HospitalInspections.org

Based on observation, interview and policy review, the facility failed to ensure expired or unlabeled medication and supplies were removed from immediate use. This deficient practice has the potential to affect all outpatient services and 19 inpatients in the hospital.

Findings include:

Observations on 11/03/21 at 7:30 AM, during a tour of surgery, with operating room (OR) Manager 6, outside the sub-sterile area, the intravenous (IV) sedation cart had three of six culture tubes with the expiration date of 10/30/21. The emergency malignant hyperthermia cart had two zip lock bags with five blood tubes for emergency use. Two gray top tubes expired 09/30/21 and two blue top tubes expired 10/31/21.

Interview on 11/03/21 at 7:30 AM, the OR Manager 6 confirmed expired supplies should not be on the carts for immediate use.

Observation on 11/03/21 at 3:45 PM, during a tour of the radiology department with Director of Radiology 28, in the IV start kit box were two bottles of Lidocaine 400 milligrams (mg)/2 milliliters (ml) with 20 ml of solution, lot # 09-058-DK, expired 09/01/21. Two ampules of Epinephrine 1 mg/1 ml, lot #20204 expired 10/21.

Interview on 11/03/21 at 3:45 PM, the Director of Radiology 28 stated, "there is a process for checking outdates, but it was obviously not being done."

Observation on 11/03/21 at 3:55 PM, during a continued tour of the radiology department with Director of Radiology 28, in a cabinet for immediate use, was an open vial of Marcaine 0.5% injectable, labeled "single use" on the shelf in the cabinet available for use. Lidocaine 2% injectable, 13 vials expired 09/01/21.

Interview on 11/03/21 at 3:55 PM, the Director of Radiology 28 stated, opened single use vials should be discarded, and confirmed the process for checking outdates, was obviously not being done.

Observation on 11/04/21 at 8:15 AM, of the medical/surgical unit drawer, were six unlabeled syringes filled with a clear liquid. Also, in the drawer were vials of Normal Saline (NS).

Review of the facility's policy titled, "Administration of Medication" dated 01/30/20, revealed the policy does not include staff responsibility with expired medication or supplies.

Interview on 11/04/21, the Interim Chief Nursing Officer 1 confirmed that there was no policy on expired medications and supplies.

Observation on 11/04/21 8:15 AM, six unlabeled syringes in a drawer with a clear liquid. Also in the drawer were vials of Normal Saline (NS).

Interview on 11/04/21 at 8:15 AM, Registered Nurse (RN) 26 said that the hospital has run out of NS in prepacked syringes that they get from pharmacy. RN26 stated that he/she was told by pharmacy that he/she could draw up the NS. RN 26 stated that he/she had two more syringes of NS in his/her scrub top pocket.

Review of facility's policy titled, "Pre-Packaging Medications", dated 08/27/20 revealed, "Since the pharmacy cannot always purchase drugs in unit dose or in the final packaging configuration that is required for our needs, it becomes necessary for some drugs to be Pre-Packaged or Re-Packaged to meet our patient's needs. Therefore, it is the policy of Humboldt General Hospital that Pre-Packaged Medication Conform to current USP (United States Pharmacopeia) standards. Procedure: Drugs pre-packaged or re-packed by the pharmacy will be labeled with the following information: drug name, strength or concentration, quantity, manufacture and lot number, date prepared, expiration date (aka beyond use date) that corresponds to the ISP [International Standards for Phytosanitary] packaging standards, any precautionary stickers or other pertinent information, an internal lot or control number that corresponds to the record of this drug being pre-packaged or re-packaged, all such packaging of drugs will be logged & recorded to meet USP Packaging Standards."

Interview on 11/04/21 at 11:55 AM, the Pharmacy Director 18, stated that he/she did not tell nursing staff to draw up NS in advance to use. Pharmacy Director 18 stated that if a nurse "pulled a medication from a vial it had to be for immediate use and that if nurses did not use it immediately it must be disposed of."



