HospitalInspections.org

Based on observation and staff interview, the facility failed to ensure accepted standards of practice for the storage of drugs and sterile/clean supples in 1 or 1 anesthesia carts. A second anesthesia cart was not available to the surveyor for inspection. The findings were:

Observation during a tour of the surgical department on 6/14/10 from 1:08 PM to 2:45 PM showed the operation suites were not in use that day. The facility was observed to have two operating/surgical suites. During the tour of suite #1, the operating room (OR) nurse stated the contents of the anesthesia cart housed in suite #1 could not be viewed as the certified registered nurse anesthetist (CRNA) was on vacation. The OR nurse stated she/he believed only the CRNAs had keys to the anesthesia carts. A call to the pharmacy by the compliance officer touring with the OR nurse and surveyor confirmed the CRNAs had the only key to the carts. The OR nurse called the available CRNA and reconfirmed only the CRNAs had cart keys. The CRNA came to the facility so the anesthesia cart could be inspected. The following concerns were found when the cart in OR suite #2 was inspected:
a. There were ten unpackaged syringes of various sizes on a plastic tray on top of the cart. A piece of tape across the corner of the tray was labeled "clean." Interview with the OR nurse at the time of finding confirmed the integrity of the syringes could not be assured since the syringes were out of the package and had been out of the direct sight of whoever opened them. The OR nurse stated she would never use them since they had been opened. She stated she has certification as a surgical nurse, and the practice was against the standards set by the Association of Perioperatvie Registered Nurses.
b. While the surveyor, OR nurse, and corporate compliance officer waited for the CRNA to arrive and unlock the cart, the OR nurse took a phone call. During the call, the OR nurse stated, "It's too late, she already found them." Upon hanging up the phone, the OR nurse stated the CRNA had called and request the syringes be discarded.
c. At 2:27 PM, the CRNA arrived. The cart inspection and interview occurred with the CRNA present. The corporate compliance officer and OR nurse were also present. The inspection revealed unpackaged syringes with medication drawn up (three labeled epinephrine 10 mg/ml and one labeled neosynephrine without dosage per milliliter markings) and a syringe of medication the CRNA identified as Propofol. Also noted was a vial of Naloxe HCL (a medication use to reverse the effects of narcotic drugs) that had been labeled "single use," opened and dated "6/10/10." In addition, there were unwrapped supplies including blood tubing and an esophageal stethoscope/thermometer. The packaging for the esophageal stethoscope was labeled "sterile unless package opened."
d. When interviewed at 2:27 PM, the CRNA stated the supplies were open and available for emergency case situations. She stated she felt the opened supplies and medications remained intact as they were stored. She further stated the single dose vial was good for use up to 30 days from the open date marked on its label. Interview also revealed the CRNA last worked on Thursday, 6/10/10. The supplies and medications in syringes had been stored in the cart since then.

Interview with the infection control officer on 6/14/10 at 3:34 PM revealed the following related to the concerns found on the anesthesia cart:
a. The infection control officer stated the blood tubing and esophageal stethoscope would only be good for use up to 24 hours after opening.
b. The integrity of the syringes, once removed from their package, could not be assured once they left the view of the person opening them.
c. The vial of medication labeled "single use" could only be used once. She stated the medication should have been discarded.
d. The medications in the syringes should have been discarded if not used immediately.
The infection control officer stated the anesthesia carts could only be monitored during days when surgeries were scheduled because there were no keys available for oversight at other times.

Reference: Elkin, Perry, Potter, "Nursing Interventions & Clinical Skills," 4th edition, Mosby Elsevier, copyright 2007, Chapter 17, Administration of Injections, page 416: "Injections instill medication into body tissues for systemic absorption....Injections are invasive. Use strict aseptic technique during preparation and administration to minimize the risk of infection....Syringes are single dose and disposable." Page 420: "A single-dose vial is entered and then discarded, regardless of the amount of medication used." Chapter 5, "Basic Sterile Techniques," Page 79. Strict adherence to the principles of sterile technique limits a client's risk for infection during invasive procedures, although infection can occur because of the presence of endogenous organisms on the skin and mucous membranes. Although surgical asepsis is commonly practiced in operating rooms (ORs), labor and delivery (L&D) areas, and major diagnostic or special procedure areas, nurses also use surgical aseptic techniques at the client's bedside [reference box information given] in three primary situations: 1. During procedures that require intentional perforation of a client's skin, such as insertion of an intravenous (IV) catheter 2. When the skin's integrity is broken, such as with a surgical incision or burn 3. During procedures that involve insertion of devices or surgical instruments into normally sterile body cavities..." Page 80. "A sterile object or field becomes contaminated by prolonged exposure to air;...Open sterile items just before use....If there is any question or doubt of an item's sterility, the item must be considered unsterile. A sterile object or field out of the range of vision or an object held below a person's waist is contaminated."

Based on medical record review, staff interview, and review of the facility's Rules and Regulations of the Medical Staff, the facility failed to ensure all entries in 12 of 24 medical records were signed, dated, and/or timed. Findings were:

Record review revealed medical records lacked applicable signatures, dates, and/or documented times that entries were made in each of the following records:

a. Patient #2's admission orders dated 4/21/10 were not timed.
b. Patient #4's physician progress note dated 5/13/10 was not timed.
c. Patient #5's physician progress noted dated 5/2/10 was not timed.
d. Patient #6's discharge summary form dictated on 6/12/10 at 1639 was not signed by the physician.
e. Patient #7's record lacked a date or time on his/her admissions orders, lacked a time on the post anesthesia care orders dated 5/6/10, and lacked a date or time on the post operative orders.
f. Patient #8's medical record had physician progress notes dated 5/11/10 and 5/12/10 that were signed, but not timed by the physician.
g. Patient #10's physician progress note dated 5/16/10 was signed, but not timed by the physician. Standing orders for this same patient to rule out myocardial infarction were not dated or timed by the physician who signed them. In addition, this patient was initially seen in the emergency room prior to admission, however the time the patient was seen by the physician was left blank on the emergency physician record.
h. Patient #11's record contained the following entries that were not timed: admission orders dated 5/21/10, and physician's orders dated 5/23/10 and 5/24/10.
i. Patient #12's record contained standing intrapartum orders that were signed and dated by the physician, but not timed.
j. Patient #17's record contained telephone orders dated 6/9/10 at 1945 that were not signed by the physician. In addition, this patient's face sheet and the emergency room report lacked all required signatures.
k. Patient #18's record revealed s/he was seen in the emergency room on 6/8/10; however, the patient's emergency room report was not signed by the physician.
l. Patient #21's record revealed this patient's admission orders were not dated or timed. In addition, three orders written by the physician on 3/24/10 were not timed.

Interview with the manager of the medical records department on 6/14/10 at 3:45 PM verified she was aware that medical record entries by physicians did not always include dates or times as required.

The Rules and Regulations of the Medical Staff were reviewed. According to Section 9: Medical Records, "All entries in the medical records by hospital staff or medical staff members shall be legible, permanently recorded, dated, timed, and authenticated by the name and title of the person making the entry..."

Based on medical record review the facility did not ensure that an assessment for 1 of 1 swing bed patients (#25) was signed by a responsible individual. Findings were:

Review of the closed medical record for patient #25 revealed s/he had a Mimimum Data Set for Swing Beds [an assessment tool] in the record. Although all sections of the assessment document had been completed, the place for the signature of the registered nurse (RN) coordinator was blank. There were no other signatures on the document, and it could not be determined who was responsible for the accuracy or the timing of this assessment.