pursuant to the Licensed Practical Nurse-Certified Practice Act as such act existed on such date, (b) graduates from an approved program of practical nursing on or after May 1, 2016, or (c) holds a valid license as a licensed practical nurse issued on or before May 1, 2016, and completes, within five years after August 24, 2017, (i) an eight-hour didactic course in intravenous therapy which shall include, but not be limited to, peripheral intravenous lines, central lines, and legal aspects of intravenous therapy and (ii) an approved employer-specific intravenous therapy skills course. 9 (2) This section does not require a licensed practical nurse who does not provide intravenous therapy in the course of employment to complete the course described in subdivision (1)(c)(ii) of this section. Source: Laws 2017, LB88, § 69.

Review of Nebraska Department of Health and Human Services 172 NAC 99 reveals: 005.04 LICENSED PRACTICAL NURSE REQUIREMENTS. A licensed practical nurse must practice nursing only under circumstances in which direction is provided by a registered nurse or licensed practitioner.
005.04(A) COMPETENCE. A license practical nurse must exercise competence in providing and directing nursing interventions;
005.04(C) DIRECTION. A licensed practical nurse must provide nursing interventions according to the direction and instructions identified by a registered nurse or licensed practitioner. Direction can be provided by protocols.
007.02(B) INDIRECT SUPERVISION. If protocols are used to provide direction to a licensed practical nurse, indirect supervision by a registered nurse or licensed practitioner is required. This must include: (i) Periodic inspection and evaluation, the frequency of which must be determined by a registered nurse or licensed practitioner;

C-1140

485.639 Condition of Participatioin: Surgical Services

This CONDITION is not met as evidenced by:

Based on observation, staff interviews, policy and procedure review and staff training review, the facility failed to provide surgical services in accordance with acceptable standards of practice by failing to ensure 36 vials of Dantrolene Sodium (a medication used to treat a severe reaction to certain drugs used for anesthesia) were available in immediate operating room areas to meet the potential emergent need of a patient in Malignant Hyperthermia (a severe reaction to certain drugs used for anesthesia) crisis and the facility failed to complete routine Malignant Hyperthermia drills and training.

These findings presented a serious threat to the health and safety of all patients susceptible to Malignant Hyperthermia (MH). The Malignant Hyperthermia Association of United States (MHAUS) stated "High incidence areas in the United States include Wisconsin, Nebraska, West Virginia and Michigan. However, the prevalence of genetic change that predisposes to MH is much higher. About one in 2,000 patients harbor a genetic change that makes them susceptible to MH.

Findings are:

Observation during tour of surgical and anesthesia department on 7/14/21 at 2:45 PM revealed that the Malignant Hyperthermia Kit had 6 vials of Dantrolene Sodium.

Interview with Surgical Nurse on 7/14/21 at 2:30 PM revealed that there were 6 vials of Dantrolene Sodium available and that there were 30 other vials but they had expired so they were disposed of and not replaced.

On 7/15/21 Surgical Nurse and Vice President (VP) of Patient Care Services (PCS) were notified that they needed to order Dantrolene immediately and provide receipt by noon that day. It should be known that there were no surgeries scheduled in the next month and the facility does not provide emergency surgeries. (Facility provided a receipt for their order of 30 vials of Dantrolene Sodium on 7/15/2021 at 11:15am).

Facility policy and procedure for "Malignant Hyperthermia" dated 4/2019 revealed "A Minimum stock of 36 vials of Dantrolene Sodium (Dantrium) is kept in the Surgery Department and immediately available as defined by the MHAUS." The policy also revealed that there was no mention of MH drills and/or training. The policy did not indicated how the MH drills would be conducted or what frequency they would be performed. MHAUS recommends teams perform mock MH drills every year

Interview with CRNA (Certified Registered Nurse Anesthetist) on 7/14/21 at 2:00 PM revealed that it had been "several years" since an MH drill or training had been performed.

Interview with VP of PCS on 7/15/21 revealed that the facility had no evidence of MH training or any drills being completed.