HospitalInspections.org

Based on observations, facility policy and procedure and interviews, it was determined the hospital failed to ensure that expired medications and supplies were not available for patient use and multi-dose medications were initialed and dated when opened. This had the potential to affect all patients.

The findings include:

Facility Policy:
Subject: Medication Administration Guideline
Reference # NUR 1703

...Preparing and Dispensing
...Length of use of Multi-Dose Vials:
1...When multi-dose vials...are used, the expiration date for the affected medication will be 28 days from the day the vial is opened...
2. Multi-dose vials (containing a preservative) that are opened by personnel will be labeled with the date opened and the initials of the person opening the vial...

During the initial tour of the facility on 2/26/13 at 12:05 PM the surveyor observed the following medications with expired dates:

1-Humalog 50/50 10 ml (milliliters) bottle expired 10/2012
1-Novolin 10 ml bottle expired 1/2013
24- Tablets of Lactinex expired 12/11/12
8- Packets of Lactinex expired 2/14/13
2 - Bottles of Epogen 1 ml bottle expired 11/2012
2 - Package of 3 Lemon- Glycerin Swabs expired 10/2011
3 -package of Tegaderm AG Mesh 4 inch by 5 inch expired 12/2011
14 - Packages of White Petrolatum Expired April 2012
1- Bottle of Hemoccult Developer 15 ml Expired April 2011




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A tour of the nursing unit was conducted 2/26/13 at 2:50 PM with Employee Identifier (EI)'s # 16 and # 17, staff nurses. During the tour, the surveyor observed a bottle of Hydrocodone/APAP (acetaminophen) Elixir 7.5 mg(milligrams)/500 mg per 15 ml (milliliter), Lot number- IL17 and Poly-Tussin 3 mg/5 ml, Lot 1451, in the narcotic lock box, open with no date or initials of the person who opened the multi-dose medication. EI # 16 reported the bottles were not initialed and dated.

During the tour, the surveyor inspected the nursing unit crash cart with EI # 15, Registered Nurse. Ten laboratory tubes were found on the crash cart. Ten of ten laboratory tubes were expired. EI #15 removed the tubes and reported she would get the tubes replaced.

An interview, conducted 2/27/13 at 3:30 PM, with EI # 1, Director of Nursing (DON), validated multi-dose medications must be dated and initialed by staff when opened.

A tour of the Rehab (Rehabilitation Unit) was conducted 2/28/13 at 12:50 PM, with EI # 6, Director of Therapy. During the tour, the surveyor identified the following with expired dates:
45 individual packs of Xeroform Petroleum dressing 5 inch by 9 inch expired 4/2012.
1 roll of Gelocast 3 inch by 10 yards expired 7/16/12.
1 bottle of Sterile Water 1000 milliliters expired 5/2011.
1 jar of Thermazine Silver Sulfadrazine Cream 1 % 14 ounces expired 8/2010.
7 packs of Opsite 10 centimeters (cm) by 20 cm expired 8/2011.
42 individual packs of Xeroform Petroleum dressing 5 inch by 9 inch expired 10/2012.
1 pack Q-Zene antimicrobial whirlpool additive expired 3/2008. EI # 6 reported Q-Zene is no longer used.

One tube of Collagenase Santyl 30 grams (gm) NDC 0064-5010-30 and one tube of Santyl 15 gm NDC-0064-5010-15, opened with no initials or date, was found in the cabinet drawer in the rehab unit.

During the tour, an interview was conducted with EI # 6, who confirmed the above findings.





32470

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.

Findings were:

Refer to Life Safety Code violations.

Based on medical record (MR) review, review of nursing policy and procedure, review of personnel files, and staff interview, the facility failed to ensure nursing staff were competent to perform whirlpool treatments. This affected MR # 19 and had the potential to negatively affect all patients served by the facility.

The findings include:

MR # 19 was admitted to the facility 8/16/12 with diagnosis of Cellulitis of both lower legs. Record review revealed the following physician orders: "... 8/16/12 1709 Nursing service-whirlpool tx (treatment) Bilat (bilateral) L.E.(lower extremity) BID (twice daily) at 10 (AM) & 2200 (10PM). Wound care to BLE (bilateral lower extremity)-clean with hibiclens, lightly scrub with 4x4's (gauze), then whirlpool, pat dry, apply telfas (nonadherent dressing), 4x4's, then secure with kling and tape..."

Review of 8/16/12 and 8/17/12 nursing documentation revealed whirlpool treatment was performed by a Licensed Practical Nurse (LPN).

