HospitalInspections.org

17956

Based on observations, record reviews and staff interviews, it was determined the facility failed to ensure the appropriate patient care policy and procedure was developed, approved, and in place for nursing staff to utilize and follow in regards to Z-track Injections for the care of Patient #7.

Findings include:

Observations made during a medication pass on 04/27/10 at 11:00 AM, revealed Licensed Practical Nurse (LPN) #1 gave an intramuscular injection of iron to Patient #7 in his/her left dorsal gluteal (outer hip/buttocks region). While performing the injection, LPN #1 pinched up a large amount of tissue and injected the iron into the tissue.

An interview with LPN #1, on 04/27/10 at 11:15 AM, revealed iron should be administered in the Z-track method to prevent staining of the skin. She stated she thought she had administered the iron using the Z-track method. She thought Z-track involved "twisting" the patient's skin.

An interview with the Director of Nursing (DON), on 04/27/10 at 2:00 PM, revealed the proper procedure for administering iron by Z-track method was to draw up the iron, dispose of the needle, place a new needle on the syringe, and include .3 to .5 ml of air in the syringe. The administration technique included holding the skin and subcutaneous tissue about 1 to 1.5 inches laterally from the injection site and hold the displaced skin and tissue until after the needle is removed. She revealed the facility had no written patient care policy and procedure in place regarding Z-track injections.

The facility failed to have written protocols and/or a policy and procedure regarding administering iron in the Z-track method. Additionally, LPN #1 failed to administer the iron in the Z-track method and had no facility resources.

Based on observations, interviews and record review, it was determined the facility failed to ensure its' policies and procedures were updated to address what level of practitioner could perform the medical screening exam (MSE) of patients presenting to the Emergency Department (ED) to determine if an emergency medical condition (EMC) existed.

Observations made during a tour of the ED on 04/26/10 at 11:20 AM, revealed Advanced Registered Nurse Practitioner (ARNP) #1 was staffed in the ED to provide the MSE to patients. On 04/28/10 at 2:20 PM, Physician's Assistant (PA) #1 was staffed in the ED to provide the MSE to the ED patients.

Interviews with PA #1 and the ED Nurse Manager on 04/28/10 at 2:20 PM, revealed ARNPs and PAs had been working in the ED for the past year. They stated a physician was present in the facility and available if needed but the ARNP or the PA could provide the MSE to determine if an EMC existed or not. The ED Nurse Manager stated the hospital failed to update the facility policies and procedures and the bylaws and rules regulations to include PAs and ARNPs in performing the MSE.

Review of the facility's ED policy and procedure entitled "Supervision" revealed there would be a "Physician on duty to evaluate the emergency patients." Review of the the facility's bylaws and rules and regulations revealed there was no evidence the hospital addressed who was qualified to perform the MSE.`

An interview with the Executive Assistant on 04/28/10 at 2:50 PM, revealed the facility bylaws and rules and regulations had not been revised in many years and did not address who the facility had determined to be qualified to perform the MSE to determine if an EMC existed.

Based on observations, interviews and record reviews, it was determined the facility failed to ensure all drugs that were available for patient use were not outdated (expired) and were properly labeled.

Findings include:

Observations conducted during a medication pass on 04/27/10 at 10:15 AM, revealed two bottles of Welchol 625 mg and one bottle of Vitamin D 1000 IU were in Patient #10's medication drawer. There were no pharmacy labels on the medication bottles and the expiration dates on the bottles had been marked out. Eight Bisacodyl 10 mg suppositories was stored in the medication refrigerator. The expiration dates on the suppositories were not legible.

An interview with Licensed Practical Nurse (LPN) #1 on 04/27/10 at 10:20 AM, revealed Patient #10 brought in the bottles of Welchol and Vitamin D when admitted to the facility. They had been administering both the Welchol and the Vitamin D from the bottles brought in by the patient.

An interview with the Director of Nursing (DON) on 04/27/10 at 10:30 AM, revealed the nurses should not administer medications that had not been inspected and labeled by the hospital pharmacy. Drugs should not be administered if the expiration date was not clear or the bottle had been tampered with.

