HospitalInspections.org

Based on observation, interview, and policy review, the provider failed to ensure medications (meds) had been properly monitored and secured to prevent unauthorized access to them in the following areas:
*Medication disposal in a sharps container by one of one registered nurse (RN) (B) during medication admistration for one of one patient (12).
*One of one randomly observed soiled utility room located on the medical unit.
*Randomly observed sharps containers holding partially used meds in two of two procedure rooms.
Findings include:

1a. Observation on 7/24/18 at 8:10 a.m. in the soiled utility room on the medical floor revealed:
*The room was unlocked and contained several cupboards with a sink and eye wash station.
*In the back of the room was a large red biohazard disposal garbage bin.
*A small shelf was attached to the wall above the biohazard disposal bin.
-That shelf had a sign hanging from it with instructions for the staff to leave the filled sharps waste containers there.

b. Observation on 7/24/18 at 8:30 a.m. of RN B with patient 12 revealed:
*The patient had been placed in isolation for a diagnosis of Clostridium difficile (C-Diff).
-That type of isolation required all staff and visitors to wear personal protective equipment (PPE) when in his room.
*RN B had:
-Prepared to administer the patient his morning medications.
-Put on the appropriate PPE and entered the room with those medications.
-Opened a small package containing his morning dose of Metoprolol and cut it in half.
-Given one-half of the pill to the patient and put the other half inside of a sharps container attached to the wall.
*The sharps container had multiple syringes, medication vials, and needles inside of it.

Interview on 7/24/18 9:30 a.m. with RN B regarding the above observation revealed:
*She stated:
-"He is on isolation and I wasn't sure what to do with the other half of the pill."
-"I didn't think I should take it out of his room."
-"Typically I would have taken it to the med room and put in our medication waste container."
-"We are told not to flush any meds down the toilet. They don't want them in our sewer."
-"I've never been told I can't put meds in the sharps container except for controlled meds, we can't do that."
*She confirmed the above observation in the soiled utility room.
*She stated:
-"Once the sharps containers are full we are supposed to put them on a shelf in the soiled utility room."
-"Maintenance will pick-up the sharps containers from there and put them in a room until the biohazard staff comes to get them."
-"I'm not sure where that room is."
*She confirmed all the staff, patients, and visitors had access to those sharps containers in the soiled utility room until the maintenance staff had picked them up.

c. Observation and interview on 7/25/18 at 9:15 a.m. with RN E of the procedure rooms revealed:
*Both of the rooms had large biohazard sharps containers sitting unsecured on the floor.
*The sharps containers:
-Were approximately 15 gallons in size.
-Had large black lids attached to them that easily slid open and shut.
-Allowed for easy access of the contents inside of them when the lids were opened.
-Contained partially used syringes, vials of meds, and small red boxes containing needles that had been used during procedures.
*She confirmed there were meds in those containers that would have been used for anesthesia purposes.
*Once the containers were full the maintenance staff were responsible to remove them and replace it with a new one.
*The doors were locked when the procedure rooms had not been in use.
-All the surgical, maintenance, and housekeeping staff had access to those rooms.
*She agreed:
-If meds were disposed of in the sharps containers only authorized staff should have access to them.
-Housekeeping and maintenance were not considered authorized staff.
*She stated "These containers are new and are being used by all the regional facilities."

d. Interview on 7/25/18 at 9:50 a.m. with the maintenance technician F regarding the observations inside of the procedure rooms revealed:
*He confirmed:
-The above observations and interviews with RNs B and E regarding the security, handling, and disposing of all the sharps containers in the facility.
-Maintenance and housekeeping were not licensed staff and should not have had access to those meds.

Surveyor: 20031
Interview on 7/25/18 at 10:00 a.m. with the maintenance mechanic revealed only he and three other people in the maintenance department had keys to the holding room for the biohazard waste. He stated the nurses or staff on the floor would notify the maintenance department if they had full sharps containers. They would pick them up and put them in the holding room. He was not aware they had been keeping the full containers in other rooms.

