HospitalInspections.org

Based on review of the emergency room (ER) medical records, the Alabama Board of Nursing Administrative Code, hospital's Emergency Department Policies and Procedures and staff interview, it was determined the hospital failed to ensure a registered nurse (RN) performed a comprehensive assessment of 14 of 22 patients who presented to the ER for treatment from January 2012 through March 2012.

This practice delegated to the licensed practical nurse (LPN) the responsibility of making the decision of how the patients who presented to the ER were triaged to be seen by the ER physician. This affected ER medical record #s 1, 2, 3, 4, 5, 7, 10, 11, 13, 18, 19, 20, 21 and 22 and had the potential to affect all patients who presented to the ER for treatment.

Findings include:

Alabama Board of Nursing
Administrative Code

610-X-6-.01 Definitions

(2) Assessment, Comprehensive: the systematic collection and analysis of data including the physical, psychological, social, cultural and spiritual aspects of the patient by the registered nurse for the purpose of judging a patient's health and illness status and actual or potential health needs. Comprehensive assessment includes patient history, physical examination, analysis of the data collected, development of the patient plan of care, implementation and evaluation of the plan of care.

(3) Assessment, Focused: An appraisal of a patient's status and specific complaint through observation and collection of objective and subjective data by the registered nurse or licensed practical nurse. Focused assessment involves identification of normal and abnormal findings, anticipation and recognition of changes or potential changes in patients.

610-X-6-.04 Practice of Professional Nursing (Registered Nurse Practice)

(1) The practice of professional nursing includes, but is not limited to: ...

(e) Conducting and documenting comprehensive assessments and evaluations of patients and focused nursing assessments patient's health status, and may contribute to a comprehensive assessment performed by the registered nurse ...

610-X-6-.05 Practice of Practical Nursing (Licensed Practical Nurse Practice)

(1) The practice of practical nursing includes, but is not limited to: ...
(d) Conducting and documenting focused nursing assessments of the health status of patients.

610-X-6-.09 Assessment Standards
(1) Patient assessment shall be provided in accordance with the definitions of professional nursing and practical nursing as defined in the Alabama Nurse Practice Act, Section 34-21-1.
(2) The registered nurse shall conduct and document comprehensive and focused nursing assessments of the health status of patients ... ...

Hospital Policy

Nursing Service
Subject: ER Record
Issued: 09/97
Related to: Emergency Department

Statement of Policy and Procedure

(2) The ER nurse is responsible for triaging every patient that presents to the ER. The patient is placed in the triage room, located across from nurses desk, where the nurse obtain the patient's name, vital signs, and chief complaint and will triage the patient into one (of) three categories described in initial ER screening.

Nursing Service
Subject: Triage/Screening/Treatment
Issued: 09/97
Related To: Emergency Department

One of the most compelling terms of COBRA 87 is paraphrased by saying "Any person who presents to a hospital emergency room for treatment must be evaluated by an appropriate medical professional to determine whether an emergency medical condition (according to set guidelines) exists." ......


All patients will be screened by a licensed nurse. After initial screening, the following information will be relayed to the appropriate (physician will determine if treatment or referral is necessary).
1. Chief complaint
2. Screening data
3. Pertinent information relating to patient

The following categories will be used to classify seriousness of each illness:

Triage Category - "Non-Urgent"
Patient will be seen as time allows. No threat to Life and low risk of morbidity....

Triage Category - "Urgent"
Treatment requiring attention as soon as possible. No immediate threat to life, Increased morbidity.....


Review of 22 ER records revealed the LPN performed the triage assessment for 14 of the aforementioned ER records and determined how the patient was triaged. There was no documentation the RN performed a comprehensive assessment to determine if the patient required "urgent" or "non-urgent" care or was present to supervise the LPN's assessment and evaluation of the patients.

During a tour of the emergency room on 5/1/12 at 1:20 PM, the surveyor observed there was one nurse working in the ER, Employee Identifier # 6, the LPN.

During an interview on 5/1/12 at 2:05 PM, EI # 6 confirmed he/she was the ER nurse for that day. EI # 6 stated that whoever is assigned as the ER nurse does the triaging of the patients.

