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Based on records review and interviews, the facility did not ensure 1 of 1 patient (Patient #1) received care in a safe environment, in that a registered nurse (RN) (Personnel #8) did not follow current standards of practice for infection control. Personnel #8 did not use a sterile tubing when administering intravenous antibiotic on 8/3/14.

Findings included:

Per medical records, Patient #2 was admitted in 10 West Telemetry Room #1072 on 7/28/14 for chest and abdominal pain. She was subsequently discharged on 8/2/14.

Per medical record, Patient #1 was admitted as an inpatient to the facility on 8/2/14, at 8:45 PM, in the same room as Patient #2, Room #1072. The admitting diagnoses included End Stage Renal Disease (ESRD), for acute dialysis/ unfunded chronic dialysis, and antibiotic administration for cellulitis of the right lower extremity.

The Medication Administration Record on 8/3/14, at 2:35 AM, indicated the night shift primary care nurse (Personnel #8) administered antibiotic intravenously as ordered by the physician to Patient #1. The ordered antibiotic was "Zosyn 3.375g" which was to be infused extendedly for 4 hours due to Patient #1's renal insufficiency.

Nurses Notes on 8/3/14, at 7:24 AM, by staff nurse (Personnel #12) showed "...IV tubing in room start date was 7/31, NS (normal saline) TKO (to keep open) with the name of another patient. Tubing discarded."

In an interview on 9/9/14 via telephone call, Personnel #8 acknowledged that he re-used the tubing that was used by Patient #2 who previously occupied Patient #1's room.

Based on records review and interviews, the registered nurse (RN) failed to administer medications in accordance with nationally accepted standards of care to reduce the risk of infection in 1 of 1 patient (Patient #1). Patient #1 received intravenous (IV) antibiotic medication via used tubing of another patient that previously occupied Patient #1's room on 8/2/14.

The RN failed to:

(1) check a patient's room to ensure it was clean and ready to be occupied by Patient #1;

(2) ensure that the staff RN (Personnel #8) had appropriate communication with the staff who initially transported Patient #1 for admission to the unit; and

(3) ensure that once the incident was discovered, it was immediately reported to management.


Findings included:

Per medical records, Patient #2 was admitted in 10 West Telemetry Room #1072 on 7/28/14 for chest and abdominal pain. She was subsequently discharged on 8/2/14.

Per medical records, Patient #1 was admitted in 10 West Telemetry, same room as Patient #2, Room #1072, on 8/2/14 for End Stage Renal Disease (ESRD) for acute dialysis/ unfunded chronic dialysis and antibiotic administration for cellulitis of the right lower extremity (RLE).

(1) Medication Administration Record dated 8/3/14, at 2:35 AM, indicated the night shift primary care nurse (Personnel #8) administered antibiotic intravenously to Patient #1 as ordered by the physician. The ordered antibiotic was "Zosyn 3.375g" which was to be infused extendedly for 4 hours due to the patient's renal insufficiency issue.

Nurses Notes on 8/3/14, at 7:24 AM, by staff nurse (Personnel #12) on Patient #1 showed "...IV tubing in room start date was 7/31, NS (normal saline) TKO (to keep open) with the name of another patient. Tubing discarded."

In an interview on 9/9/14, at 11:00 AM, via telephone call, Personnel #8 acknowledged that he re-used the tubing that was used by a patient who previously occupied Patient #1's room. Personnel #8 acknowledged that he did not have time to inspect the room to ensure it was clean and ready for Patient #1's admission.


(2) The RN did not ensure that the staff RN (Personnel #8) had effective communication with the staff who initially transported Patient #1 for admission to the unit.

There was no documentation in the patient's medical record that a nurse received report from the staff who transported Patient #1 to the unit.

In an interview on 9/9/14, at 11:00 AM, via telephone call, Personnel #8 acknowledged that he did not receive report from the individual who transported Patient #1 to the unit.


(3) The RN did not ensure that once the incident was discovered, it was immediately reported to management.

Medical records indicated the incident was discovered on 8/3/14 at 7:24 AM.

In an interview on 9/8/14, at 9:48 AM, Personnel #12 stated that she discovered the incident the morning of 8/3/14. However, she did not report this to the charge nurse (Personnel #13) until 3:00 PM on the same day.

In an interview on 9/3/14, at approximately 1:00 PM, Personnel #1, in the presence of Personnel #2, was asked about the delay of reporting of the incident to the proper channels. Personnel #1 acknowledged that there was a delay of the incident reporting from the staff nurse (Personnel #12) to the charge nurse (Personnel #13) to the supervisor (Personnel #10).

Hospital policy Admin 6-40 "Hands Off Communication - All" dated 8/2013 showed:

"Purpose: To provide consistent, accurate, timely and unambiguous communication between members of the clinical staff including the opportunity to ask and respond to questions...

Procedure: 1. Nurse to Nurse Hand-off A. Situations where Nurse to Nurse Hand-off is required 1. Transport of patient's care from one nurse to another...examples...Emergency Department (ED) to inpatient, Inpatient to inpatient...Methods...1. Telephone, 2. Face to Face...II. Nurse to ancillary staff for transport housewide...this will provide opportunity for each staff member to ask and respond to questions."


Hospital policy Admin 5-18 "Adverse Events" dated 2/2013 page 9 and 11 showed "Medication Error: Any preventable that may cause or lead to inappropriate medication use, patient harm...Such events may be related to professional practice...G. For all events, immediately notify appropriate leadership..."