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Based on policy review, observation, record review and interview the facility failed to protect the confidentiality of 12 of 12 patient records by maintaining records in folders on an open shelf inside the patient's room by the entry door, making the folders readily assessable to visitors and/or anyone entering the patients' room on the Rehabilitation unit. The facility had a census of 144 and the Rehabilitation unit had a census of 12.

Findings included:

Facility policy titled "Confidentiality of Information", effective 05/14/10 showed on page 1 of 2, "Information known or contained in the patient's medical record shall be treated as confidential and will be released in appropriate circumstances only with the written consent of the patient or legal guardian".

Observation on 08/16/10 at 3:45 p.m. in the Rehabilitation unit showed staff stored plastic colored folders (large enough to hold eight and a half by eleven sheets of paper) inside each patient door on an open shelf.

Review showed the folder contained a patient education record, a nursing care record, a surgical incisions/Braden scale record (skin assessment), a fall risk assessment record, a daily nursing assessment record and progress notes. These had the patient's name and date of birth and were accessible to anyone on the nursing unit.
During an interview on 08/16/10 at 3:55 p.m. Staff C, registered nurse (RN) said the records with personal identification information were pulled out of the rooms after a survey in May but staff decided to put the records with this information back into the rooms because they were concerned they might chart on the wrong patient. Staff C acknowledged the records contain personal identifiers for each patient.

Based on policy review, interview and record review the facility failed to obtain a physician's order for a physical hold restraint for one patient (#87) of four restraint orders reviewed. The facility had a census of 144.

Findings included:

Review of facility policy "Restraints and Seclusion" last revised 05/10 shows the definition of restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient of move his or her arms, legs, body, or head freely.

Further review of the policy showed holding a patient in a manner that restricts the patient's movement against the patient's will is considered restraint. This includes holds what may be termed "therapeutic holds". The use of restraint or seclusion must be in accordance with the order of a licensed physician who is responsible for the care of the patient. Restraint orders must include but not limited to the following: a. date and time the order was received; b. time limits of the order; c. type of restraint used; and d. reason for restraint/seclusion.

Current record review of the history and physical dated showed Patient #87 entered the facility on 07/25/10 for treatment of severe behavioral problems.

During an interview on 08/17/10 at 11:05 a.m. the Behavioral Health Nurse Manager Staff Y said staff needed to place Patient #87 in restraints and seclusion on 08/16/10. Staff Y said he/she took hold of Patient #87's arm and took the patient to the seclusion room prior to the application of restraints on 08/16/10. Staff Y said he/she obtained an order for restraints and seclusion from the physician but did not obtain an order for a physical hold. Staff Y said that the episode [restraint episode] was one continuous motion.

Review of the physician's orders dated 08/16/10 showed no order for a physical hold.

Based on policy review, record review and interview the facility failed to ensure restraint orders are not written as a PRN (as needed) order for one patient (#86) of four restraint orders reviewed. The facility had a census of 144.

Findings included:

Review of the facility policy PC.1021 last reviewed 05/10 showed in part in section V #7 the facility will not use standing orders or PRN orders for restraints or seclusion.

Open record review showed Patient #86 entered the facility 08/08/10 following a suicide attempt.

Review of a physician order dated 08/16/10 at 7:45 p.m. showed the physician ordered, "May hold pt. (patient) if needed (pt. tried to hang self)."

During an interview on 08/18/10 at 10:35 a.m. the Behavioral Health Nurse Manager Staff Y confirmed the physician ordered a PRN restraint.

Based on facility credential review, record review and interview physician staff failed to have credentialing for performed anesthesia services for 2 (Patient #88 and Patient #89) of 2 emergency room (ED) records reviewed that received Propofol sedation. Facility census was 144.

Findings included:

1. Facility physician credential review for Physician QQ on 08/20/10 at 11:30 a.m. revealed physician delineated privileges included approval for Moderate sedation.

2. Facility physician credential review for Physician RR on 08/20/10 at 11:30 a.m. revealed physician delineated privileges included approval for Moderate sedation.

3. During an interview on 08/20/10 at 10:00 a.m. Staff MM, Pharmacist stated Propofol is past moderate sedation. Propofol induces an unconscious state. Propofol is used for deep sedation.

