HospitalInspections.org

Based on observation, interview, and policy review, the provider failed to ensure medications were stored securely in:
*One of one operating room (OR).
*One of one crash cart in the emergency department (ED).
*One of one ambulance transfer kit.
*One of one labor and delivery emergency kit (e-kit).
*One of one opened vial of betamethasone (steroid) in the ED.
Findings include:

1. Observation and interview on 2/28/22 at 4:16 p.m. with registered nurse (RN) F in the facility's ED revealed:
*The crash cart contained several medications that could be used in an emergent situation.
*The crash cart drawers were secured with a red plastic tag.
*When a tag had been removed from the crash cart, a new tag was replaced from a locked cabinet.
*There was no documentation to track the tags placed on the crash cart when medications had been removed or replaced.

Observations made on 3/1/22 at 12:30 p.m., 2:21 p.m., and 4:55 p.m. revealed the crash cart had been unsecured after use.

Observation and interview on 3/2/22 at 10:55 a.m. with RN G in the facility ED room revealed:
*A vial of medication located in a locked glass cabinet.
*RN G opened the cabinet.
*The vial was:
-A multi-use vial of Betamethasone sodium phosphate (a steroid medication).
-Dated 1/28/22 as having been opened.
*RN G:
-Was unsure why the medication was in the cabinet.
-Stated the medication should not have been in the cabinet.

2. Observation and interview on 3/2/22 at 9:45 a.m. with RN D in the facility's OR revealed:
*She and certified registered nurse anesthetist (CRNA) E were responsible for the accuracy of the medications in the anesthesia cart.
*There were three sheets they documented the amount of Ketamine, Fentanyl, and Versed on.
-The sheets had documented the doses administered by CRNA E.
*They had another sheet to verify the count of the narcotics.
*The narcotic count sheet had a check mark if the count was accurate.
*RN D confirmed:
-The check mark was to verify the Fentanyl, Ketamine, and Versed counts were correct.
-They had not been checking the other medications in the anesthesia cart.
-There was not an inventory list to inform staff what medications should have been kept in the anesthesia cart.

Telephone interview on 3/2/22 at 1:40 p.m. with CRNA E revealed there was not:
*An inventory list for the medications in the anesthesia cart.
*A system to track any medications other than the Ketamine, Fentanyl, and Versed.
*Any monitoring of other medications such as propofol (used to produce sedation during surgery).
-He agreed propofol and other medications are medications that have higher incidents of being misused or subject to diversion.



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3. Observation and interview on 3/1/22 at 2:50 p.m. in the nurses station with pharmacist B revealed:
*There was an ambulance transfer kit inside of an unlocked cupboard on the back wall of the nurses station next to the medication room.
*She was unaware of what the kit contained but knew it contained medications.
*The kit was used for times when a nurse would ride along with a patient in the ambulance for transportation to another facility.
*She stated she had not been responsible for checking the ambulance transfer kit.
*It had been the nurses responsibility to maintain and monitor it.
*The kit contained two vials of the following medications:
-Verapamil Magnesium Sulfate.
-Reglan.
-Zofran.
-Furosemide.
-Tordal.
-Benadryl.
-Solu-Medrol.
*The same kit contained four vials of the following medications:
-Narcan.
-Metaprolol.

Observation and interview on 3/1/22 at 3:00 p.m. inside of the labor and delivery storage room with pharmacist B revealed:
*The door to the storage room had been locked.
*She asked the nurse at the desk for a key stating she did not have a key.
*The emergency kit (E-kit) was located on the countertop of the cupboard inside the storage room.
*The E-kit would have been used for newborn babies in the event of an emergency.
*They had not used the kit recently because they did not deliver babies routinely.
*She had not thought to have those medications secured with a locking device.
*It was the nurses responsibility to maintain and monitor the E-kit.
*The E-kit contained the following medications:
-Sodium Bicarbonate.
-Narcan.
-Sodium Chloride.
-Epinephrine.

Continued observations with pharmacist B revealed:
*The ambulance transfer kit and labor and delivery E-kit had not been secured with any type of locking device.
*There was not a list inside of the E-kit for what was contained inside.
*The nurses were responsible to track, refill the kit and to check for outdates.
*They had no formal system in place to monitor what had been used, replaced, or who had been inside the kit.
*The nurses came to the pharmacy and signed out the items they took and then replaced the items inside of the kit.

Observation and interview on 3/2/22 at 1:22 p.m. with director of nursing (DON) C revealed:
*The ambulance transfer kit remained unsecured in the same cupboard in the nurses station.
*The E-kit within the locked labor and delivery storage room remained unsecured.
*Anyone within the hospital could have had access to the ambulance transfer kit.
*The people that had keys to the labor and delivery storage room were pharmacist B, the charge nurse on duty, and herself.
*She confirmed the ambulance transfer kit and the labor and delivery E-kit had not included a list of contents and should have.
*An overnight nurse had been the person who had taken on the responsibility for checking the ambulance transfer kit and the labor and delivery E-kit.
*Any medication that was used from the ambulance transfer kit and the labor and delivery E-kit would have been charted on the medication administration record.
*If a medication had been used it would have been replaced by the nurse who had administered it.
*That nurse would go to the pharmacy and write down on a log what was taken to restock the kit and the pharmacist would reconcile it the next day.
*They had no formal system for tracking E-kits that contained medications.
*Both E-kits should have been locked, secured, and had a list of contents.

