HospitalInspections.org

Based on observations, policy review, and staff interviews the facility failed to ensure nursing staff followed standards of practice and policies and procedures for appropriate hand hygiene for 4 of 11 observations (RN Staff B, RN Staff G, RN Staff V, and RN Staff Z). The hospital's failure to ensure the nursing staff perform hand hygiene as directed places patients at risk for healthcare acquired infections.

Findings Include:

Policy titled "Hand Hygiene" reviewed on 1/3/18 directed staff, wash and sanitize hands frequently and throughout the day. Indications for hand hygiene may include: Before and after contact with a patient, before handling clean or sterile items, and after removing gloves.

- Observation on 1/2/18 at 12:15 pm in the day room of the rehabilitative unit, RN Staff B was standing at the computer next to Patient #4. RN Staff B, wearing gloves, scanned the medication and patient's bracelet and then walked to a cupboard to obtain a bib. RN Staff B failed to remove gloves and perform hand hygiene after contact with Patient #4 and prior to touching the cupboard to get supplies, thus possible contaminating the cupboard. Then, RN Staff B returned to the computer and administered the medication to Patient #4. RN Staff B failed to remove gloves, perform hand hygiene, and don new gloves prior to administering the medication to Patient #4, thus possibly contaminating the computer, the medication, and Patient #4 with organisms present on the cupboard. Following the medication administration, RN Staff B removed their gloves and returned to the computer. RN Staff B failed to perform hand hygiene after the gloves were removed, thus possibly contaminating the computer.

Interview on 1/2/18 at 12:20 pm in the day room, RN Staff B stated the gloves were not really necessary to give the oral medication, "I just had them on and no I did not wash my hands after I removed them".

- Observation on 1/2/18 at 2:35 pm in Coronary Care Unit (CCU) room 3, RN Staff G was preparing to administer intravenous (IV) antibiotics to Patient #9. RN Staff G failed to perform hand hygiene when entering the patient's room. RN Staff G did not perform hand hygiene prior to preparing to attach the IV fluid to the infusion tubing that was attached to the patient's IV line. Then, RN Staff G exited the patient's room and failed to perform hand hygiene.

Interview on 1/2/18 at 2:45 pm outside of Patient #9's room, RN Staff G stated, "I know the policy, but I didn't do it", when asked the requirements for hand hygiene prior to entering a patient's room, before and after patient contact, and after leaving the room.

- Observation on 1/3/18 at 9:30 am in CCU room 2, RN Staff V was preparing to administer medication through Patient #8's feeding tube. RN Staff V donned clean gloves but failed to perform hand hygiene prior to putting on the gloves.

Interview on 1/3/18 at 11:15 am in CCU break room, RN Staff V stated, "I guess I did forget to wash my hands" when asked about the requirements for hand hygiene prior to donning gloves.

- Observation on 1/3/18 at 10:45 am in patient room 169, RN Staff Z performing two dressing changes on Patient #23. RN Staff Z, wearing gloves, removed Patient #23's abdominal dressing and then removed their gloves. RN Staff Z reapplied gloves and redressed the abdominal wound. RN Staff Z failed to perform hand hygiene between glove changes. Then, RN Staff Z had Patient #23 roll onto their side in preparation to change the back dressing. RN Staff Z removed their gloves and reapplied another pair of gloves. RN Staff Z failed to perform hand hygiene between glove changes.

Interview on 1/3/18 at 11:15 am regarding hand hygiene, RN Staff Z stated, "I always perform hand hygiene, but I guess this time I didn't perform hand hygiene between glove changes. I honestly cannot say what the policy says about hand hygiene between glove changes.

Based on observation, document review, and staff interviews, the hospital failed to ensure all medications were labeled correctly with expiration dates and administered as directed by manufacturer's guideline for 1 of 3 observations (RN Staff E). Failure to follow appropriate guidelines places all patients at risk for receiving ineffective, unsafe medications.

Findings include:

Document titled "Insulin Process Changes" directed, when placed in the Pyxis, insulin vials are to be dated according to the manufacturer recommendations. Use the following table: 28 Day Room Temperature Stability: Novolog.

- Observation on 1/2/18 at 3:10 pm in the nursing station of the rehabilitation unit, RN Staff E obtaining insulin for Patient #1. RN Staff E removed the multi-dose NovoLog (a medication given to reduce the amount of sugar in the blood) insulin vial from the Pyxis (a medication dispensing system), verified the insulin type, and drew the medication into the syringe. After replacing the cap on the syringe needle, RN Staff E replaced the vial in the Pyxis.

Interview on 1/2/18 at 3:12 pm in the nursing station of the rehabilitation unit, RN Staff E stated, "I did not look at the expiration date of the insulin." RN Staff E removed the vial from the Pyxis and noted the expiration date on the pharmacy label stated the insulin was to expire 12/28/18 (almost a year from today's date). RN Staff E further stated, "The pharmacy labels all of the multi-dose vials for when they are to expire when they stock the Pyxis. I don't really pay much attention to the expiration dates. According to the label, it is not outdated and I will give the insulin. It is a prolonged outdate but that is how the pharmacy labeled it."

Later interview on 1/2/18 at 3:45 pm, RN Staff E, stated "I spoke with the pharmacy and there was a mistake on the outdate label so they removed the vial of insulin from the Pyxis."

Interview on 1/2/18 at 4:00 pm, Pharmacist Staff C stated, "The pharmacy does label all of the multi-dose vials with the appropriate outdate when we stock the Pyxis. The Pyxis is supposed to have those outdates entered into it so staff are notified not to use an outdated medication. Because we store the insulin at room temperature instead of refrigerated, the expiration date depends on the type of insulin. We reference manufacturer's guidelines for the outdate labeling. I have no idea if nursing staff are told to monitor medication outdates. That would go to nursing, not pharmacy."