The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

MEMORIAL MISSION HOSPITAL AND ASHEVILLE SURGERY CE 509 BILTMORE AVE ASHEVILLE, NC 28801 Dec. 3, 2015
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital policies and procedures, medical record review, observation, and interviews, the hospital nursing staff failed to implement measures to prevent skin breakdown for 3 of 3 sampled patients at risk for skin breakdown (#2, 6, and 9).
The findings include:
Review on 12/02/2015 of the hospital's policy titled "Nursing Management of Simple Wounds" initial policy dated 07/18/2014 revealed "General Information ...B. The Wound Ostomy Continence (WOC) RN (registered nurse) or the Wound Resource Nurse (WRN) is consulted for assistance in the management of pressure ulcers and wounds as needed in addition to collaborating with the attending ...Procedure: E. Implement interventions per the Prevention Guidelines for Pressure Ulcers policy ...for patients with a Braden Score of 18 or less is skin/wound issues are identified. 1. RN may place an order for a specialty bed or mattress if criteria are met per the Specialty Bed policy ...Wound Type and Interventions: ...H. Shallow open wound(s) with drainage, stool contamination possible: ...4. Evaluate for specialty bed, per policy ..., and order if appropriate ... "
Review on 12/02/2015 of the hospital's policy titled "Specialty Beds / Low Air Loss Mattresses" initial policy dated 03/05/2014 revealed "Policy: ...This policy is implemented when the patient meets the defined criteria for implementation ...Procedure: ...B. Specialty Bed/Low Air Loss Mattress Types and Selection Criteria 1. Low Air Loss Surface Criteria: a. Initial Assessment: Indications for placement on appropriate Low Air Loss Surface ...4) Patient meets at least three of the following criteria: a) Braden Scale of 18 or less; b) Patient unable to independently reposition or turn self due to physical and/or mental disability; ... f) Nutritional status of "at risk" to poor" as evidenced by taking < 50 % intake PO (eating less than 50% of meals by mouth), NPO (nothing by mouth), and/or maintained on clear liquids or IV fluids for more than five days; g) Need for moisture management due to incontinence (inability to control bowel or bladder) or excessive perspiration ... "
Review of the hospital's policy titled, "Pressure Ulcer Prevention Guidelines" initial policy effective November 14, 2013 revealed "Policy: All healthcare providers plat a role in pressure ulcer prevention. Each patient will be assessed by the RN at admission and at least once every 12-hour shift for individual risk and/or actual pressure related skin breakdown. The nursing staff will implement the prevention protocol for any patient who scores 18 or less on the Braden Risk Assessment Scale ... Procedure: B. 1. All patients are on pressure redistributing mattresses. Staff should refer to the policy on specialty beds to determine if patient meets criteria for low air mattress or replacement bed ...3. Provide pressure redistributing foam chair cushion for at-risk patients ...D. Implement Interventions to Manage Moisture/Incontinence as appropriate: ... 5. Avoid use of diapers except for when incontinent patients are ambulating or going off unit for a procedure ... "
1. Closed record review on 12/01/2015 of the History and Physical (H&P) completed by medical doctor (MD) #2 dated and timed 05/21/2015 at 0502 revealed a [AGE] year old (y.o.) female (Patient #2) presented to the hospital's Emergency Department (ED) on 05/21/2015 from a Skilled Nursing Facility (SNF) with complaints of shortness of breath (SOB), fever, a productive cough, hypoxemia (low oxygen levels in the blood) with an oxygen saturation (O2 sat: measures the amount of oxygen in the blood. Normal values 95-100% with anything below 90% considered low. For COPD patients O2 sat of 88-92% is the goal range) of 80% on room air. Review revealed Patient #2 had a history of Chronic Obstructive Pulmonary Disease (COPD: Chronic lung disease). Review revealed Patient #2 was treated for Pneumonia the week prior to presentation to the ED and completed treatment with Levaquin (medication used to treat infection) on 05/14/2015. Continued review revealed Patient #1 received Zosyn and Quinolone (used to treat infection) while in the ED. Review revealed Patient #2 reported no stomach pain and no nausea or vomiting. Further review revealed Patient #1 was admitted to unit A with the following diagnoses[DIAGNOSES REDACTED][DIAGNOSES REDACTED] (high levels of fat in the blood).