Review of the Pharmacy policy entitled "Unit Inspection" revealed all drug labels must be legible and in compliance with state and federal requirements. Drugs shall not be kept in stock after the expiration date on the label. Review of the Pharmacy policy entitled "Proper Labeling" revealed the following: Labeling shall include the name and strength of the drug, the trade name, the lot number or reference code and the expiration date.

17956

Based on observations, record reviews and staff interviews, it was determined that the facility failed to ensure their system for identifying infection control problems was effective.

Findings include:

Review of the facility policy entitled "Standard Precautions" revealed facility staff were to use Standard Precautions for avoiding exposure to blood and body substances to minimize the risk of transmission of infectious diseases. All employees were to routinely use appropriate barrier precautions to prevent skin and mucous membrane exposure when contact with blood or body substances of any patient was anticipated by wearing gloves, masks, gowns or apron, and protective eyewear when procedures were performed.

1. Observations made on 04/27/10 at 10:00 AM of Patient #1 revealed Registered Nurse (RN) #1 assisted the patient to his/her side so the skin condition could be assessed. Patient #1 was non-ambulatory, was wearing disposable underwear, and was lying on an incontinent pad. RN #1 rolled Patient #1 to his/her side and pulled the patient's underwear down. RN #1 touched the buttocks and rubbed areas on the buttocks with her unloved hand while assessing the skin. RN #1 then repositioned Patient #1, pulled the privacy curtain back, and placed her hands on her hips (on her uniform). No gloves were worn by RN #1 at any time during the examination.

2. Observations made during a medication pass on 04/27/10 at 10:50 AM, revealed RN #2 was administering medication to Patient #6. RN #2 entered Patient #6's room and placed the medication administration record (MAR) on the patient's bedside table. When RN #2 finished administering medication to Patient #6, she took the MAR out of the room, back to the medication room, and placed the MAR back in the medication book.

3. Observations made on 04/28/10 at 11:00 AM, of Patient #10 revealed the Case Manager and the Activities Director positioned Patient #10 on his/her back. Patient #10 was wearing incontinent briefs. The staff untaped the brief and touched the buttocks of Patient #10 with ungloved hands.

4. Observations made during a medication pass on 04/27/10 at 11:00 AM, revealed Licensed Practical Nurse (LPN) #1 entered Patient # 7's room with the patient's MAR and two injections. She had the patient roll over and placed the patient's MAR on the bed sheets where the patient had been lying. She administered an intramuscular (IM) injection of iron to Patient #7 in his/her left dorsal gluteal (outer hip/buttocks region) and an IM injection of Vitamin B12 in his/her right dorsal gluteal. Observations of both IM injections revealed LPN #1 failed to wear gloves during the IM injections. Additionally, after LPN #1 had finished administering the IM injections to Patient #7, she removed the patient's MAR off the patient's sheets and proceeded to the medication room, where she placed the MAR back into the medication book.

An interview with the Director of Nursing (DON) on 04/28/10 at 1:00 PM, revealed anytime staff handled an area of a patient where they might come into contact with body fluids, gloves should be worn. Additionally, placing a MAR on a bedside table of a patient and/or on the patient's sheets, without some type of barrier and then taking it out of the room, had a potential to cause cross contamination.

17956

Based on record reviews and staff interviews, it was determined the facility failed to ensure nursing care plans were developed, individualized to meet each patient's specific care needs, updated, and kept current for five patients (#1, #2, #7, #10, and #14) in the selected sample of twenty.

Findings include:

1. Record review of Patient #1 revealed he/she was admitted on 04/19/10 with some redness to his/her buttocks. Patient #1 was unable to walk and was incontinent at times. Review of the care plan for Patient #1 revealed skin integrity was not identified as a problem until 04/24/10. The skin care plan did not include any goals related to impaired skin integrity and the only intervention was "Continue skin care protocol."

2. Review of the nursing care plans for Patients #2, #7, #10, and #14 revealed skin integrity was identified as a potential problem. The intervention to be implemented was "Initiate skin care protocol." Thereafter, the intervention was documented as "Continue skin care protocol." There were no specific interventions included on the care plans.

Review of the facility's policies and procedures and protocols revealed the facility had no skin protocols developed and in place for staff to utilize and/or implement for patient care.

An interview with the DON on 04/28/10 at 10:00 AM, revealed the facility did not have any skin protocols or an assessment tool to assess patients for potential impaired skin integrity.