30958

30958

Based on observation, document review, and interview, the facility failed to ensure that the system implemented to minimize the risk of medication administration errors was being used as intended by nursing staff. Failure to scan the patient's wristband when administering medication has the potential to contribute to medication errors and possible adverse patient events for the 19 current inpatients.

Findings include:

During an observation of medication preparation and administration on 11/02/21 at 8:10 AM, Preoperative Registered Nurse (RN)20 stated, "I use the scanner, but the medication scanner system can be overridden."

Review of a facility document titled, "Medication Barcode Scanning % for Past 30 Days" for the period of time between 10/05/21 to 11/03/21 revealed the patients' wristbands were scanned 74.4 percent of the time when nurses on the medical patient care ("Med/Surg") unit gave medications to the patients.

During an interview on 11/04/21 at 11:55 AM, the Pharmacy Director stated nurses are supposed to contact the pharmacy if there are any concerns with the scanner not functioning correctly during medication administration and the pharmacy will check if the medication was discontinued, the dose was changed, if it is the incorrect medication, or if it is an issue with the scanner. The Pharmacy Director confirmed the 74.4 percent shown on the "Medication Barcode Scanning % for Past 30 Days" report included the times pharmacy was notified of an issue with the scanner and reviewed the medication. The report indicated that 25.6 percent of the time a medication is given to a patient the nurse does a scanner "over-ride" which means the correct medication, time, and patient are not identified by the medication administration system. The Pharmacy Director stated scanning a patient's wristband when giving medications is done to minimize the chance of a medication error and he/she would expect the percent of time the patient's wristband is scanned when giving medications to be in the 90th percentile.

During an interview on 11/04/21 at 12:30 PM, the Interim Chief Nursing Officer (CNO) stated the facility expectation is the patients' wristband will be scanned by the nurse prior to giving medication and confirmed it would be possible for medication errors to occur if the nurse did a scanner "over-ride." The Interim CNO was not able to locate a policy that addressed the use of the scanner during medication administration.

30958

Based on observation, interview, and policy review, the facility failed to ensure infection prevention and control practices were implemented for four of four patients' (Patient (P) 7, P8, P14, and P21) care observations on the medical unit and for one of one patient (P1) observation in the operating room suite. This failure had the potential for cross contamination and spread of infectious disease among all current patients receiving care on the medical unit and in the operating suites.

Findings include:

1. Observation on 11/03/21 at 7:55 AM, showed Certified Nurse Aide (CNA) 14 pushed a data scope (term used by the facility to describe the stand which contains a thermometer, blood pressure machine), and oximeter (device placed on a finger that provides information about a patient's pulse and oxygen saturation level) into P8's room and placed an oximeter on P8's finger. CNA14 completed taking P8's vital signs, removed the oximeter from P8's finger, and left the room without cleaning the oximeter. CNA14 was then observed going into the room of P7 and placed the same oximeter on P7's finger. After taking P7's vital signs, CNA14 removed the oximeter from P7's finger, and left the room without cleaning the oximeter.

During an interview at the time of the above observation when asked if the oximeter should be cleaned between each patient CNA14 stated, "I clean it before starting to take the vital signs of patients on the unit and again after I finish taking all the vital signs." CNA14 stated he/she was not aware the equipment should be cleaned in between checking vital signs of each patient.

During an interview on 11/03/21 at 9:15 AM, the Interim Chief Nursing Officer stated the oximeter should be cleaned between each patient's use.

Review of a facility policy titled, "Infectious Disease Control Policy," dated 01/24/20, revealed, "Data scopes need to be cleaned between each patient use to prevent potential cross contamination."

