HospitalInspections.org

Based on observation, interview and record review, the hospital failed to ensure that drugs and biologicals were administered in accordance with approved medical staff policies and procedures or accepted standards of practice, in 1 of 1 medication administration observations conducted (RN Q).

Findings include:

On 4/27/15 at 4:20 p.m., observations were made of RN (Registered Nurse) Q administering intravenous narcotic pain medication [Morphine sulfate 2 mg. by IV (intravenous) push] to Patient #1. RN Q had 3 syringes, 2 normal saline flush syringes and 1 syringe filled with the IV pain medication. RN Q was observed to clean the needleless connector with alcohol pad, allow alcohol to dry, and attach saline flush syringe to port and inject the normal saline into the IV tubing. Q then disconnected the saline syringe and without benefit of (alcohol) needleless connector access port disinfection, connected the syringe containing the pain medication to the needleless connector port, administering the medication. Q then disconnected the medication syringe, and without benefit of needleless connector disinfection to the access port, connected the second normal saline syringe and infused the normal saline to flush the pain medication away from the needleless connector port. Q failed to cleanse the needleless connector's access port, when injecting the pain medication and second normal saline syringes used.

During interview with Chief Nursing Officer R at 4:30 p.m. on 4/27/15, R stated that "nursing staff had been re-educated on the intravenous medication policy".

Record review of the hospital's nursing inservice training document on 4/27/15 at 4:30 p.m., "Infection Control Update dated 4/14/15" states under " 5. Scrub catheter hubs on intravenous (IV) catheter ports with alcohol before accessing..." .