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Based on facility policy review, record review, and interview, the facility failed to ensure medications were administered as scheduled for two patients (Patient #11 and #12) of three patients observed for medication administration. The facility census was 122.
Findings included:
1. Review of the facility policy titled, "Medication General Information", revised 1/08, gave direction, in part, to include the following:"All routinely ordered medications should be given within 60 minutes before or after the scheduled time; however, nursing judgment may allow some variance, depending on the medication involved."
2. Review of current Patient #11's medical record on 1/5/10 at 9:25 a.m. showed the following medication was not administered on time:Piperacillin-Tazabactam (antibiotic) 3375 mg (milligram) vial IV (intravenous [administered through a vein]) scheduled to be given at 6:00 a.m. was given at 6:44 a.m. on 1/5/10.
3. Review of current Patient #12's medical record on 1/5/10 at 10:30 a.m. showed the following medications were not administered on time:Valsartan (medication to treat high blood pressure) 80 mg tab (tablet) orally scheduled to be given at 9:00 a.m. was given at 7:53 a.m. on 1/5/10.Aspirin 81 mg tablet orally scheduled to be given at 9:00 a.m. was given at 7:53 a.m. on 1/5/10.Imdur (medication to prevent chest pain) 30 mg tablet orally scheduled to be given at 9:00 a.m. was given at 7:54 a.m. on 1/5/10.Folic Acid (Vitamin B9) 1 mg tablet orally scheduled to be given at 9:00 a.m. was given at 7:53 a.m. on 1/5/10.Comtan (medication to treat Parkinson's Disease) 200 mg tablet orally scheduled to be given at 9:00 a.m. was given at 7:53 a.m. on 1/5/10.Cardizem (medication to treat high blood pressure) 60 mg tablet orally scheduled to be given at 9:00 a.m. was given at 7:53 a.m. on 1/5/10.Sinemet (medication to treat Parkinson's Disease) 25/100 one tablet orally scheduled to given at 9:00 a.m. was given at 7:53 a.m. on 1/5/10.Antivert (medication to treat vertigo [dizziness]) 12.5 mg tablet orally scheduled to be given at 9:00 a.m. was given at 7:53 a.m. on 1/5/10.
4. During an interview on 1/5/10 at 10:45 a.m., Registered Nurse, shift manager, staff R, stated that medication can be given one hour before or after the scheduled time. Staff R stated that the medication nurse had eight patients so he/she must have started early (why Patient #12 received medications early).
5. During an interview on 1/5/10 at 4:10 p.m., Vice President, Chief Clinical Officer, staff P, confirmed that the policy allowed medication administration one hour before and after the scheduled time. Staff P stated they researched it at the time of writing the policy and had to be realistic.