4. Review of facility Policy & Procedure titled "Moderate and Deep Sedation" with a last review date of 05/19/10 states in part:
2. All physicians/licensed independent practitioners administering moderate and deep sedation shall apply for and be granted privileges through the Medical Staff Office and approved by the Physician Medical Director of each respective department where moderate and deep sedation is administered.
Documentation of these privileges shall be maintained in the Medical Staff Office.

5. Record review on 08/20/10 at 12:00 noon revealed Patient #88 admitted to the ED on 07/08/10. Record review reveals Patient #88 received Propofol 100 milligrams (mg) at 2:22 a.m. per Staff RR. Staff RR failed to be privileged for deep sedation.

6. Record review on 08/20/10 at 12:30 p.m. revealed Patient #89 admitted to the ED on 08/02/10. Record review reveals Patient #89 received Propofol 200 mg at 9:24 a.m. per Staff QQ. Staff QQ failed to be privileged for deep sedation.

Based on Missouri statute review, document review and interview the facility failed to ensure two Physician Assistants (PAs) (Staff R and Staff PP) of three PAs have a written supervision agreement with a physician and the facility failed to ensure one (Staff TT) of 12 nurse practitioners have a written collaborative agreement with a physician, which contains all the elements required in a collaborative agreement. The facility census was 144.
Findings included:
Review of the Missouri State Board of Registration for the Healing Arts, Missouri Regulations CSR Title 4, Division 150, Chapter 7 revised 08/05 showed the scope of practice is: delegated health care services provided for in the PA supervision agreement which are consistent with the scopes of practice of both the supervising physician and the PA, including, but not limited to, any restrictions placed upon the supervising physician's practice or license.
The regulation documents the physician assistant must practice with a written supervision agreement. The agreement must be jointly signed and dated by supervising physician(s) and PA.
Review of the personnel file for Physician Assistant Staff R showed no supervision agreement with a collaborating physician.
During an interview on 08/19/10 at 11:35 a.m. the Director of Clinical Affairs Staff JJ said none of the physician assistants have a supervisory agreement.
During a telephone interview on 08/24/10 at 10:15 a.m. the Medical Staff secretary, Staff F said one of the three physician assistants have a supervisory agreement with a physician. Staff F said the personnel file for physician assistant Staff PP does not contain a supervisory agreement with a physician.
Review of Missouri Revised Statutes Chapter 334 section 334.104 showed the required elements of a collaborative agreement between a physician and an advanced practice registered nurse include in part:
1. Complete names, home and business addresses, zip codes, and telephone numbers of the collaborating physician and the advanced practice registered nurse;
2. All specialty or board certifications of the collaborating physician and all certifications of the advanced practice registered nurse;
3. The manner of collaboration between the collaborating physician and the advanced practice registered nurse, including how the collaborating physician and the advanced practice registered nurse will; a. engage in collaborative practice consistent with each professional's skill, training, education and competence; b. Maintain geographic proximity; and c. Provide coverage during absence, incapacity, infirmity, or emergency by the collaborating physician.

Review of the personnel file for Family Nurse Practitioner Staff TT showed a form titled Collaborative Practice Agreement. The form showed, "This document is a formal written statement addressing the parameters of the collaborative practice which are mutually agreed upon by the advanced practice registered nurse (APRN) and one or more licensed physicians."
The signature of the nurse practitioner and the physician are beneath, "This document is a collaborative agreement between:"

There are no other required elements on the agreement.

Based on medical record review, facility policy review, and interview the facility failed to develop a nursing care plan to meet patient's nursing needs and failed to follow the facility's internal policy regarding care planning for four out of ten open medical records reviewed for care planning. (Patient #84, Patient #7, Patient #8, Patient #9). The census at the time of the survey was 144 patients.

Findings included:

1. The facility policy titled Assessment, Reassessment and Care Planning, effective 07-10 and last reviewed/revised on 6-10 states in part under the heading of Assessments and Care Planning in the Inpatient Setting, Care Plan: The initial assessment shall lead to the development of a nursing care plan focused on the problems and issues identified".