Review of the 8/18/12, 8/19/12 and 8/20/12 nursing documentation revealed whirlpool treatments were performed by two Registered Nurses (RN's).

Review of the Nursing Policy/Procedure Manual failed to include a policy for whirlpool treatments.

An interview with Employee Identifier # 1, Director of Nursing, was conducted on 2/28/12 at 9:00 AM, who validated no whirlpool treatment competencies were performed on the three nursing staff that provided the whirlpool treatments on MR # 19.

Based on review of the hospital policy and procedure, medical record (MR) reviews and interview with Employee Identifier (EI) # 1, the Director of Nursing (DON), the facility failed to ensure that care was administered as ordered by the physician for 2 of 2 patients (MR # 19 and MR # 21) with wounds and 4 (MR # 4, MR # 20, MR # 19 and MR # 21) of 22 patients received care as ordered by the physician.

The findings include:

Policy
Swing Bed Care Plans
Reviewed and Revised 09/12
Purpose
To ensure, based on the physician's order, in terms of the patient's physical and mental condition these services require the involvement of skilled nursing personnel to meet the patient's medical needs, promote recovery and ensure medical safety.

1. MR # 14 was admitted to the facility 2/11/13 with diagnoses including Severe Bilateral Cellulitis of the feet and lower legs.

A Physician's Order dated 2/11/13, listed, "Apply Gentamicin Cream to legs BID (twice a day) and cover with Kerlix."

Another Physician's Order dated 2/15/13, "May apply Aquaphor cream to affected areas. PRN (when needed)." This order did not indicate where the affected areas were located.

The Medication Administration Record dated 2/15/13 to 2/18/13 for MR # 14 included, "Gentamicin cream apply to legs BID (2 times a day) per patient". The physician order did not direct the patient to medicate himself.

2/12/13 PT (Physical Therapy) Note- Dressings removed from bilateral LEs (left extremities) ... Sharp debridement to bilateral feet, Gentamicin applied to bilateral heels and wrapped with Kerlix, Medipore tape and covered with stretch netting. Skin tear ... right shin area ... suggested applying Gentamicin to that area as well and wrap." There was no physician order for the Gentamicin to be applied to the skin tear.

2/13/13 PT Note - "Sharp Deb (debridement) to both feet w (with) scissors and tweezers. Redressed w Gentamicin cream, Xeroform, Telfa, and lg (large) Kerlix." There was no physician order for the debridement, Xeroform, Telfa, or Kerlix.

2/18/13 PT Note - "Pt seen for wound MGMT (management) this AM, Patient LE (lower extremities) Unna Boots removed. Then Sharp debridement performed as needed to bilateral feet. Patient then dressed with wound Hydrogel, Xeroform, Kling, spandage (bandage)." There was no physician order for the Sharp debridement, Xeroform, Unna Boots, or Kling.

2/19/2013 PT Note - "Patient's dressings to bilateral LE'S removed today. Sharp debridement as needed to bilateral feet. Wound Hydrogel applied, Xeroform Petroleum and wrapped with Kling and Coban." There was no physician order for the Sharp debridement, Xeroform, Kling, or Coban.

2/20/13 PT Note - "Dressings to bilateral feet removed, sharp debridement as needed. Hydrogel applied to bilateral feet. Xeroform Petroleum dressing applies and covered with Kling, Coban and netting." There was no physician order for the Sharp debridement, Xeroform, Kling, or Coban.

2/21/13 PT Note - "Dressings removed to bilateral feet, sharp debridement performed as needed. Hydrogel applied, and redressed with Kerlix between toes to absorb any excess sweat Xeroform to bottoms of feet. Kerlix from base of foot to just below knees, Coban and netting." There was no physician order for the Sharp debridement, Xeroform, Kerlix, or Coban.

2/22/13 PT Note - "Dressings removed on bilateral feet, sharp debridement as needed to bilateral feet. Hydrogel applied. Xeroform Petroleum dressing, Kerlix between toes and covered from toes to just below knees with Kerlix and Coban." There was no physician order for the Sharp debridement, Xeroform, Kerlix, or Coban.

2/23/13 PT Note - "Patient received sharp's debridement of both feet today with considerable dry tissue removed from both feet." There was no physician order for the debridement of MR # 14's feet.

2/25/13 PT Note - "Dressings removed to bilateral feet. Sharp debridement completed as needed. Applied Hydrogel to bilateral feet. Redressed with Xeroform Petroleum dressings to heels and bottom of feet followed by Kerlix and Coban, bilateral feet wrapped this way from toes and ankle, applied lotion from ankles to knee." There was no physician order for the Sharp debridement, Xeroform, Kerlix, or Coban.

2/26/13 PT Note - "Hydrogel applied followed by Xeroform Petroleum dressings, Kerlix, Coban and netting." There was no physician order for the Xeroform, Kerlix, or Coban.

EI # 1, Director of Nursing (DON), was interviewed on 2/28/13 at 12:30 PM, and verified there was no physician order for the debridement, Gentamicin to be applied to the skin tear, Xeroform Petroleum dressings, Kerlix, Coban, or Telfa as documented in the medical record.


30952

The medical record for MR# 14 also revealed physician medication orders dated 2/22/13 included Vistaril 50 mg (milligrams) 1 po (by mouth) tid (three times daily) prn (as needed) itching.

Review of the Medication Administration Record documentation revealed Vistaril 50 mg 1 po was administered on 2/25/13 at 0400, 0945, 1610 and 2100 and Vistaril 50 mg 1 po was administered on 2/26/13 at 0415, 1000, 1630 and 2100.

The Vistaril was administered more frequently than the physician ordered.

An interview with EI #1, conducted 2/28/13 at 9:05 AM, confirmed the tid prn dosing was not followed as ordered.

2. MR # 21 was admitted to the facility 12/28/12 with diagnoses including Acute Anemia and Renal Insufficiency. Review of 12/28/12 physician orders included daily weights.

Review of the 12/28/13 nursing documentation revealed a documented weight of 162.5 pounds. There were no weights documented on 12/29/12 and 12/30/12 as ordered. The patient was discharged home 12/30/12.

An interview with EI #1, conducted on 2/28/13 at 11:00 AM, confirmed the record failed to reveal documentation of daily weights.

3. MR # 19 was admitted to the facility 8/16/12 with diagnosis of Cellulitis of both lower legs. Record review revealed the following physician order: "... 8/16/12 1709 Nursing service-whirlpool tx (treatment) Bilat (bilateral) L.E.(lower extremity) BID (twice daily) at 10 (AM) & 2200 (10PM). Wound care to BLE (bilateral lower extremity)-clean with hibiclens, lightly scrub with 4x4's (gauze), then whirlpool, pat dry, apply telfas (nonadherent dressing), 4x4's, then secure with kling and tape..."

Review of 8/16/13 to 8/20/13 nursing documentation revealed the staff failed to include wound measurements to the affected areas of the bilateral lower extremities.

Review of 8/17/13 nursing documentation failed to reveal a description of the wound sites including status of the wound bed/s, amount and type of wound drainage and skin integrity of the periwound site.

Review of 8/18/13 nursing documentation failed to reveal the wounds were cleaned with hibiclens prior to the whirlpool treatment as ordered.

An interview with EI #1, conducted 2/28/13 at 9:00 AM, confirmed nursing staff failed to document wound measurements, wound description and specific wound care provided for MR # 19.


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4. MR # 20 was admitted to the facility 9/26/12 with diagnoses including Pneumonia and Diabetes. Record review revealed physician orders dated 9/26/2012 to call MD (Medical Doctor) for oxygen saturation less than 90%.

Review of the nursing admission note revealed the patients oxygen saturation was "89% on room air and to notify MD of saturation less than 90%."

There was no documentation in the medical record to indicate the physician was notified of low oxygen saturation level.

Review of the physician's order dated 9/26/12, included to decrease the rate of IV (intravenous) fluids to 40 ml (milliters) an hour. On 9/28/12 a new physicians order was written to "decrease the rate of IV fluids to 20 ml an hour".

Review of the nurses notes dated 9/28/12 -10/1/12 revealed the IV fluids continued to run at a rate of 40 ml an hour and was not decreased per physician orders.

An interview conducted on 2/28/13 at 10:40 AM with EI# 1, Director of Nursing, confirmed there was no documentation the physician was notified of the low oxygen saturation and the physician's orders were not followed.

Based on interview and review of the personnel folders for the contracted staff the facility failed to ensure the contracted staff were competent in their positions to care for the facility patients.

The findings include:

A review of the personnel files for the Physical Therapist (PT), Employee Identifier (EI) # 6, and the Occupational Therapist (OT), EI # 14, revealed there were no initial competencies in the files.

EI # 13, Administrator, on 2/27/13 at 2:00 PM, confirmed there were no competencies documented in the contracted employee files. The competencies would ensure the PT and OT possessed the abilities to perform debridement and care for this specific population of patients.