Review on 12/01/2015 of Patient #2's progress notes by MD #3 dated 05/22/2015 through 05/25/2015 revealed Patient #2 was experiencing "No nausea, No vomiting, No diarrhea" or complaints of pain and discomfort noted. Review of MD #3's progress note dated and timed 05/25/2015 at 0944 revealed "She feels better but has a lot of anal itching which is irritating her..." Review revealed "Yeast infection (fungal infection that causes irritation, discharge and intense itchiness) sx (symptoms). Review of MD #3's progress note dated and timed 05/26/2015 at 0759 revealed "Patient seen at bedside...Has some [DIAGNOSES REDACTED] (reddening of the skin cause by injury or irritation) around anus as incontinent (inability to control bowel or bladder)." Review revealed "...Yeast infection sx." Record review of MD #4's progress note dated 05/27/2015 through 05/28/2015 revealed "... No diarrhea..."
Review on 12/01/2015 of Patient #2's physician orders and Medication Administration Record (MAR) revealed Patient #2 received 38 doses of antibiotics, all of which can cause diarrhea, throughout the course of hospitalization . Review revealed an orders by MD #3 on 05/21/2015 for Vancomycin (used to treat infection) 1500 mg IVPB (intravenous piggy back: method used to administer medications directly in the blood stream) every 24 hours and Cipro (used to treat infection) 400 mg IVPB every 8 hours. Continued review revealed an order by MD #3 on 05/26/2015 at 0807 for Augmentin (antibiotic used to treat infection) 875 mg by mouth twice daily. Review revealed an order from MD #6 on 05/21/2015 at 0044 for a one time dose of Zosyn (antibiotic used to treat infection) 3.375 g (grams: unit of measurement) IVPB and a one time dose of Levaquin (antibiotic used to treat infection) 750 mg IVPB. Further review revealed another order for Zosyn 3.375 g IVPB every 8 hours by MD #2 on 05/21/2015 at 0419.
Review on 12/01/2015 of Patient #2's nursing assessment of the bladder function revealed that on admission, Patient #2 had no bowel or bladder difficulties. Review revealed on 05/22/2015 at 2015, Patient #2 was assessed as having problems with "urgency" (a sudden, strong urge to urinate). Review on 05/23/2015 at 0521 revealed Patient #2 was placed in an adult brief secondary to difficulties urinating and "Incontinent." Review revealed Patient #2 remained in an adult brief until discharge on 05/28/2015. Review on 12/01/2015 of Patient #2's nursing assessment of the bowel function revealed no evidence of diarrhea or incontinence prior to admission. Review revealed Patient #2 began to have incontinent diarrhea (4 episodes documented) on 05/22/2015 through 05/24/2015. Continued review revealed on 05/24/2105 at 2108, 4 episodes of diarrhea were documented through 05/26/2015. Further review revealed 2 episodes of incontinent diarrhea on 05/27/2015 and 2 on 05/28/2015. Review on 12/01/2015 of Patient #2's documented activity status over the course of hospitalization revealed the required assistance with turning and repositioning and walking to the bedside commode; recliner; and bathroom. Review revealed Patient #2 had "generalized weakness, SOB (shortness of breath), and was unsteady" through 05/25/2015. Review revealed on 05/26/2015 Patient #2 required total assistance with toileting with periodic use of bedpan throughout the remainder of hospitalization .
Record review revealed Patient #2 received antibiotics prior to admission with no diarrhea or incontinence problems noted until 05/22/2015 and was placed in an adult brief on 05/23/2015. Review revealed over the course of hospitalization , 38 additional doses of antibiotics were administered and assistance with repositioning was required. Review revealed Patient #2 developed a number of risks for skin breakdown and the facility did not implement preventive measures outlined in hospital polices resulting in skin breakdown.
Review on 12/01/2015 of Patient #2's Braden Skin Assessment (tool used to determine an individual's risk of developing a pressure ulcer by examining six criteria: ... 23 points, with a higher score meaning a lower risk of developing a pressure ulcer and vice versa) by registered nurse (RN) #2 dated and timed 05/21/2015 at 1333 by RN #3 revealed a score of 18 and "occasionally moist", limited mobility, "no apparent problem" with friction (rubbing) or shearing (torn), and limited awareness of sensation. Review revealed no change in the Patient #2's Braden score until 05/25/2015 at 0436, which was 16 per RN #4. Continued review revealed the change in assessment was from "occasionally moist" to "very moist" and "no apparent problem" with friction and shearing to "potential problem" creating a higher risk of skin breakdown. Review revealed the score was raised to 17 on 05/26/2015 at 2039 by RN #5 with "occasionally moist" driving the score back up. Further review revealed 05/27/2015 at 2050, the Braden score returned to 16 per RN #6 with "Problem" noted for friction and shearing, indicating skin breakdown, and remained 16 until discharge on 05/28/2015. Review revealed an order by MD #3 on 05/26/2015 at 0758 for a "Wound Care Nurse" consultation to "Evaluate and treat, Incontinence Care."