During an interview on 5/3/12 at 11:00 AM, EI # 1, Director of Nurses, confirmed that LPNs triage patients in the ER.

Based on observations of medication administration, interview with administrative staff, and review of the facility's policies for medication administration, it was determined the nursing staff failed to prepare and administer medications according to the facility's policy for 4 of 4 observations. This affected Medical Records (MR) # 1, # 3 and Observation Patients (OP) # 1 and 2 and had the potential to affect all patients served by this facility.


Findings include:

Facility Policy

Administration of Oral Medication

... Method

1. Verify medication to be given with MAR (Medication Administration Record).

2. Wash hands...

4. Prepare specific dosage...


Observations were conducted on 5/2/12 from 8:30 AM to 9:15 AM of medication administrations by Employee Identifier (EI) # 2, Registered Nurse and EI # 3, Licensed Practical Nurse.

During the observation time, the surveyor observed EI # 2 prepare and administer medications for MR # 3 and OP # 1. EI # 2 failed to wash her hands prior to preparation or administration of the either patient's oral medications.

Also during this observation time, the surveyor observed EI # 3 prepare and administer medications for MR # 1 and OP # 2. EI # 3 failed to wash her hands prior to preparation or administration of the either patient's oral medications.


An interview was conducted on 5/3/12 at 1:25 PM with EI # 1, Director of Nurses, who verified the staff should have washed their hands prior to medication preparation or before and after medication administration.

Based on review of emergency room (ER) records and staff interview, it was determined the ER physicians failed to document the time of the first assessment for 13 of 22 patients who presented to the ER for treatment. This affected ER record #s 2, 3, 4, 5, 8, 10, 11, 12, 13, 14, 16, 18, and 19 and had the potential to affect all patients who presented to the ER for treatment.

Findings include:

Review of 22 ER records from January 2012 through March 2012, revealed there was no documentation of the time the physician performed the first physical assessment for 13 aforementioned ER patients.

During an interview on 5/3/12 at 11:00 AM, Employee Identifier (EI) # 1, Director of Nurses, confirmed the aforementioned findings.

Based on observation, facility policy review and staff interview, it was determined the staff failed to ensure the medication cart was locked when it was not in a secured area. This had the potential to affect all patients served at the facility.

Findings include:

Facility Policy
Nursing Service
Subject: Storage of Medications
Revised: 11/97
Policy:
Drug storage must meet the manufacturer's recommendation....The storage area must be properly locked.

On 5/2/12 at 8:35 AM, the surveyor observed the medication cart in the hallway of the Inpatient unit. The medication cart was unattended and the surveyor observed that the cart was not locked.

During an interview on 5/2/12 at 8:40 AM, Employee Identifier (EI) # 2, Registered Nurse (RN), confirmed the medication cart was not locked. EI # 2 confirmed the medication cart should have been locked.

Based on observation, facility policy review and staff interview, it was determined the facility failed to ensure that controlled medications were stored in a double locked storage area at the emergency room (ER) nursing station. This had the potential to affect all patients who presented for treatment at the facility.

Findings include:


Facility Policy

Nursing Service
Subject: Storage of Medications
Revised 11/97

Policy:
.....Controlled drugs must be stored under double locks.....

Facility Policy

Nursing Service
Subject: Controlled Substances
Revised: 11/97

Policy:

.....They must be kept under double lock at all times......

The following statement constitute minimum requirements for security of controlled substances:
1. Controlled substances must be kept under double lock at all times.


On 5/1/12 at 12:00 PM, the surveyor observed Employee Identifier (EI) # 6, a licensed practical nurse, use a key to open the cabinet door to the controlled medications at the ER nurses station. The surveyor observed there was only one door to the controlled medication storage area.

At the time of the observation, EI # 6 confirmed the controlled medications at the ER nurses station were not double locked.

During an interview on 5/2/12 at 8:10 AM, EI # 1, Director of Nurses, confirmed the controlled medications at the ER nurses station was not double locked. EI # 1 stated that the outside door of the storage area was broken but was being repaired.