Based on record review and interview, the facility failed to ensure physician orders were authenticated (signed, dated, and timed) for two patients (Patient #12 and #13) of 27 patients' (18 current patients and nine discharged patients) medical records reviewed. The facility census was 122.
Findings included:
1. Review of the facility's Medical Staff Rules and Regulations, revised 7/04, gave direction, in part, to include the following:"6.2 Verbal and telephone orders must be authenticated by the ordering physician or other practitioner responsible for the patient's care (including the covering physician) within 48 hours.6.3 Authentication consists of electronic signature or written signature at the bottom of the order and the date and time the signature was placed on the order."
Review of the facility's policy titled, "Physician Orders", revised 12/07, gave direction, in part, to include the following:"C.1. Verbal and telephone orders must be authenticated by the ordering physician or other practitioner responsible for the patient's care (including the covering physician) within 48 hours.C.2. Authentication consists of electronic signature or written signature at the bottom of the order and the date and time the signature was placed on the order."
2. Review of current Patient #12's medical record on 1/5/10 at 10:30 a.m. showed the following admitting orders, written on a pre-printed order sheet titled, "Unstable Angina (chest pain) Order Set", set of 2 pages, was signed by the physician but was not dated and timed:"Admit to Dr. FlaimAllergies: PCN (penicillin [antibiotic used to treat infections])Status: Telemetry (heart monitoring)Diagnosis: Chest Pain, COPD (Chronic Obstructive Pulmonary Disease [lung disease]), CHF (Congestive Heart Failure [condition where the heart is not pumping blood adequately])Diet: Cardiac dietRespiratory: Oxygen per nasal cannula (administered through prongs inserted into the nose) at 2 L (liters)/min (minute)Labs: Serial cardiac enzymes (CK [enzyme in blood that elevates with heart damage], CKMB [enzyme that helps determine if damage is from the heart or another muscle], and troponin [protein in blood that elevates with heart damage]); Chem (chemistry) 12 [a panel of blood tests commonly used to help diagnose]; CBC (complete blood count [routine blood tests]); BNP (brain natriuretic peptide [test to help determine how well the heart is working]); ABG (arterial blood gases [test to help determine how well the lungs are working])Other tests: Portable chest x-rayIV fluids: Saline lock (catheter inserted into vein and capped off without fluid infusing) and flush every shiftMedications: Nitroglycerine (medication used to relieve chest pain) 0.4 mg (1/150) 1 tablet sub-lingual (under the tongue) q (every) 5 minutes PRN (as needed) chest pain (up to 3 doses)."
Review of current Patient #12's medical record on 1/5/10 at 10:30 a.m. showed the following telephone order was written on 12/31/09 but was not signed by a physician:"Change Carafate (medication used to treat ulcers) to Carafate Elixir (liquid)."
Review of current Patient #12's medical record on 1/5/10 at 10:30 a.m. showed the following telephone order was written on 12/31/09 but was not signed by a physician:"Vicodin (pain medication) 5/500 mg (milligrams) po (by mouth) q (every) 7 hours PRN (as needed)."
Review of current Patient #12's medical record on 1/5/10 at 10:30 a.m. showed the following telephone orders were written on 1/1/10 but were not signed by the physician:"Atrovent (medication used to improve breathing) 0.5 mg (milligrams)/2.5 ml (milliliters) nebulizer tx (treatment) q (every) 4 hours PRN (as needed)Albuterol (medication used to improve breathing) 25 mg/0.5 ml nebulizer tx q 4 hours PRNGive first dose of Atrovent and Albuterol now."
Review of current Patient #12's medical record on 1/5/10 at 10:30 a.m. showed the following telephone order was written on 1/3/10 but was not signed by a physician:"Foley catheter (tube and drainage system inserted into the bladder to collect urine) as per pt (patient) request."
During an interview on 1/5/10 at 10:30 a.m., Registered Nurse, shift manager, staff R, confirmed the telephone orders for Patient #12 were not signed electronically or on paper.
3. Review of current Patient #13's medical record on 1/5/10 at 2:25 p.m. showed the following admitting orders were written on 1/2/10, signed by the physician, but not timed:"Admit to Dr. Baldwin (surg [surgical]), Dr. DavisonDx (Diagnosis) abd (abdominal) pain / fevervs (vital signs) q (every) 4 hoursBRP (bathroom privileges) IV (intravenous [tubing inserted into the vein for administering fluids and medication]) N.S. (normal saline [fluid]) 75 cc (cubic centimeters)/hr (hour)Rocephin (antibiotic) 2 gm (grams) IVPB (intravenous piggy-back [method of administering medications through the IV]) q (every) dailyTylenol 1 gm p.o. (by mouth) q 4 h (hour) PRN (as needed)Notify (unable to interpret writing) when pt (patient) reaches floorDilaudid (pain medication) 1 mg (milligram) q 4 h IVP (intravenous push [method of administering medication through the IV])"
Review of current Patient #13's medical record on 1/5/10 at 2:25 p.m. showed the following telephone order written on 1/2/10 was signed by the physician but not dated and timed indicating when the physician signed the orders:"NPO (nothing by mouth)Change IV fluids to (unable to interpret writing) at 150 Clarification order for Dilaudid (pain medication) 1 mg q (every) 4 hrs (hours) PRN pain"

