HospitalInspections.org

The Critical Access Hospital reported a census of one acute care patient and four swing bed patients. Based on observation, staff interview and policy review the facility failed to ensure staff followed hospital policy and recommended standards of practice to prepare and administer medications.

Findings include:

- Policy #N-3010, " Reconstitution of parental medications " , failed to direct staff to use one needle and one syringe, one time only, and failed to direct staff to acquire a new needle and syringe when re-entering an Intravenous bag (IV) or vial of medication.

- Staff A, a Registered Nurse (RN) was observed on 2/5/13 at 1:00pm using a 30 syringe and needle to remove 20cc of normal saline from a 100 ml bag. Staff A failed to change the needle and syringe before entering the IV bag the second time to draw another 20cc of Normal Saline. With the same needle and syringe, Staff A, RN proceeded to draw up the ordered amount of Levaquin (a medication used to decrease an infection) 500mg to add to the IV bag with the same needle and same syringe.

Staff A, RN, interviewed on 2/6/13 at 1:00pm confirmed they did not know it was necessary to change needles and syringes when using them for the same patient.

Staff D, RN, Infection Control Nurse, interviewed on 2/6/13 at 2:30pm confirmed they did not know it was necessary to change the needles and syringes for the same patient.