Based on observation, policy review and staff interview, it was determined the facility failed to ensure that unauthorized staff did not have access to the main pharmacy in the Inpatient Unit. This had the potential to affect all patients and staff at the facility.

Findings include:

Facility Policy

Nursing Service
Pharmacy
Subject: Pharmacy Procedures
Revised: June 2008

Procedure:
1. The Pharmacist, DON (Director of Nurses), Pharmacy Tech, ADON ( Assistant DON) and the Charge Nurse are the only persons to enter the main pharmacy located on the Inpatient Unit.....


During a tour of the Inpatient Unit on 5/2/12 at 8:45 AM, the surveyor asked to see the medication room for the unit. Employee Identifier (EI) # 3, a Licensed Practical Nurse (LPN), went to the door of the main pharmacy located in the Inpatient Unit and started to unlock the pharmacy door with a key.

The surveyor asked EI # 3 who had access to the pharmacy. EI # 3 stated that the medications for the patients are kept in the medication cart but if a medication was not in the cart they could go into the pharmacy and get the medicine. The surveyor observed there was no medication room in the Inpatient Unit.

On 5/2/12 at 8:50 AM, the surveyor asked EI # 5, the Pharmacy Technician, who was suppose to have access to the pharmacy and she stated the Director of Nurses and the Charge Nurse. She confirmed the Charge Nurse was a Registered Nurse (RN).

During an interview on 5/3/12 at 8:35 AM, EI # 1, DON, confirmed the LPNs were not suppose to have access to the main pharmacy in the Inpatient Unit.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.

Findings include:

Refer to Life Safety Code violations.

Based on observation and staff interview, it was determined the facility failed to assure all medical supplies available for patient use in the Emergency Room (ER)) were not expired. This had the potential to affect all patients.

Findings include:

The surveyor conducted a tour of the ER on 5/1/12 at 1:25 PM. During the tour the surveyor observed the following expired supplies in ER treatment room # 3:

1 Adult QuickTrach to be used by 5/2007
1 Pediatric QuickTrach to be used by 11/2011
1 EZ 15 Gauge (G) needle set expired 10/2011
3 EZ Connect Fluid Transducer sets expired 04/2011
1 EZ Connect Fluid Transducer set expired 11/2011
4 EZ Connect Fluid Transducer sets expired 5/2011
2 Ross 14 French (FR) Enteral Feeding tubes use by 6/2007
3 Insyte Autoguard Intravenous 18 G (IV) catheters expired 3/2009
1 Insyte Autoguard IV 18 G catheter expired 6/2010
1 Insyte Autoguard IV 18 G catheter expired 1/2010
1 Insyte Autoguard IV 16 G catheter expired 1/2010
1 Insyte Autoguard IV 16 G catheter expired 3/2007
6 Insyte Autoguard IV 16 G catheter expired 5/2008
2 Insyte Autoguard IV 24 G catheter expired 12/2011
2 Insyte Autoguard IV 24 G catheter expired 3/2010
1 Insyte Autoguard IV 24 G catheter expired 10/2009
1 Insyte Autoguard IV 24 G catheter expired 10/2010
2 18 G Huber Needles expired 12/2011
1 Bottle of Plain Packing Strips expired 11/2011

During an interview on 5/1/12 at 2:05 PM, Employee Identifier, (EI) # 6, a licensed practical nurse (LPN), confirmed the aforementioned findings.

Based on observation and interview with administrative staff, it was determined the hospital failed to ensure staff followed the facility policy for aseptic wound care techniques and ensure appropriate infection control practices were carried out throughout the hospital departments. This affected Medical Record (MR) # 3 and had the potential to affect all patients admitted to the facility who had wounds and had the potential to affect all patients who required Computed Tomography (CT) with Intravenous (IV) contrast.


Findings include:

Facility Policy

Procedures for Washing Hands
Purpose

1. To clean hands, before and after handling equipment or caring for the patient; to protect the patient, yourself and others.

2. To reduce the possibility of transmitting infection to the patient or from him to yourself or others.

Special Notation

Adequate washing of hands is one of the most effective methods to control the spread of disease...

Subject: Handwashing

Handwashing is the single most effective deterrent to the spread of infections.