Based on observation and interview, the facility failed to ensure medications were secured in one unit of the hospital. The facility census was 122.
Findings included:
1. Review of the facility policy titled, "Patient Care Area Inspections and Audits", revised 4/09, gave direction, in part, to include the following:"Purpose: To determine that medications are properly handled throughout the hospital by performing regular inspections.""Policy: The Director of Pharmacy or qualified, appropriately trained designee shall conduct at least monthly inspections of all areas in the organization where medications are dispensed, administered, or stored.""Notations shall be made concerning the following: Destruction of all opened multi-dose vials at least every thirty (30) days, unless shorter shelf life is indicated in the package insert or on the label.""Corrective actions shall be taken to resolve deficiencies. Immediate action will be taken, when possible."
2. Observation on 1/4/10 at 4:30 p.m. in the obstetrical unit's C-section room (operating room for delivering babies by cesarean section), showed an unsecured room with the door open. On top of the anesthesia cart (medication/supply cart used by anesthesia) was an open vial of Lidocaine (medication used to anesthetize [numb] an area) 20 ml (milliliters). The vial was unsecured and not dated/initialed by the person who opened the vial. Registered Nurse, shift manager, staff N, confirmed this medication was not appropriately secured and marked.
3. Observation further showed that the anesthesia cart was locked. Next to the anesthesia cart, in another supply cart used by anesthesia, a key was found in an unsecured drawer. This surveyor used the unsecured key to unlock and open the anesthesia cart that held the medications. The entire top drawer of the cart held medications, to include controlled substances.
4. During an interview on 1/4/10 at 4:30 p.m., staff N confirmed that this surveyor spent very little time finding this key and unlocking the anesthesia cart. Staff N stated that this room is usually locked but confirmed there was a sign taped to the door stating, "DO NOT SHUT THIS DOOR" and that there was tape covering the lock. Staff N stated that medical technicians usually cleaned this room and confirmed that medical technicians should not have access to medications.
5. During an interview on 1/4/10 at 4:40 p.m., CRNA (Certified Registered Nurse Anesthetist), staff O, stated he/she carried a key for the anesthesia cart but remembered there was an extra key in the other cart.
6. Review of the facility's document titled, "OB (Obstetrical) Cart", dated 12/4/09, showed an inspection was completed by pharmacy. There was no documentation on this document that showed the medications were not secured.
7. During an interview on 1/6/10 at 10:20 p.m., Director of Pharmacy, staff Y, stated that the anesthesia carts are checked once a month by a pharmacy technician. Staff Y confirmed that the anesthesia carts contain controlled substances, are to be kept secured, and should only be accessed by pharmacy, physicians (anesthesiologists), and CRNAs. Staff Y stated that an open vial should be disposed of at the end of that procedure.

Based on observation, interview, and record review, the facility failed to ensure staff follow the facility's internal policies and standard of practice to prevent the risk of transmission of organisms for three patients (Patient #14, #12, and #11) out of eight current patients observed during nursing care procedures and failed to maintain a clean and safe environment with two patient-use mattresses. The facility census was 122.

Findings included:

1. Record review of the facility Hand Hygiene Policy and Procedure, reviewed 4/04, in the Infection Control Manual showed the following (in part):
-Policy: "Hand hygiene is practiced before and after patient care, after removal of gloves, and in accordance to the Standard Precaution guidelines. Adequate supplies are at the sinks. When sinks are not available or hands are not visibly soiled; antiseptic hand gel/rinse may be used."

Review of the facility Policies and Procedures related to the electronic glucose monitoring device, showed the following (in part):
-After performing the blood glucose test with the device, "remove the used test strip(s) and disposable gloves and discard them according to your facility's infection control policy."
-"Cleaning and maintenance of the" blood glucose device "is performed daily and documented on the" blood glucose device "Supplies and Maintenance Log."
Review showed the following blood glucose device cleaning procedure (in part):
-"You may also wipe the surfaces with a soft cloth slightly dampened (not wet) with 70% isopropyl alcohol, full strength. Make sure no streaks remain on the touchscreen."
-If using commercially available pre-moistened cleaning cloths, squeeze off excess cleaning solution or blot on a dry paper towel to remove any excess cleaning solution before cleaning the surface of the meter and base."

Review of the facility's policy titled, "Mobile Computer Care and Cleaning", initiated 3/06, showed direction, in part, to include the following:
- "FLO (mobile computer) devices are wiped down daily and as needed with a hospital-approved disinfectant."
- "Hands are to be washed after procedures and before using the FLO device to prevent contamination."