2. Medical record review conducted on 08/18/10 at 4:00 p.m. showed the following:
- Patient #84 was admitted to the facility on 08/17/10.
- Admission orders dated 08/17/10 show an order for telemetry, insulin, and a 1,800 Calorie ADA diet.
- The Initial Nursing Admission Assessment showed the patient's primary diagnosis included the patient is blind, is a diabetic with insulin and has an indwelling foley catheter (a tube inserted into the bladder to allow the flow of urine).
- The Acute Hemodialysis Record dated 08/17/10 shows the patient has a right subclavian vascular catheter (central line specific for dialysis).
- The patient's Interdisciplinary Plan of Care did not include that the patient is a diabetic, is on telemetry, has an indwelling foley catheter, has a special diet, and has a central line for dialysis. (The process to remove liquid and chemicals from the blood that the kidneys would normally remove if they were present and functioning).

Staff KK, RN (Registered Nurse) said during an interview on 08/18/10 at 4:30 p.m.that these should have been included in the care plan, and that nursing staff should be assessing the right subclavian line for bleeding following dialysis.


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3. Medical record review conducted on 08/17/10 at 11:20 a.m. for Patient #7 showed the following:
- Patient admitted on 08/14/10 to the facility
- Patient admission weight is charted at 426# - Patient is 5'5" tall
- Patient is on a 2000 calorie ADA (American Dietetic Diet)
- Patient is on sliding scale insulin
- Patient admission orders list morbid obesity as an admission diagnosis
- The Patient's Interdisciplinary Plan of Care did not include a plan of care for nutrition related to the patient's Therapeutic diet and patient's morbid obesity.

During interview on 08/17/10 at 11:45 a.m., Staff Q registered nurse (RN) compliance officer confirmed the lack of care planning for diabetes, insulin and weight.


4. Medical record review conducted on 08/17/10 at 1:30 p.m. for Patient #8 showed the following:
- Patient admitted on 08/16/10 to the facility
- Patient chief complaint of dizziness
- Patient physician ordered neurological checks every 2 hours for 12 hours and then every 4 hours
- Patient care plan did not address patient dizziness under Self-Care Defecit in the care plan
- Patient care plan did not address patient Potential for Injury due to dizziness
- Patient care plan did not address Altered Neurologic Status due to patient diagnosis of Ischemic Cerebral Vascular Accident

During an interview on 08/17/10 at 4:20 p.m. Staff O, RN stated care plan needs updating and the patient needs need to be addressed.

5. Medical record review conducted on 08/17/10 at 3:15 p.m. for Patient #9 showed the following:
- Patient admitted on 08/12/10 to the facility
- Patient consultant report states patient is 13 weeks pregnant
- Patient had a surgery on 08/15/10 for a ruptured appendix with a large abscess per post operative note
- Patient care plan failed to address under discharge plan - pregnancy/parenting issues*
- Patient care plan failed to address Self-Care Defecit related to wound care
- Patient care plan failed to address Infection - actual (patient on numerous antibiotics for abscess)
- Patient care plan failed to address Altered Skin Integrity related to surgical wound with drain and wound vacuum
- Patient care plan failed to address Nutrition related to wound healing and pregnancy
- Patient care plan failed to address Elimination record reveals patient has a Foley catheter
- Patient care plan fails to address Spiritual Needs - patient is 13 weeks pregnant and has a serious infection and surgical intervention

During an interview on 08/17/10 at 4:00 p.m. Staff Q, RN verified the lack of care plans to meet patient #9's needs.

Based on observation, facility policy review and interview, facility staff failed to follow facility policy with regard to administering medication via Intravenous I.V. (a line directly into a vein) push (IVP) for two (Patient #8 and Patient #4 ) of two patients observed receiving medication via IVP. The census at the time of the survey was 144 patients.

Findings include:

1. The facility medication guideline "Nurses 2010 Drug Handbook" states in part:
For Dexamethasone medication (a drug used to decrease inflammation-swelling)
I.V.
*For direct injection, inject undiluted over at least 1 minute

2. During observation of medication administration to Patient #8 on 08/17/10 at 9:50 a.m., showed Staff O, Registered Nurse (RN) administer IVP Dexamethasone 6 mg (milligrams) in 45 seconds

Interview with Staff O after the medication administration revealed the following:
*believe I gave over 1 minute
*compared second hand to surveyor's watch, Staff O stated, maybe looked at watch wrong


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3. The facility medication guideline, "Nursing 2010 Drug Handbook" states in part for Reglan (a medication that will prevent or arrest vomiting), administration by IV, "Give doses of 10 mg or less by direct injection over 1 to 2 minutes".