2. Observation on 11/03/21 at 8:15 AM showed the Physical Therapist (PT) and Physical Therapy Assistant (PTA) did not complete hand hygiene in between glove changes when providing wound care to P21's right leg. The PT was observed removing the dressing covering P21's right leg with gloved hands. The PT then removed the gloves and without performing hand hygiene donned a new pair of gloves. The PT completed wound debridement by removing small pieces of dead tissue on the edges of the wound with a tweezers and placed each piece removed onto a four inch by four-inch (4x4) gauze. The PT removed the gloves and donned a new pair of gloves without completing hand hygiene in between. The PT had the PTA placed a bed protector under the patient's right leg and poured a small amount of normal saline over the wound. While the PT was cleaning the wound, the PTA was observed opening wound supplies on the bedside table which the PTA had covered in paper towels. The PTA removed the gloves and without performing hand hygiene, donned a new pair of gloves and began opening individual packages four-by-four gauze. The PTA opened the gauze further so that the length totaled eight inches. The PTA then opened a package of Adaptic (a non-adherent silicone wound dressing), and the PT removed the Adaptic from the package and placed it on the P21's right leg wound. The PT removed the gloves and without performing hand hygiene, donned a new pair of gloves and covered the Adaptic with the gauze and taped the gauze in place.

During an interview on 11/03/21 at 12:10 PM, when asked should hand hygiene be performed after removing gloves and before donning new gloves, the PT stated, "I guess I got a little fuzzy on that." The PT also stated he/she "remembered getting trained" on completing hand hygiene after removing gloves and before putting on new gloves.

Review of a facility policy titled, "Hand Hygiene" dated 06/11/20, revealed, "Hand hygiene indications include: ... before donning gloves ... After removing personal protective equipment including gloves."

3. Observation on 11/03/21 at 9:00 AM with the Operating Room (OR) Manager, of surgical suite 2 being set up for P1, Surgical Assistant (SA) 22 was opening the sterile field without the sterile gown properly secured at the waste. This caused the gown to fall forward onto the sterile field as the sterile supplies were placed on the sterile field. At 9:05 AM, the OR Manager walked over and told SA22 to tie the sterile gown.

During an interview on 11/03/21 at 9:07 AM, the OR Manager confirmed that the sterile surgical attire must be worn to protect the sterile field.

Observation of P1's surgical procedure for insertion of a pacemaker on 11/03/21 from 9:41 AM until 10:36 AM, procedure, revealed Surgical Equipment Representative (SER) wearing short sleeved surgical scrubs and was observed within 3-6 inches of the sterile field using his/her right bare arm to reach over the sterile field to point out needed equipment to SA22.

During an interview on 11/03/21 at 12:15 PM, when asked about the SER's proximity to the surgical field and having a bare arm directly over the sterile field, the OR Manager stated, "that most equipment representatives have a laser pointer to avoid being so close to the sterile field. The OR Manager stated being that close and having a bare arm over a sterile field does not meet Association of peri Operative Registered Nurses (AORN) standards or hospital policy.

Review of a facility policy titled, "Sterile Field-Preparing, Maintaining, and Monitoring" dated 08/30/21, revealed, "A sterile field will be prepared for patients undergoing surgical and other invasive procedures. All perioperative personnel moving within or around a sterile field will do so in a manner that prevents contamination of the sterile field ... Perioperative personnel will observe for, recognize, and immediately correct breaks in sterile technique when preparing, performing, or assisting with operative or other invasive procedures, and will implement measures to prevent future occurrences."

4. Observation on 11/03/21 at 9:49 AM, at the start of P1's surgical case for an insertion of a pacemaker started, the Surgeon and SA22 were not wearing eye protection and did not wear eye protection throughout the case.

During an interview on 11/03/21 at 12:15 PM, the OR manager stated that the Surgeon and SA22 should have been wearing eye protection.

During an interview on 11/04/21 the Chief of Staff, when asked about if the surgeon should wear eye protection, the Chief of Staff stated that the medical staff have to comply with the medical staff by-laws that require them to be compliant with all state, federal laws, and regulations, and follow hospital policy and confirmed the expectation that eye protection should have been worn.

Review of a facility policy titled, "Surgical Attire" dated 08/04/19 revealed, "Protective eyewear or face shields are worn whenever activities could place one at risk for a splash to the face or eyes."