2. Observation on 1/5/10 at 11:05 a.m. showed Graduate Nurse (GN), staff V, enter Patient #14's room and placed the case containing the blood glucose monitoring device on the patient's top sheet of his/her bed. Staff V donned gloves, removed the electronic blood glucose monitoring device from the case, cleansed the patient's finger, pricked the patient's finger with a test needle, applied a drop of blood from the patient's pricked finger to the test monitoring strip of the electronic glucose monitoring device. While still wearing the same gloves, staff V applied pressure to the patient's pricked finger to contain the blood flow. After performing the blood glucose test, while still wearing the same gloves used to apply pressure to the patient's finger stick area, staff V punched the device buttons to enter information in the blood glucose monitoring device. While still wearing the same gloves, staff V placed the blood glucose monitoring device back in the case, placed the blood glucose monitoring device case directly on the patient's bedside table without placing a barrier between the case and the patient's bedside table. Staff V removed his/her gloves and did not wash his/her hands before picking up the blood glucose monitoring case and placing the case on a shelf on the mobile medication cart. After washing his/her hands, staff V took the case containing the blood glucose monitoring device from the mobile medication cart, removed the blood glucose device and placed it in the "docking station" (to download the test information in to the electronic medical record system.)

During an interview on 1/5/10 at 11:15 a.m., staff V said unit staff are directed to clean the glucose monitoring devices once a day.

During an interview on 1/6/10 at 9:30 A.M. Registered Nurse (RN), Unit Director, staff I, said the night shift staff clean the blood glucose devices. Staff I said staff do not keep a log to document completion of cleaning mobile patient care equipment. Staff I said the cleaning log for the blood glucose monitoring device is maintained in the laboratory.

Review of the laboratory blood glucose device log for 1/6/09 through 1/04/10 showed documentation contained in the log consisted of high and low readings and a statement that the machine is "validated as OK." Review of the log revealed no information showing staff cleaned the blood glucose device daily or in between use of each patient requiring blood glucose testing.


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3. Observation on 1/4/10 at 2:00 p.m. in the Emergency Department's trauma room showed a stretcher mattress with two small open areas in the cover of the mattress. The open areas were confirmed by Registered Nurse, Shift Manager, staff M, who agreed that the open areas prevented thorough cleaning of the mattress.

4. Observation on 1/4/10 at 4:20 p.m. in the Obstetrical unit's C-section room (operating room for delivering babies by cesarean section) showed an operating table mattress with two small open areas in the mattress. The open areas were confirmed by Registered Nurse, Shift Manager, staff N, who agreed that the open areas prevented thorough cleaning of the mattress.

During an interview on 1/6/10 at 8:55 a.m., Infection Control Nurse, staff W, and the Director of Infection Control, staff X, confirmed that mattresses with open areas should be replaced as they cannot be cleaned properly with open areas.

5. Observation on 1/5/09 at 9:00 a.m. showed Licensed Practical Nurse, staff S, administer medications to two patients, Patient #12 and Patient #11. Staff S administered medications to Patient #12, removed trash from the patient's bedside and threw it in the trash can, then completed documentation on the "FlO" (computer on mobile cart used to document patient's record). Staff S did not perform hand hygiene between direct patient care and touching the FLO. Staff S did not clean the keyboard surface of the FLO before wheeling it into the next patient's room, Patient #11. Staff S assisted Patient #11 back into bed, administered the medications, which included holding the patient's cup and straw for him/her to drink from, and then moved the FLO. After performing hand hygiene, staff S assessed the wounds on Patient #11's arm, threw dirty linen in the hamper, and again moved the computer with soiled hands. Staff S did not clean the FLO before leaving Patient #11's room.

During an interview on 1/5/09 at 2:00 p.m., Vice President, Chief Clinical Officer, staff P, confirmed that if the FLO is contaminated with soiled hands, it should be cleaned prior to taking into the next patient's room.

During an interview on 1/6/10 at 8:55 a.m., Infection Control Nurse, staff W, and the Director of Infection Control, staff X, stated that the FLO should be cleaned if it has come in contact with soiled hands.