4. During observation of medication administration to Patient #4 on 08/17/10 at 10:15 a.m. showed Staff LL administer Reglan 10 mg. IVP over approximately 10 seconds.

Staff LL said during an interview on 08/17/10 at 2:00 p.m. that she had pushed the Reglan over a period of approximately 10 seconds. Staff LL said that he/she did not know the recommended time of administration for this medication.

Based on review of the medical staff rules and regulations, policy review and record review the facility failed to ensure physician's orders are not written to "continue" previous orders for one (Patient #12) of four records reviewed on the Rehabilitation unit and for one patient on the Progressive Care Unit (PCU) (Patient #17). The facility had a census of 144 and the Rehabilitation unit had a census of 12.
Findings included:
1. Review of the medical staff rules and regulations dated 2010 showed on page 11 that using only "renew", "repeat", and/or "continue orders," is not acceptable.
2. Review of facility policy 12.11 Verification and Clarification of Orders last reviewed 05/09 showed that "Continue home meds" or "Resume previous orders" are not legitimate, complete orders and shall be clarified.
3. Record review for current Patient #12 showed an order dated 08/11/10 written by a physician assistant to continue all other previous orders.
During an interview on 08/17/10 at 2:05 p.m. the Rehabilitation Manager Staff C said that Patient #12 transferred to the Rehabilitaion unit on 08/11/10 and the physician assistant wrote the order before the transfer.



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4. Review of Patient #17's medical record on 08/17/10 at 4:35 p.m. showed a physician order written on 08/18/10 at 9:45 a.m. that stated, "DC (discontinue) Oxycontin (pain medication). Continue all prior pain medications".

Based on medical record review, facility policy review and review of the facility's medical staff by-laws, facility staff failed to ensure physician telephone orders were authenticated within forty-eight hours for four patients (Patients #85, #17, #86 and #10) of forty-four current records reviewed. The facility census was 144.

Findings included:

1. Facility Medical Staff Rules and Regulations dated 2010 states in part, "All patient medical record entries must be legible, complete, dated, timed and authenticated in written or electronic form by the person responsible for providing or evaluation the service provided. In addition, all verbal and telephone orders must be authenticated within forty-eight (48) hours".

2. Facility policy titled "Verbal and Telephone Orders" states in part, "Verbal/telephone orders shall be subsequently authenticated (verified) and countersigned by the prescribing practitioner or other responsible practitioner within 48 hours of written notation or in accordance with State Law".

3. Medical record review of Patient #85 on 08/18/10 showed the following telephone orders that had not been authenticated by a physician:
- A telephone order written 08/10/10 at 1:30 p.m. for Darvocet 100mg. (milligrams) four times a day as needed;
- A telephone order written 08/11/10 at 1:40 p.m. for Lasix 20mg. IVP (intravenously);
- A telephone order written 08/11/10 at 3:10 p.m. for Cardiovascular Insulin Orders.

4. Medical record review of Patient #17 on 08/17/10 at 4:35 p.m. showed the following telephone order that had not been authenticated by a physician.
- A telephone order written 08/14/10 at 1:25 p.m. to hold pain medications, blood gas now, Lasix 20mg. IVP (intravenously) now then may move patient to PCU (Progressive Care Unit) with telemetry. (Continuous monitoring of a patient's heart rate and rhythm from a remote location).




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5. Medical record review for current Patient #86 on 08/18/10 showed the following orders:
- A telephone order written 08/08/10 at 11:00 p.m. for Risperdal (is indicated for the treatment of auditory hallucinations such as schizophrenia) 1 mg po (by mouth) HS (at bedtime)
The order is not signed by the physician.
- A verbal order written 08/11/10 at 6:00 p.m. to D/C (discontinue) Zyprexia (used to treat the symptoms of psychotic conditions such as schizophrenia) if not done yet. The physician signature lacks a date and time. There is no evidence the physician signed the verbal order within 48 hours.
- A telephone order dated 08/12/10 at 10:00 p.m. for Ibuprofen 800 mg po q (every) 4 to 6 hrs (hours) prn (as needed) pain
The telephone order is not signed by the physician.

