HospitalInspections.org

Based on observation, interview and document review, it was determined that the facility failed to administer medication in accordance with accepted standards of practice by leaving medications unattended on one (1) medication cart.

The findings include:

During a facility tour on May 7, 2018 at approximately 11:20 a.m. with Staff Member # 3, a medication cart was observed in the doorway of a patients room. Observed on top of the medication cart was two (2) empty pill packages, 1 pill package containing an orange pill and a syringe containing normal saline The curtain was pulled so no patient or staff could be observed from the hallway. Staff Member # 4 entered the room to address an alarm. Staff Member # 4 exited the room, took a few steps before returning to the room and removing the two (2) empty pill packages, the pill package containing the orange pill and the syringe and placing in the "red hazardous waste" container in the room.

An interview with Staff Member # 4 revealed "there were only empty pill packages on the cart and I discarded them". Staff Member # 4 denied he/she was the nurse assigned to that patient and did not leave the medication cart there. When informed there was more than empty pill packages on the cart, Staff Member # 4 stated "let me find the nurse". Staff Member # 4, after speaking with the nurse, stated "the nurse stated she found the aspirin on the floor and left the syringe on top of the cart after being distracted".

A review of the facility policy titled "Medication Administration" provided on May 7, 2018 at approximately 2:00 p.m. by Staff Member # 3 reads in part "the nurse remains with the patient until all oral medications have been actually swallowed and all medications taken".

Standards of practice for medication administration states "never leave medications unattended" per the American Nurses Association.

Based on medical record review and interview, it was determined that the facility staff failed to monitor and treat patients with complications of intravenous (IV) infusions for three (3) of ten (10) patients (Patients # 4, # 15 and # 18).

The findings include:

1. A medical record review for Patient # 15 on May 7, 2018 at 11:00 a.m. revealed documentation on February 21, 2018 at 9:24 a.m.: "Right Hand, peripheral IV, placed 02/19/2018 at 9:37 p.m.,1 attempt, size 20 G, removal date 02/21/2018 at 9:24 a.m., reason infiltration." There is no documentation of the infusion. There is no further documentation.
On February 21, 2018 at 1:05 p.m. documentation revealed: "Left forearm, peripheral IV, placed 02/21/2018 at 1:05 p.m., 2 attempts, size 22 G, removal date 02/21/21/2018 at 3:56 p.m." Documentation of the infusion reads "dextrose 5% - 0.4% NaCl with KCL 40 mEq/L". There is no further documentation.

A medical record review for Patient # 18 on May 8, 2018 at 11:30 a.m. revealed documentation on November 1, 2017 at 12:56 a.m.: "Peripheral IV, placed 10/30/2017 at 5:55 p.m., 1 attempt, size 18 G, removal date 11/01/2017 at 12:56 a.m." There is no documentation of the site or infusion. There is no further documentation.

An interview with Staff Member # 2 on May 8, 2018 at 2:00 p.m. revealed there was no further documentation on the intravenous (IV) sites or infusions for Patients # 15 and # 18.

An interview with Staff Member # 9, a registered nurse (RN) with twenty three (23) years of experience, on May 9, 2018 at 8:30 a.m. revealed: "If an infiltration occurs the extremity affected should elevated with cold or hot applied as appropriate for regular infusion. If the medication is damaging to the tissue, tell the Nurse Practitioner (NP) on call and administer antidote to prevent damage. Flush if possible."

The facility policy titled "Extravastation of vesicant agents" was reviewed. No general infiltration policy was provided.


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2. Patient #4's medical record documented an IV line placed on 2/11/18 in the left wrist, which Patient #4 pulled out at 8:00 A.M. on 2/13/18.
The IV was replaced at 8:30 A.M. on 2/13/18 in the left wrist. This IV was removed at 1400 (2:00 P.M.) on 2/13/18 due to infiltration. There was no indication in the medical record that any type of treatment was used for this infiltration.

Staff Member #6 stated, "I would have let the Charge Nurse and or the PA (Physician's Assistant) know the IV infiltrated and I would not have restarted it without a physician's order. I did not make a note about what I did for the infiltration and I should have."

Based on medical record review, interview and document review, it was determined that the facility failed to deliver respiratory care services in accordance with facility policy by delaying application of Bilevel positive airway pressure (BiPap) and/or continuous positive airway pressure (CPAP) device for one (1) patient (Patient # 18). (CPAP is a machine that forces air into the nasal passages at pressures high enough to overcome obstructions in the airway and stimulate normal breathing. BiPap is very similar to CPAP but has two pressure settings: one pressure for inhalation and a lower pressure for exhalation).

The findings include:

A medical record review on May 8, 2018 at 11:30 a.m. for Patient # 18 revealed the following:
Patient # 18 was admitted on October 29, 2017 at 3:32 p.m. The admission history and physical (H&P) reveals chief complaint: shortness of breath, history of present illness: the patient has a history of hypertension and chronic obstructive pulmonary disease (COPD). He also has a history of obstructive sleep apnea. The plan reads, in part: "will start him on bedtime BiPap in view of his history of obstructive sleep apnea."
Physicians orders reveal an order for BiPap on October 29, 2017 at 7:40 p.m. Another order is documented for CPAP on October 30, 2017 at 8:07 p.m.
Flowsheets reveal CPAP applied on October 30, 2017 at 1:41 a.m. by a respiratory therapist (six (6) hours after it was ordered).

An interview with Staff Members # 10 and # 11 on May 9, 2018 at 9:00 a.m. revealed the following:
Staff Member # 10 stated: "We always have machines (BiPap/CPAP) in the department that patients can use". Staff Member # 10 stated: "When orders are placed, they populate onto the work list on the computer. All staff have access to the worklist". Staff Member # 10 revealed respiratory would normally make rounds around 7 or 8 p.m. and talk with patient and return to set up machine before their bedtime.
Staff Member # 11 stated: "It is the expectation that the machine would be in the room and on the patient long before 1:00 a.m."

The facility policy titled " Non invasive positive pressure ventilation (NIPPV) / BIPAP for adults" provided by Staff Member # 3 on May 9, 2018 at 9:30 a.m. reads, in part: "the (facility name)'s goal is to provide a noninvasive way to ventilate and oxygenate patient to ensure comfort, safety and optimal clinical outcomes. Upon receipt of a physician order, proper patient instruction, initiation and monitoring will be provided per protocol to ensure patient understanding, compliance and proper utilization of therapy."