Review on 12/01/2015 of Patient #2's progress notes revealed notation by the Wound, Ostomy, and Continence Nurse (WOCN) #2 on 05/26/2015 at 1043 stating that Patient #2 met criteria for a specialty low air loss mattress (used to decrease the risk of skin breakdown) according to hospital guidelines and the recommendation was made that one be ordered, "if the patient is still here tomorrow." Continued review revealed Patient #2 was discharged on [DATE] at 1826 with no evidence of an order for a specialty low air loss mattress determined as necessary to prevent further skin breakdown by the WCON #2 and in accordance with the hospital's "Nursing Management of Simple Wounds" and "Specialty Beds/Low Air Loss Mattresses" policies. Review on 12/01/2015 of Patient #2's nursing Plan of Care (POC) implemented for "Risk of Pressure Ulcer" revealed "Preventive Skin Care Measures" (measures taken to prevent skin breakdown or other issues) performed each shift dated 15/21/2015 - 05/28/2015 revealed "Avoid Pressure Over Bony Prominences...Avoid Pressure Points from Lines (IV), Tubes (NC), and sheets ...Time in Chair Limited to 2 Hours or Less at a Time; Chair Foam Provided ..." measures were put into place to avoid skin breakdown or damage due to pressure. Review revealed no evidence of a providing Patient #2 with a "specialty bed/low air loss mattress" as indicated in B. 4. of the hospital's "Specialty Beds/Low Air Loss Mattresses" policy.
Interview on 12/02/2015 at 1010 with WCON #2 revealed the "superficial ulcer" was not considered a pressure ulcer because it was not caused by pressure. Interview revealed the "superficial ulcer" wound be treated as a "wound" and staff would follow the hospital's "Nursing Management of Simple Wounds" policy, which outlines measures to be taken when a patient's "Braden Score is 18 or less or if skin/wound issues are identified." Interview revealed WCON #1 was not aware adult briefs were being used for Patient #2's stool and urinary incontinence. Interview revealed "I would not recommend it (use of adult briefs). Typically we don't like to place any patient in them (adult briefs) unless they are ambulating (walking) on the hall or going somewhere for a procedure." Interview revealed "I don't think (Patient #2) had one on. If she did, I would've addressed it at that time." Interview revealed WCON #1 an order for a Wound Care Consultation was written by MD #3 on 05/26/2015 and that Patient #2 was evaluated for skin/wound issues on 05/26/2015 at 1043. Interview revealed a "specialty bed/low air loss mattress keeps air flowing through the mattress maintaining it in a floating state to avoid any pressure" in vulnerable areas. Interview revealed the "specialty bed" was indicated for Patient #2 and was to be ordered "if the patient is not discharged today." Interview revealed the patient was not discharged on [DATE] and should have been placed in a "specialty bed" because "(Patient #2) met the criteria." Interview revealed, "If the bed was not ordered, I would have to say our policy ("Nursing Management of Simple Wounds") was not followed."
Interview on 12/02/2015 at 1010 with WCON #1 revealed specialty bed mattress are indicated for patients with "multiple risk factors (for skin/pressure issues)." Interview revealed patient's requiring the specialty bed mattress are "at greater risk for skin breakdown." Interview revealed any patient with a "Braden Score is 18 less or if skin/wound issues are identified" should be placed receive a specialty bed mattress as a preventive measure to help reduce the risks of the development of a pressure ulcer or other skin/wound issues. Interview revealed "I would have to agree with (WCON #2)" indicating that if an order for a specialty bed was not implemented for Patient #2, the hospital did not follow the "Nursing Management of Simple Wounds" policy. Interview revealed education addressing preventive measures for skin/wound issues is provided in orientation, via the hospital's Learning Management System (LMS: electronic learning), and one-to-one during the WCON's daily unit rounds, as needed but is not part of the hospital's annual hospital wide training. Interview revealed "This is an area we can certainly improve on."
Interview on 12/03/2015 at 1315 with WCON Director revealed education addressing skin or wound issues and preventive measures is provided during hospital orientation and "use to be done every year during our Blitz (a time that all required annual education is provided)." Interview revealed annual training was removed from the hospital's Blitz because "it (annual training) just got so big, some trainings had to be trimmed." Interview revealed annual education addressing skin or wound issues and preventive measures had not been provided since 2013. Interview revealed education on skin or wound issues and preventive measures was indicated and would be added back to the annual Blitz." Interview revealed "This is an area we can certainly improve on."