6. Medical record review for current Patient #10 on 08/16/10 at 11:25 a.m. showed the following orders:
- A telephone order on admission which includes the following medications:
- Acetaminophen (Tylenol) 650 mg po every 4 hours PRN mild pain or fever
- Maalox Plus 10ml po every 4 hours PRN indigestion
- Milk of Magnesia 30ml po every 4 hours PRN constipation
- Bisacodyl (Dulcolax) 10 mg suppository daily PRN constipation not relieved by Milk of Magnesia
- Docusate Sodium (Colace) 100 mg po BID (twice a day) PRN stool softener
The physician signature lacks a date and time. There is no evidence the physician signed the telephone orders within 48 hours.

Based on observation and interview, the facility failed to ensure medications intended for use during patient emergencies was maintained in a tamper-resistant, locked and secured manner for patients in the Cardio-vascular operating room (CVOR) and infants in the Cesarean section operation room (C-Section). The facility census was 144.

Findings included:

1. The facility policy titled "Medication Storage" last reviewed 05/09 states in part under Emergency medications, supplies are stored in locked carts/tackle boxes/cabinets. The integrity of the storage units' contents is ensured via a daily check (areas staffed around the clock) or each day the clinical setting is open and staffed and whenever staff are called in to assist with a procedure/perform a diagnostic test, to ensure the locking device has not been opened/tampered with.

2. Observation of perfusion cart in the CVOR on 08/16/10 at 4:35 p.m. the following medications were found in the unlocked/secured cart:
- (2) 25% Mannitol (increases urinary output) 50 milliliter (ml) bottles
- Plegisol - 2 bags for cardiac perfusion
- (1) 1000 cc (a unit of measure) bag of normal saline solution

During an interview on 08/16/10 at 4:45 p.m. Staff J, Director of CVOR confirmed the unlocked medication supplies.

3. Observation of a tackle box containing a mixture of medications and Intravenous medications in the Cesarean Section room revealed no lock on the tackle box.

During an interview on 08/16/10 at 5:30 p.m. Staff H, RN Director of Women's Services said the box should have a lock on it.

Based upon observation and interview, the facility Food Service Director failed to assure pureed foods would have the appropriate temperature for two of three trays observed. The total census was 144.
Findings included:
1. In reference to The Federal Drug Administration's 1999 Food Code, as adopted for reference as 19 CSR30-20.090(13), it is stated, in part as:
" 3-501.16 Potentially hazardous food, Hot and Cold Holding.*
Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under § 3-501.19, potentially hazardous food shall be maintained:
(A) At 57°C (135°F) or above, except that roasts cooked to a temperature and for a time specified under 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54°C (130°F); "
2. Observation during the noon meal time on 08/18/10 from 11:30 to 12:30 a.m. revealed the Chef, heated the frozen, pre-prepared pureed meat for less than two minutes in a microwave prior to delivering to the trayline for patient tray service. When asked if the meat had been checked for proper temperature, the Chef stopped and checked the pureed meat, which temped at 86 degrees Fahrenheit (F).
Continued observation during the noon meal on 08/18/10 revealed the same Chef providing a second serving of pureed meat to the trayline meal service. When asked if the meat had been checked for proper temperature, the Chef stopped and checked the pureed meat, which tempted at 104 degrees F, and pureed green peas tempted at 98 degrees F.
3. During interview on 08/18/10, the Consultant Dietitian, Staff DD, shared the observation and confirmed this finding.

Based upon record review and interview, the facility nutrition screening process failed to identify two (#6, #49) patients at nutritional risk, potentially of need for therapeutic diet, and in need of nutritional assessment by consult of the Registered, Licensed Dietitian, of nine reviewed for nutrition concerns. The current census was 144 inpatients.
Finding included:
1. Record review for Patient #6, currently admitted since 08/12/10, showed the patient to be 5 foot, 6 inches tall, and weighing 110#. This is 84.6% of ideal body weight for normal frame size. The nursing admission data base, including the nutritional screening section, showed the patient had recently lost weight. This criterion is indicated as a need to refer to the Registered, Licensed Dietitian (RDLD) for a nutritional assessment consult. The record showed that no referral was made, and no nutritional consult assessment was provided.
During interview on 08/17/10 at 11:30 a.m., Staff L (RN) reviewed the record, also, and stated that no RDLD consult was found because the referral was never sent to Dietary.