Policy:

Hospital personnel shall wash their hands to prevent the spread of infections:

... 2. Before applying and after removing gloves...


During medication administration to MR # 3 on 5/2/12 at 8:45 AM, Employee Identifier (EI) # 2, Registered Nurse performed wound care to the patient's left ankle. EI # 2 failed to clean her hands prior to donning gloves, removed the old dressing to the left ankle, which had bloody drainage, then removed her gloves. EI # 2 donned clean gloves, cleaned the wound to the left ankle, applied Triple Antibiotic ointment to the wound bed, then applied Telfa, 4 by 4 and secured with tape. EI # 2 removed her gloves, donned clean gloves and assisted the patient with the application of his/her sock. EI # 2 removed gloves, then washed her hands.

EI # 2 failed to wash her hands prior to or after the application of clean gloves, after the removal of a soiled dressing, prior to cleansing the patient's wound or prior to the application of a clean dressing.

An interview was conducted on 5/3/12 at 1:25 PM with EI # 1, Director of Nurses, who verified EI # 2 failed to follow the policy for handwashing during wound care.

On 5/1/12 at 10:45 AM, the surveyor observed located in the CT room was a 1000 milliliter (ml) bag of 0.9% Sodium Chloride, which had been spiked with approximately 600 ml remaining in the bag. There was no documentation on this bag when the contents were spiked.

An interview was conducted on 5/1/12 at 10:45 AM with EI # 4, Director of Radiology, who stated that the above mentioned bag of IV fluid was to use for patients who needed IV contrast. EI # 4 stated that he hung a new bag on a daily basis. The surveyor informed EI # 4 that the bag of IV fluid was for single use only and could not be used for multiple patients.

On 5/2/12 at 2:00 PM, the surveyor returned to the CT room and found a 1000 milliliter (ml) bag of 0.9% Sodium Chloride, which had been spiked with approximately 600 ml remaining in the bag and unlabeled of when the bag was spiked. During this time, EI # 4 stated he had forgotten to remove the IV fluid bag. He then removed it to discard the contents.

Based on review of the emergency room (ER) medical records, the Alabama Board of Nursing Administrative Code, hospital's Emergency Department Policies and Procedures and staff interview, it was determined the hospital failed to ensure a registered nurse (RN) performed a comprehensive assessment of 14 of 22 patients who presented to the ER for treatment from January 2012 through March 2012.

This practice delegated to the licensed practical nurse (LPN) the responsibility of making the decision of how the patients who presented to the ER were triaged to be seen by the ER physician. This affected ER medical record #s 1, 2, 3, 4, 5, 7, 10, 11, 13, 18, 19, 20, 21 and 22 and had the potential to affect all patients who presented to the ER for treatment.

Findings include:

Alabama Board of Nursing
Administrative Code

610-X-6-.01 Definitions

(2) Assessment, Comprehensive: the systematic collection and analysis of data including the physical, psychological, social, cultural and spiritual aspects of the patient by the registered nurse for the purpose of judging a patient's health and illness status and actual or potential health needs. Comprehensive assessment includes patient history, physical examination, analysis of the data collected, development of the patient plan of care, implementation and evaluation of the plan of care.

(3) Assessment, Focused: An appraisal of a patient's status and specific complaint through observation and collection of objective and subjective data by the registered nurse or licensed practical nurse. Focused assessment involves identification of normal and abnormal findings, anticipation and recognition of changes or potential changes in patients.

610-X-6-.04 Practice of Professional Nursing (Registered Nurse Practice)

(1) The practice of professional nursing includes, but is not limited to: ...

(e) Conducting and documenting comprehensive assessments and evaluations of patients and focused nursing assessments patient's health status, and may contribute to a comprehensive assessment performed by the registered nurse ...

610-X-6-.05 Practice of Practical Nursing (Licensed Practical Nurse Practice)

(1) The practice of practical nursing includes, but is not limited to: ...
(d) Conducting and documenting focused nursing assessments of the health status of patients.