2. Record review on 12/03/2015 of the H&P completed by MD #4 dated and timed 11/27/2015 at 2201 revealed a 73 y.o. female (Patient #6) presented to the hospital's Emergency Department on 11/27/2015 with a complaint of "worsening shortness of breath (SOB).) Review revealed Patient #6 has a history of chronic respiratory failure and is on 4 L (liters: unit of measurement)." Review revealed diagnoses including Chronic Obstructive Pulmonary Disease (COPD: Chronic lung disease); possible pneumonia (inflammation of the lungs caused by infection); signs of heart failure; and suspected chronic peripheral artery disease (PAD: reduced blood flow to the legs and arms). Review revealed MD #4 was unable to palpate (feel) pulses in Patient #6's feet, indicating poor blood flow. Review revealed Patient #6's weight was 85 pounds.
Review on 12/03/ of the nursing Braden Skin Assessments revealed a score of 17 on 11/27/2015 at 2250 by RN #8; 16 on 11/28/2015 at 2256 by RN #4; and 15 on 11/29/2015 at 0715 by RN #9. Review revealed the score was assessed as a 17 on 11/29/2015 at 1943 by RN #4. Review on 12/03/2015 of Patient #6's "Adult Activity" assessments revealed assistance was required with walking, which has primarily consisted of ambulation to the bedside commode and back to bed per documentation. Review revealed Patient #6 was on continuous supplemental O2 (oxygen) administered by nasal cannula (NC: O2 delivery device) and required the head of the bed to be up to assist with breathing.
Review revealed Patient #6 presented to the hospital with a number of risks for skin breakdown with a Braden Skin Assessment score of 18 or less. Review revealed the facility did not implement preventive measures outlined in hospital polices.
Review on 12/03/2015 of Patient #6's physician orders and nursing notes revealed no evidence of a request for a WCON consultation for a Braden Skin Assessment of 18 or less in addition to other at risk criteria as indicated in hospital policy. Review of Patient #6's "Preventive Skin Care Measures" performed each shift dated 11/07/2015 - 12/03/2015 revealed "Avoid Pressure Over Bony Prominences...Avoid Pressure Points from Lines (IV), Tubes (NC), and sheets" was put into place to avoid skin breakdown or damage due to pressure. Review revealed no evidence of a providing Patient #6 with a "pressure redistributing foam chair cushion" as indicated hospital policy.
Observation on 12/02/2015 revealed Patient #6 did not have a "pressure redistributing foam cushion" or a "specialty bed/low air mattress. Observation revealed Patient #6 was sitting upright in bed with the head of the bed elevated to help with breathing. Observation revealed Patient #6's weight was below 100 pounds with multiple purple and reddened areas on the arms and legs.
Interviews on 12/02/2015 at 1430 with Patient #6 revealed "I have to stay on my back with my head up to help me breathe." Interview revealed that while staff had assisted with ambulation to the bedside commode, they had not turned and repositioned Patient #6 during her hospitalization . Interview revealed "It's hard for me to turn or reposition myself because of all the tubes (IV and NC) and equipment (heart monitor: device used to monitor electrical activity of the heart) I have hooked to me." Interview revealed "My bottom is getting tender and if I had to stay longer, I would have to have them look at it but I am supposed to go home today."
Interview on 12/02/2015 at 1451 with Nurse Manager #1 revealed that once the Braden Skin Assessment has been completed and a real or potential risk for skin breakdown/damage has been identified, a "specialty bed and foam chair cushion should be provided." Interview revealed a consultation with a WCON should also be considered for additional alternative treatment measures, assessment, and continued evaluation. Interview revealed patients at risk for skin breakdown or damage should not be placed in adult briefs except during periods of ambulation or off-unit procedures and removed immediately following return to his or her room. Interview revealed "repositioning, protective cream, and skin assessments" are used as preventive measures to aid in avoiding skin breakdown or damage. Interview revealed Nurse Manager #1 did not know Patient #6 and had not personally performed a nursing assessment of her but given her difficulty in repositioning due to medical monitoring devices, IV tubing, O2 tubing, and poor nutrition," she would be considered high risk for skin breakdown" and that the hospital's policies were not followed.
Interview on 12/02/2015 at 1010 with WCON #1 revealed specialty bed mattress are indicated for patients with "multiple risk factors (for skin/pressure issues)." Interview revealed patient's requiring the specialty bed mattress are "at greater risk for skin breakdown." Interview revealed any patient with a "Braden Score is 18 less or if skin/wound issues are identified" should receive a specialty bed mattress as a preventive measure to help reduce the risks of the development of a pressure ulcer or other skin/wound issues. Interview revealed that following review of Patient #6's condition, limited mobility, limited activity tolerance, multiple medical devices, and Braden Skin Assessment scores indicated she would be considered high risk for potential skin breakdown and preventive measures should have been implemented as outlined in the hospital's policies. