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NORTHERN LIGHT A R GOULD HOSPITAL
SUPERVISION OF CONTRACT STAFF
Tag No.: A0398
Based on document reviews, interviews and observations, the hospital failed to ensure nursing staff followed the hospital's Medication Administration and Management policy for one (1) of one (1) registered nurses observed. (RN #1).
Findings:
The hospital's policy titled, ""Medication Administration and Management policy, last revised 11/20/2024" states in part, " ... Medications should never be stored or transported in clothing or pocket ...".
On 5/20/2025 at 9:00 AM, surveyors observed RN #1 preparing in the medication room and then proceeding to pt #11's room to administer medicaitons.
This observation revealed the following:
- RN #1 was observed to be carrying three (3) prefilled syringes in the cargo pocket on her right scrub pant leg to patient #11 room.
-Upon leaving patinet 11's room, RN#1 reentered the Medication Room with the same three (3) prefilled syrninges in the cargo pocket on her right scrub pant leg.
On 5/20/2025 at 9:30 AM, the Director of Inpatient Nursing and the Medical/Surgical unit Manager both confirmed that RN #1 was carrying prefilled syringes in the cargo pocket on her right scrub pant leg .
DISCHARGE PLANNING-D/C PLANNING LIST
Tag No.: A0815
Based on MR (medical record) reviews and staff interviews it was determined the hospital failed to ensure the staff provided patients a list of available home health agencies in one (1) of ten (10) inpatient MRs reviewed with a home health referral. (#DP5 )
This deficient practice had the potential to negatively affect all patients referred for post-acute care services.
-#DP5 was admitted to the hospital on 4/7/2025 with diagnoses including Acute and Chronic Pysical Deconditioning with Fall at Home; Delirium; Chronic Systolic Congestive Heart Failure, Chronic Pain Syndrome: Hypertensive Disorder; Pressure Ulcer of Sacrum; and Severe Protein Calorie Malnutrition of Chronic Illnes.
-Review of the Physician's Orders dated 4/8/2025 revealed an order to refer the patient to home health.
-Review of the MR revealed no documentation the patient was provided a list of available home health agencies which served the area.
-An interview was conducted on 5/20/20253 at 12:25 PM with the Manager of Case Management who confirmed there was no documentation the patient was provided a list of available home health agencies which served the area.