610-X-6-.09 Assessment Standards
(1) Patient assessment shall be provided in accordance with the definitions of professional nursing and practical nursing as defined in the Alabama Nurse Practice Act, Section 34-21-1.
(2) The registered nurse shall conduct and document comprehensive and focused nursing assessments of the health status of patients ... ...

Hospital Policy

Nursing Service
Subject: ER Record
Issued: 09/97
Related to: Emergency Department

Statement of Policy and Procedure

(2) The ER nurse is responsible for triaging every patient that presents to the ER. The patient is placed in the triage room, located across from nurses desk, where the nurse obtain the patient's name, vital signs, and chief complaint and will triage the patient into one (of) three categories described in initial ER screening.

Nursing Service
Subject: Triage/Screening/Treatment
Issued: 09/97
Related To: Emergency Department

One of the most compelling terms of COBRA 87 is paraphrased by saying "Any person who presents to a hospital emergency room for treatment must be evaluated by an appropriate medical professional to determine whether an emergency medical condition (according to set guidelines) exists." ......


All patients will be screened by a licensed nurse. After initial screening, the following information will be relayed to the appropriate (physician will determine if treatment or referral is necessary).
1. Chief complaint
2. Screening data
3. Pertinent information relating to patient

The following categories will be used to classify seriousness of each illness:

Triage Category - "Non-Urgent"
Patient will be seen as time allows. No threat to Life and low risk of morbidity....

Triage Category - "Urgent"
Treatment requiring attention as soon as possible. No immediate threat to life, Increased morbidity.....


Review of 22 ER records revealed the LPN performed the triage assessment for 14 of the aforementioned ER records and determined how the patient was triaged. There was no documentation the RN performed a comprehensive assessment to determine if the patient required "urgent" or "non-urgent" care or was present to supervise the LPN's assessment and evaluation of the patients.

During a tour of the emergency room on 5/1/12 at 1:20 PM, the surveyor observed there was one nurse working in the ER, Employee Identifier # 6, the LPN.

During an interview on 5/1/12 at 2:05 PM, EI # 6 confirmed he/she was the ER nurse for that day. EI # 6 stated that whoever is assigned as the ER nurse does the triaging of the patients.

During an interview on 5/3/12 at 11:00 AM, EI # 1, Director of Nurses, confirmed that LPNs triage patients in the ER.

Based on observations of medication administration, interview with administrative staff, and review of the facility's policies for medication administration, it was determined the nursing staff failed to prepare and administer medications according to the facility's policy for 4 of 4 observations. This affected Medical Records (MR) # 1, # 3 and Observation Patients (OP) # 1 and 2 and had the potential to affect all patients served by this facility.


Findings include:

Facility Policy

Administration of Oral Medication

... Method

1. Verify medication to be given with MAR (Medication Administration Record).

2. Wash hands...

4. Prepare specific dosage...


Observations were conducted on 5/2/12 from 8:30 AM to 9:15 AM of medication administrations by Employee Identifier (EI) # 2, Registered Nurse and EI # 3, Licensed Practical Nurse.

During the observation time, the surveyor observed EI # 2 prepare and administer medications for MR # 3 and OP # 1. EI # 2 failed to wash her hands prior to preparation or administration of the either patient's oral medications.

Also during this observation time, the surveyor observed EI # 3 prepare and administer medications for MR # 1 and OP # 2. EI # 3 failed to wash her hands prior to preparation or administration of the either patient's oral medications.


An interview was conducted on 5/3/12 at 1:25 PM with EI # 1, Director of Nurses, who verified the staff should have washed their hands prior to medication preparation or before and after medication administration.

Based on review of emergency room (ER) records and staff interview, it was determined the ER physicians failed to document the time of the first assessment for 13 of 22 patients who presented to the ER for treatment. This affected ER record #s 2, 3, 4, 5, 8, 10, 11, 12, 13, 14, 16, 18, and 19 and had the potential to affect all patients who presented to the ER for treatment.

Findings include:

Review of 22 ER records from January 2012 through March 2012, revealed there was no documentation of the time the physician performed the first physical assessment for 13 aforementioned ER patients.

During an interview on 5/3/12 at 11:00 AM, Employee Identifier (EI) # 1, Director of Nurses, confirmed the aforementioned findings.

