HospitalInspections.org

Based on observation, staff interview and policy review, the Critical Access Hospital (CAH) failed to assure one of two controlled drug (narcotic) intravenous medications were administrations according to the CAH's policy and current professional standards.

Findings include:

- Staff E, observed on 4/26/11 at 9:36am, prepared a syringe of morphine sulfate (a narcotic pain medication) and labeled the syringe for administration to patient #33. Staff E administered 2cc's (cubic centimeters) of the medication solution to patient #33 intravenously.

- Staff G, observed on 4/26/11 at 10:15am, revealed the administration of 2cc's of medication solution from a syringe. Staff G confirmed they did not prepare the medication solution. Observation of the syringe confirmed it was the syringe prepared by staff E on 4/26/11 at 9:30am. Staff G incorrectly identified staff H as the nurse who prepared the medication solution. Staff E, interviewed on 4/26/11 at 10:30am, confirmed they prepared the medication solution and handed the prepared syringe to staff H, who then handed it to staff G for administration to patient #33.

- Staff A, on 4/26/11 at 10:30am, asked staff G for the location of the prepared syringe. Staff G produced the syringe from their clothing pocket.

- The CAH policy titled "Medication Administration", reviewed on 4/27/11 at 8:10am, directs staff, "Once a controlled drug had been removed (from the storage area), it will remain in the licensed health caregiver's possession until administered." Current professional standards for AJIC (American Journal of Infection Control) published in April 2010, reviewed on 4/27/11 at 4:00pm, revealed "Never store or transport syringes in clothing or pockets" and "Prepare syringes as close to administration as feasible".

- Staff A, interviewed on 4/26/11 at 10:30am, confirmed the syringe with controlled drug solution is to be prepared by the staff who administer the medication and any remaining solution is to be discarded.

Based on observation, staff interview and document review, the Critical Access Hospital (CAH) failed to identify and control the potential spread of infections. The CAH failed to assure staff follow the CAH's infection control policies. The CAH failed to assure hand hygiene during the care of one of one patient's (#11) with a dressing change and stored clean patient care equipment in the soiled utility room with potential for cross-contamination.

Findings include:


- Review of "Hospital Information Sheet" completed by the CAH on 4/25/11, revealed staff E was responsible for the infection control program. Staff A and I, interviewed on 4/27/11 at 12:15pm confirmed the CAH lacked a job description for the person in charge of the infection control program.

- Patient #11's clinical record, reviewed on 4/25/11 at 12:25pm revealed an admission date of 4/20/11 with diagnoses including cellulitis and history of an infection. Staff C was observed on 4/26/11 at 11:15am performing a dressing change to the patient's legs. Staff C put on clean protective gloves, then applied a second pair of gloves over the first pair. Staff C removed the soiled dressing on the patient's left leg and applied medication to the wounds. Staff C then removed the top pair of the gloves and proceeded to apply a clean dressing while continuing to wear the gloves applied first.

Staff C then removed the soiled dressing from the patient's right leg and applied the medication. Staff C removed the soiled gloves, opened the patient's room door, then applied two gloves to each hand without performing hand hygiene. Staff C applied the medication and removed the outer pair of gloves and applied the dressing.

Staff C, interviewed on 4/26/11 at 11:45am, confirmed they applied two pair of gloves at a time.

- The CAH's policy, reviewed 4/26/11 at 3:45pm, titled "Hand Hygiene Guidelines" revealed staff are to perform hand hygiene before applying and after removing gloves.

- Staff A, interviewed on 4/26/11 at 12:30pm, confirmed staff are to wear one pair of gloves at a time and to perform hand hygiene before applying and after removing gloves.



21996

- Observation on 4/26/11 at 10:15am of the soiled utility room across from the nurse's station revealed a large gray container with bags of trash, a red trash container with red bagged biohazard trash, and a yellow container with dirty linen. The soiled utility room also contained clean patient care equipment (intravenous (IV) infusion pumps and a fluid warmer).

Staff D interviewed on 4/26/11 at 10:15am acknowledged the staff stored the clean patient care equipment in the dirty utility room.

Staff B interviewed on 4/26/11 at 11:40am acknowledged the staff stored clean patient care equipment in the same room that contained contaminated trash and linen.

The CAH failed to identify and control the potential spread of infections by assuring staff follow infection control policies, perform hand hygiene and store clean patient medical equipment separately from contaminated trash and linens in the dirty utility room.