2. Record review for Patient #49, an infant born 03/13/10 and currently admitted since 08/14/10 for Acute respiratory distress, Downs Syndrome, and recent history of atrial septal defect and recent history of failure to thrive due to neglect, now improved showed the nutritional screen by the nursing admission assessment to not have noted the failure to thrive or recent history of very low weight. No referral was made to the RDLD for this patient; and no nutritional consult assessment was provided. The child was 2 foot, 4 inches long; and weighed 5 pounds in 06/10, now improved to 13 pounds, at admission.

Based on record review and interview and observation, the nursing staff failed to document the meal intake of persons identified at nutritional risk for two (#18, #47) of nine patients reviewed for nutritional concerns.
The total census was 144.
Findings included:
1. Record review for Patient #18, currently admitted since 07/30/10 for heart attack, congestive heart failure, diabetes, and history of bilateral leg amputations, showed the patient was admitted weighing 253 pounds. By 08/10/10, the patient weighed 225 pounds, a loss of 28 pounds in 11 days. Review of the patient's meal consumption for days 08/05/10-08/09/10 showed twelve of thirty-nine meals were left blank and undocumented. The patient was to begin dialysis; and the meal intake and weight monitoring are critical for ongoing nutritional analysis.
During interview on 08/16/10, the Registered, Licensed Dietitian (RDLD) agreed with this record review and the finding.
2. Record review for Patient #47, currently admitted since 08/01/10 showed the patient to have deficient protein stores and weight of 101 pounds. Observation on 08/17/10 at 2:00 p.m. showed the patient to be very thin and 'hiding' in the covers of the bed.
Meal intake for the days 08/01/10 to 08/15/10 showed that 23 of 33 meal documentations were left blank (08/08/10 and 08/13/10 and 08/14/10 pages were not available for review). The nutritional screen process was completed on admission by the nursing staff, and the screening outcome was negative (no concerns had been noted).
It is not possible to provide accurate and ongoing nutritional assessment without detail information regarding the patient's tolerance and acceptance of the meals and snacks.

Based on observation, interview and policy review the facility failed to provide a safe environment for all patients by ensuring staff maintain supplies that are usable with current dates and intact packaging for 2 of 4 crash carts (operating room anesthesia cart and Obstetrical (OB) section crash cart). Facility census was 144 on the first day of survey.

Findings include:

1. Review of the facility's policy titled, "Disposal of Outdated Supplies", reviewed 03/10,
States in part:
Policy: All supplies shall be checked at least once a month.

Procedures: All items in stock are checked for dates once a month. Stock is rotated to keep dates in proper order.
Any other items, if out-dated or have damaged packages, making them unsterile, are properly destroyed before being disposed of making it impossible for any future use.

2. Observation on 08/16/10 at 4L00 p.m. of the operating room anesthesia cart revealed the following outdated supplies:
- 2 - 25 ga (gauge) IV (intravenous) needles
- 1 - open ET (endotracheal) tube - package states sterile unless open

During an interview at the time of the anesthesia cart review Staff G, certified registered nurse anesthetist (CRNA) confirmed out dated supplies.

3. Observation on 08/16/10 at 5:15 p.m. of OB section crash cart revealed the following outdated supplies:
- (1) - 14 French urological catheter dated 12/09
- (3) Packages connecting tubing dated 02/10
- (1) Package suction tubing dated 06/10

During an interview at the time of the crash cart review Staff H, RN Director of Women's Services confirmed the outdated supplies.

Based on observation, and interview the facility failed to adhere to acceptable standards of practice for infection control practices for one patient (Patient #4).
The census at the time of the survey was 144 patients.

Findings included:

During observation of medication administration to Patient #4 on 08/17/10 at 10:05 a.m. showed a urinal containing what appeared to be urine on the bedside table on a partially damp paper towel. Staff LL placed the patient's medications, which included (IV) intravenous medications on the table next to the urinal and partially on the paper towel. Staff LL placed a Fentanyl 25 mcg. (micrograms) (pain medication) patch to the patient's back, then administered Reglan 10 mg. (milligrams) (antiemetic medication) intravenously.
Staff NN, Certified Nurse Assistant came into the patient's room and removed the urinal from the bedside table and emptied the contents into the toilet in the patient's bathroom at 10:15 a.m.
Patient #4 was nauseated and could not take his/her medications by mouth. Staff LL took the medications from the bedside table and placed them back into the medication cart.

Staff OO, Infection Control Practitioner said during an interview on 08/19/10 at 3:00 p.m. that this example was not acceptable standard of practice in regard to infection control.