Interview on 7/25/18 at 1:30 p.m. with the director of nursing and nurse manager H regarding the security, handling, and disposing of the meds in the sharps containers revealed they:
*Confirmed:
-The nursing staff had been able to dispose of any partially used medications into the sharps containers.
-The maintenance staff handled the sharps containers when they were full and placed them in a secured area until the biohazardous waste company retrieved them.
*Agreed access to meds should have been limited to authorized staff only.
-Housekeeping and maintenance were not considered authorized staff.

Review of the provider's June 2017 Hazardous Materials/Wastes: Receipt, Handling, Storage and Disposal Of policy revealed:
*"Hazardous materials are broadly defined as any item, substance or mixture of substances having properties capable of producing adverse effects on the health or safety of a human being or the environment. These items include, but are not limited to, materials that are corrosive, ignitable, reactive, toxic, radioactive, sharps, and infectious materials."
*"Hazardous wastes are defined as those wastes which are generated from the use of hazardous material and which may require special handling and/or must be disposed of in other than normal waste streams."
*Confirmed the above process for handling and disposing of the sharps containers after they were full.
*It had not been updated to reflect the process for security, handling, and disposing of the new sharps containers in the two procedure rooms.

Based on observation, interview, and policy review, the provider failed to ensure:
*Hand hygiene was completed for two of three observed patients (12 and 35) during the provision of patient care by two of two observed registered nurses (RN) (B and D).
*Patient use items were protected from possible contamination in:
-Two of two intensive care unit (ICU) rooms.
-One of one whirlpool tub room.
-One of two clean supply rooms located by the whirlpool tub room.
Findings include:

1a. Observation on 7/24/18 at 8:30 a.m. of RN B with patient 12 revealed:
*The patient had been placed in isolation for a diagnosis of clostridium difficile (C-Diff).
-That type of isolation required all staff and visitors to wear personal protective equipment (PPE) when in his room.
*She had prepared to administer the patient his morning medications (meds).
-Several of those meds had been in pill form and remained inside of their original packages.
--Those meds had been placed inside of a paper drinking cup.
-One of the meds required administration through an intravenous (IV) line and was in two separate vials.
*After sanitizing her hands she had put on the appropriate PPE to wear into the patient's room.
-That process had included putting on a clean pair of gloves.
*With those gloves on she had:
-Carried her meds and supplies into the patient's room.
-Placed the meds and IV supplies directly on the patient's bedside stand.
--She had not cleaned, disinfected, or laid a barrier down on top of that stand.
-Moved the computer monitor for better viewing and pulled out the keyboard for easier access.
-Touched the keypad and pulled up the patient's medication list.
-Picked up the scanner and scanned in each of those medications.
-Opened the packages containing his pills, placed them into a med cup, and handed the meds to him.
-Opened two packages one containing a ten cubic centimeter syringe and the other a needle.
-Attached the needle to the syringe.
-Pulled the medication in the vials up into the syringe.
*While she had been priming the syringe/needle some of the medication had dripped onto his bedside table and the floor.
*After she had finished priming the syringe/needle she used an alcohol pad to:
-Clean off the liquid med from the bedside table.
-Wipe-up the med from the floor.
*Without changing her gloves or sanitizing her hands she had:
-Cleansed the IV port with an alcohol wipe and flushed the IV site with normal saline (NS).
-Attached the med filled syringe to the IV port and administered the med.
*RN B:
-Had used the same pair of gloves during the entire process above.
-Removed her PPE and sanitized her hands prior to leaving the room.

