HospitalInspections.org

Based on document review and interview, the registered nurse failed to ensure all hazardous substances were removed from the bedside for 1 of 10 patient's (P1).

The cumulative effect of this deficient practice prevented the facility from providing a safe environment by the nursing staff.

Based on document review and interview, the registered nurse failed to ensure all hazardous substances were removed from the bedside for 1 of 10 patient's (P1).

Findings include:

1. Review the policy titled "Hazardous Drugs", Policy and Procedures No. 40-34 S, last reviewed date 08/05/2022, indicated on page 1. Purpose to provide guidelines for the administration of hazardous drugs (HD). Page 2. IV. It is the policy of F1 that HD will be administered, handled, and disposed of in a manner that will protect health care personnel, patients, and the environment from unnecessary exposure to potentially hazardous substances.

2. Review of P1 medical record indicated the patient was ordered to have hemodialysis completed at the patient's bedside on 3/3/2023.

3. MR indicated on 03/04/2023 dialysate was found in patient room located on the counter by the hand washing sink. MR indicated that the dialysate was left at the bedside in anticipation of returning to dialyze P1 later that night. N2 did not return until 03/05/2023 at 1830 hours.

4. MR indicated that P1 had an incident of using dialysate in humidifier on his CPAP on night of 03/04/23. Nurses note dated 03/05/2023 at 2134 hours written by N3 (Registered Nurse) indicated Poison Control contacted regarding the CPAP incident that was reported. Discharge diagnosis on 3/11/23 indicated inhalation of dialysate fluid on P1 CPAP machine.

5. Interview on 04/03/2023 with A7 (Dialysis Manager) at 1330 hours, confirmed that the facility failed to remove the jug of dialysate from patient bedside.