Based on observation, facility policy review and staff interview, it was determined the staff failed to ensure the medication cart was locked when it was not in a secured area. This had the potential to affect all patients served at the facility.

Findings include:

Facility Policy
Nursing Service
Subject: Storage of Medications
Revised: 11/97
Policy:
Drug storage must meet the manufacturer's recommendation....The storage area must be properly locked.

On 5/2/12 at 8:35 AM, the surveyor observed the medication cart in the hallway of the Inpatient unit. The medication cart was unattended and the surveyor observed that the cart was not locked.

During an interview on 5/2/12 at 8:40 AM, Employee Identifier (EI) # 2, Registered Nurse (RN), confirmed the medication cart was not locked. EI # 2 confirmed the medication cart should have been locked.

Based on observation, facility policy review and staff interview, it was determined the facility failed to ensure that controlled medications were stored in a double locked storage area at the emergency room (ER) nursing station. This had the potential to affect all patients who presented for treatment at the facility.

Findings include:


Facility Policy

Nursing Service
Subject: Storage of Medications
Revised 11/97

Policy:
.....Controlled drugs must be stored under double locks.....

Facility Policy

Nursing Service
Subject: Controlled Substances
Revised: 11/97

Policy:

.....They must be kept under double lock at all times......

The following statement constitute minimum requirements for security of controlled substances:
1. Controlled substances must be kept under double lock at all times.


On 5/1/12 at 12:00 PM, the surveyor observed Employee Identifier (EI) # 6, a licensed practical nurse, use a key to open the cabinet door to the controlled medications at the ER nurses station. The surveyor observed there was only one door to the controlled medication storage area.

At the time of the observation, EI # 6 confirmed the controlled medications at the ER nurses station were not double locked.

During an interview on 5/2/12 at 8:10 AM, EI # 1, Director of Nurses, confirmed the controlled medications at the ER nurses station was not double locked. EI # 1 stated that the outside door of the storage area was broken but was being repaired.

Based on observation, policy review and staff interview, it was determined the facility failed to ensure that unauthorized staff did not have access to the main pharmacy in the Inpatient Unit. This had the potential to affect all patients and staff at the facility.

Findings include:

Facility Policy

Nursing Service
Pharmacy
Subject: Pharmacy Procedures
Revised: June 2008

Procedure:
1. The Pharmacist, DON (Director of Nurses), Pharmacy Tech, ADON ( Assistant DON) and the Charge Nurse are the only persons to enter the main pharmacy located on the Inpatient Unit.....


During a tour of the Inpatient Unit on 5/2/12 at 8:45 AM, the surveyor asked to see the medication room for the unit. Employee Identifier (EI) # 3, a Licensed Practical Nurse (LPN), went to the door of the main pharmacy located in the Inpatient Unit and started to unlock the pharmacy door with a key.

The surveyor asked EI # 3 who had access to the pharmacy. EI # 3 stated that the medications for the patients are kept in the medication cart but if a medication was not in the cart they could go into the pharmacy and get the medicine. The surveyor observed there was no medication room in the Inpatient Unit.

On 5/2/12 at 8:50 AM, the surveyor asked EI # 5, the Pharmacy Technician, who was suppose to have access to the pharmacy and she stated the Director of Nurses and the Charge Nurse. She confirmed the Charge Nurse was a Registered Nurse (RN).

During an interview on 5/3/12 at 8:35 AM, EI # 1, DON, confirmed the LPNs were not suppose to have access to the main pharmacy in the Inpatient Unit.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.

Findings include:

Refer to Life Safety Code violations.

Based on observation and staff interview, it was determined the facility failed to assure all medical supplies available for patient use in the Emergency Room (ER)) were not expired. This had the potential to affect all patients.