b. Observation on 7/24/18 at 9:00 a.m. of RN B with patient 12 revealed she:
*Had prepared to administer an antibiotic through the patient's IV line.
*Had after sanitizing her hands put on the appropriate PPE to wear into the patient's room.
-That process had included putting on a clean pair of gloves.
*With those gloves on had:
-Carried her meds and supplies into the patient's room.
-Placed the meds and IV supplies directly on the patient's bedside stand.
--Not cleaned, disinfected, or laid a barrier down on top of the table.
-Moved the patient's breakfast tray and opened a piece of paper to check his dietary meal order form.
-Removed three IV med bags from the IV pump and placed them in the garbage can.
--She pushed down the contents in the garbage can while disposing of the IV bags.
-Touched the keyboard and pulled up the patient's medication orders.
-Picked up the scanner and scanned in his IV antibiotics.
-Hung the IV antibiotic on the IV pole, opened the IV pump door, and put the IV tubing in place.
-Closed the IV pump door to secure the IV tubing.
-Cleansed the patient's IV port with an alcohol wipe, flushed the IV site with NS, and attached the IV tubing containing the above solution to that port.
-Touched the key pad on the IV pump and entered the appropriate infusion rate for the antibiotic to be administered.
*RN B:
-Had used the same pair of gloves during the entire process above.
-Removed her PPE and sanitized her hands prior to leaving the room.

Interview on 7/24/18 at 3:30 p.m. with RN B revealed she:
*Was not sure the medication observations above had been her usual process.
*Stated "I just wanted to keep everything clean with a surveyor there."
*Had not recognized the following surfaces as unsanitary:
-Bedside table.
-The outside surfaces of the medication and IV supply packages.
-IV med vials and bag.
-Computer monitor.
-The keypad for the computer and scanner to scan in the medications.
-The surfaces of the IV pump.
-The dietary meal order form.
-The contents in the garbage can.
-Old IV solution bags and tubing.
-Breakfast tray.
*Agreed:
-All of those surfaces had not been considered clean and the processes above were not completed in a sanitary manner.
-The care provided for patient 12 had created the potential of cross-contamination of germs to have been transmitted to him.
*Could not remember having a competency review completed on her during mediation administration.

Continued interview on 7/24/18 at 2:40 p.m. with RN D regarding the above observation with RN B revealed she:
*Confirmed:
-The medication administration process provided for patient 12 had not been completed in a sanitary manner.
-That process had created the potential for cross-contamination of germs to have been transmitted to the patient.
*Had not completed any competency reviews/audits with the nursing staff completing medication administration.

2. Observation on 7/24/18 at 2:05 p.m. with RN D with patient 35 revealed:
*She had:
-Prepared to complete a dressing change on the patient's right lower leg stump.
-Gathered all of the necessary supplies to complete that dressing change and placed them on top of a small table.
-Placed a clean barrier underneath of those supplies.
*Several of the supplies remained enclosed inside of their original packages.
*On top of the supply packages she had placed several clean gloves.
*She had:
-Sanitized her hands and put on a pair of the gloves that had been on top of the supply packages.
-Opened a bottle of NS and poured some of it into a plastic container containing clean 4 x 4 gauze pads.
-Removed the old dressing, sanitized her hands, changed her gloves, and cleaned the wound with the gauze pads.
*Prior to applying the new dressing she had removed her soiled gloves, sanitized her hands, and put on another pair of the gloves laying on top of the dressing packages.
*With those gloves on she:
-Opened several of the dressing packages.
-Opened a package containing clean tweezers and used the tweezers to pack the dressing into the wound.
-Covered the wound with a protective dressing that had been inside one of packages that had required opening.
*She removed her gloves and sanitized her hands.

Interview on 7/24/18 at 2:35 p.m. with RN D revealed:
*The above observation had been her usual process for completing wound care and dressing changes.
*She had not recognized the following surfaces as unsanitary:
-The outside surface of the NS bottle.
-The outside surface of the dressing supplies.
*She agreed:
-The wound care and dressing change for patient 35 had not been completed in a sanitary manner.
-That process had created the potential of cross-contamination of germs to have been transmitted to the patient.

3. Interview on 7/25/18 at 2:20 p.m. with the director of nursing (DON) regarding the above observations further supported the interviews with RNs B and D.