4. Interview and review of the inventory list of medications in the anesthesia cart on 3/2/22 at 2:55 p.m. with DON C and pharmacist B regarding the ED crash cart and the OR anesthesia cart revealed:
*They did not have a system in place to monitor the medications in the ED crash cart and in the OR anesthesia cart.
*There were not ten bottles of propofol in the anesthesia cart as the list stated, there were only five bottles.
*Pharmacist B was not aware of what quantities of propofol should have been in the anesthesia cart.
*Ketamine, Fentanyl, and Versed were not listed on the inventory sheet.
*Pharmacist B was unsure of the quantities of medications that CRNA E had in the anesthesia cart.
*DON C was unsure of who had keys to the anesthesia cart.
*The crash cart should have been re-filled and locked after use.
*Pharmacist B and DON C stated the multi-use vial of betamethasone sodium phosphate should have been brought back to the pharmacy after it had been used or discarded when expired.

Review of the provider's April 2021 Medication Standardization and Restocking policy revealed:
*"To standardize contents of crash cart and ambulance bag throughout the institution; to ensure stock levels and outdate integrity of medications; to provide for prompt replacement of items used during emergency situations in the absence of pharmacy services and to provide security of medications at all times."

Based on observation, interview, and policy review, the provider failed to ensure infection control practices were maintained for:
*The disinfection and reuse of single-patient items.
*One of one operating room (OR)'s uncovered patient care supplies were protected from cross-contamination.
*Three of four walls in the OR there were no cracks and the walls were uncleanable.
*One of one emergency department (ED) room had opened patient care supplies.
*One of one OR had opened anesthesia supplies.
*Three of six patient rooms had opened patient care supplies.
Findings include:

1. Observation on 2/28/22 at 4:02 p.m. in the ED revealed:
*The ED room contained two bays.
*There was a crash cart in the middle of the room, located between the two beds.
*On top of the crash cart were opened laryngoscopes in a pink kidney-shaped basin, uncovered.
*One the right side of the room, there was a roll of tape with lint, placed with the lab supplies.
*There was a drawer with 10 milliliter (ml) and 6 ml syringes:
-They had been taken out of their packing and had a needle attached to the end.
-The needles had also been taken out of their sterile packaging.
-There was a total of six syringes and needles that had been opened.
-There was also a butterfly intravenous needle (IV) that had been removed from the sterile package and placed in the drawer.
*On the left side of the room, was uncovered suction tubing attached to the suction canister and the end was opened to air.

2. Observation on 2/28/22 at 4:28 p.m. of a patient room titled "LDRP" [labor, delivery, postpartum, recovery] revealed:
*The room appeared to have been cleaned and ready for the next patient.
*There was suction tubing out of the sterile packaging and connected to the suction canister.

Observation on 2/28/21 at 4:25 of patient room 109 and 110 revealed there was oxygen tubing that had been opened and connected to the suction canister.

3. Observation on 3/1/22 at 11:00 a.m. in the facility's ED revealed:
*Staff were cleaning the room after a patient had been discharged.
*There were two rolls of red Coban (elastic bandage) that had been used on that patient. Those rolls were placed back with the clean lab supplies.
*There were packaged syringes that had been wiped down with a disinfectant.
-The packaged material was paper and plastic.

4. Observation and interview on 3/1/22 at 2:21 p.m. with surgical technician (ST) H and registered nurse (RN) G in the facility OR revealed:
*The anesthesia cart suction container had suction tubing attached and was laying on top of the cart.
*To the right of the anesthesia cart were many supplies:
-The supplies were in opened bins.
-There was a peg board with various supplies hanging, including a clipboard with paper.
-There had been various syringes, oxygen supplies, and scope supplies uncovered.
*RN G and ST H stated each item was not disinfected after each procedure.
*They agreed since the items were not covered there was a potential for contamination.
*There were cracks in the north and west walls and the ceiling.
*The cracks created uncleanable surfaces for the OR walls and ceiling.

Interview on 3/2/22 at 10:45 a.m. with RN G revealed:
*She was the facility's infection preventionist.
*Coban and tape were not cleanable and should have been discarded after each patient use.
*Paper packages should not have been wiped with a liquid disinfectant.
*Tubing and other items should not have been opened ahead of use and should have been discarded when the room was disinfected.

Interview on 3/2/22 at 4:00 p.m. with director of nursing (DON) C revealed she agreed:
*The supplies in the OR could have been contaminated since they were uncovered.
*Oxygen tubing and suction tubing should not have been opened prior to use.
*Paper packages should not have been cleaned with a liquid disinfectant.
*The walls in the OR that contained cracks were not considered cleanable.
*Single use patient items should not have been discarded after use.
*Syringes and needles should not have been prematurely taken out of their sterile packages.

Review of the provider's August 2019 Cleaning of Emergency Room policy revealed:
*"3. Remove all used supplies from countertops, etc. [etcetera] for disposal. All supplies exposed to patient but unused will be disposed of if contained in paper packaging. Unused sterile instruments will be resterilized. All single-use patient care items will also be disposed of."

Review of the provider's March 2020 Infection Control in the OR policy revealed: "1. All body substances and contaminated equipment and supplies are to be considered potential sources of infection and handled in accordance to the Standard Precautions policy."

Review of the provider's March 2020 IC [Infection Control] in Anesthesia policy revealed;
*"a. Cleaning and sterilizing anesthesia equipment. All single use disposable items must be properly discarded after one-time use. All reusable equipment will be cleaned and processed according to Central Sterilization and Reprocessing protocols."

Review of the provider's undated Infection Control for General Nursing policy revealed:
*Supplies would be stored in clean and dry areas.
*"All sterile supplies not stored on supply carts will be stored in enclosed cupboards..."
*"All sterile packaged supplies will be assessed for signs of package compromise prior to use..."