Findings include:

The surveyor conducted a tour of the ER on 5/1/12 at 1:25 PM. During the tour the surveyor observed the following expired supplies in ER treatment room # 3:

1 Adult QuickTrach to be used by 5/2007
1 Pediatric QuickTrach to be used by 11/2011
1 EZ 15 Gauge (G) needle set expired 10/2011
3 EZ Connect Fluid Transducer sets expired 04/2011
1 EZ Connect Fluid Transducer set expired 11/2011
4 EZ Connect Fluid Transducer sets expired 5/2011
2 Ross 14 French (FR) Enteral Feeding tubes use by 6/2007
3 Insyte Autoguard Intravenous 18 G (IV) catheters expired 3/2009
1 Insyte Autoguard IV 18 G catheter expired 6/2010
1 Insyte Autoguard IV 18 G catheter expired 1/2010
1 Insyte Autoguard IV 16 G catheter expired 1/2010
1 Insyte Autoguard IV 16 G catheter expired 3/2007
6 Insyte Autoguard IV 16 G catheter expired 5/2008
2 Insyte Autoguard IV 24 G catheter expired 12/2011
2 Insyte Autoguard IV 24 G catheter expired 3/2010
1 Insyte Autoguard IV 24 G catheter expired 10/2009
1 Insyte Autoguard IV 24 G catheter expired 10/2010
2 18 G Huber Needles expired 12/2011
1 Bottle of Plain Packing Strips expired 11/2011

During an interview on 5/1/12 at 2:05 PM, Employee Identifier, (EI) # 6, a licensed practical nurse (LPN), confirmed the aforementioned findings.

Based on observation and interview with administrative staff, it was determined the hospital failed to ensure staff followed the facility policy for aseptic wound care techniques and ensure appropriate infection control practices were carried out throughout the hospital departments. This affected Medical Record (MR) # 3 and had the potential to affect all patients admitted to the facility who had wounds and had the potential to affect all patients who required Computed Tomography (CT) with Intravenous (IV) contrast.


Findings include:

Facility Policy

Procedures for Washing Hands
Purpose

1. To clean hands, before and after handling equipment or caring for the patient; to protect the patient, yourself and others.

2. To reduce the possibility of transmitting infection to the patient or from him to yourself or others.

Special Notation

Adequate washing of hands is one of the most effective methods to control the spread of disease...

Subject: Handwashing

Handwashing is the single most effective deterrent to the spread of infections.

Policy:

Hospital personnel shall wash their hands to prevent the spread of infections:

... 2. Before applying and after removing gloves...


During medication administration to MR # 3 on 5/2/12 at 8:45 AM, Employee Identifier (EI) # 2, Registered Nurse performed wound care to the patient's left ankle. EI # 2 failed to clean her hands prior to donning gloves, removed the old dressing to the left ankle, which had bloody drainage, then removed her gloves. EI # 2 donned clean gloves, cleaned the wound to the left ankle, applied Triple Antibiotic ointment to the wound bed, then applied Telfa, 4 by 4 and secured with tape. EI # 2 removed her gloves, donned clean gloves and assisted the patient with the application of his/her sock. EI # 2 removed gloves, then washed her hands.

EI # 2 failed to wash her hands prior to or after the application of clean gloves, after the removal of a soiled dressing, prior to cleansing the patient's wound or prior to the application of a clean dressing.

An interview was conducted on 5/3/12 at 1:25 PM with EI # 1, Director of Nurses, who verified EI # 2 failed to follow the policy for handwashing during wound care.

On 5/1/12 at 10:45 AM, the surveyor observed located in the CT room was a 1000 milliliter (ml) bag of 0.9% Sodium Chloride, which had been spiked with approximately 600 ml remaining in the bag. There was no documentation on this bag when the contents were spiked.

An interview was conducted on 5/1/12 at 10:45 AM with EI # 4, Director of Radiology, who stated that the above mentioned bag of IV fluid was to use for patients who needed IV contrast. EI # 4 stated that he hung a new bag on a daily basis. The surveyor informed EI # 4 that the bag of IV fluid was for single use only and could not be used for multiple patients.

On 5/2/12 at 2:00 PM, the surveyor returned to the CT room and found a 1000 milliliter (ml) bag of 0.9% Sodium Chloride, which had been spiked with approximately 600 ml remaining in the bag and unlabeled of when the bag was spiked. During this time, EI # 4 stated he had forgotten to remove the IV fluid bag. He then removed it to discard the contents.