On 7/25/18 the following policies and procedures had been requested from the DON:
*Medication administration with a revision date of September 2017.
*Intravenous Therapy with a revision date of 2017 .
*Wound Care Protocol with a revision date of January 2018.
*Review of those policies they had not provided a process for the staff to follow to ensure medication administration and wound care was provided in a sanitary manner.

Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 9th Ed., St. Louis, Mo, 2017, pp. 410 and 411, revealed:
*"Contaminated hands of health care workers are a primary source of infection transmission in health care settings."
*"The CDC (Center for Disease Control) (2002; Who, 2009) recommends the following:
-3. If hands are visibly soiled (WHO, 2009), use an alcohol-based waterless antiseptic agent for routinely decontaminating hands in the following clinical situations:
--c. After contact with inanimate surfaces or object in the patients room (eg., over-bed table)."

Review of the APIC of Infection Control and Epidemiology, 3rd Ed., Volume 1 Essential Elements, 2009, pp. 19-3 and 20-1, revealed:
*Page 19-3: "Use an alcohol-based hand rub unless hands are visibly soiled:
-Before and after direct patient contact.
-After contact with patient's skin.
-After removing gloves.
-After contact with objects and equipment in the patient's immediate vicinity."
*Page 20-1: "Aseptic technique involves using a barrier to prevent transferring microorganisms from the environment during the procedure being performed."

4a. Observation and interview on 7/24/18 from 2:45 p.m. through 2:55 p.m. with RN I revealed:
*There had been clean supply cupboards and closets located inside both of the intensive care unit (ICU) rooms. Those cupboards were unsecured and contained multiple patient use items. Those patient items had been:
-Hospital gowns, sheets, and towels.
-Unpackaged incontinent briefs.
-An unpackaged oxygen saturation monitor that was to have been secured to a patient's forehead.
*She agreed:-There was no guarantee those items had not been contaminated and would have remained clean between patients in the ICU.
-All patient supplies unless secured or packaged should not have remained in those closets/cupboards between patients admitted to that room.

b. Observation and interview on 7/24/18 from 2:56 p.m. through 3:10 p.m. with RN I revealed:
*Inside of the whirlpool tub room there had been several types of equipment stored within approximately two feet of the tub. Those items had been:
-Two mechanical patient transfer lifts.
-An over-the-bed trapeze.
-A standing weighing scale.
-A baby crib.
-Two patient stand-aides.
-A wheelchair.
*She confirmed those had been clean patient use items and would have been taken out of the room to use for patients as needed.
*She agreed:
-The clean equipment should not have been stored in the patient tub room.
-Those items had the potential of being contaminated during the bathing process of patients.
-That process had created the potential for cross-contamination of germs to have been transmitted from patient to patient.

c. Observation and interview on 7/24/18 from 3:12 p.m. through 3:30 p.m. with RN I revealed:
*In the clean supply room located next to the whirlpool tub room contained multiple patient use items. Some of those items had been:
-A cloth mattress and box spring set.
-A large box containing several new patient pillows.
*Both of those items above had been stored directly on the floor of the clean supply room.
*She:
-Confirmed the facility owned the mattress and box spring set. It had been located inside of the hospice suite. It had been replaced for a hospital bed per the patient's needs.
-Agreed both of those patient use items should not have been stored directly on the floor. They should have been stored up off of the floor to prevent contamination.

d. Observation and interview on 7/25/18 from 1:00 p.m. through 1:25 p.m. with RN H and the DON regarding the above revealed:
*They had not been aware of all improper storage of the above patient use items.
*They agreed the storage process above for those patient use items had crated the potential for germs to spread from one patient to another.

On 7/25/18 at 6:30 a.m. a policy for the proper storage of patient use items had been requested from the DON. The surveyor was not provided a policy for that process prior to exit from the facility on 7/25/18 at 5:00 p.m.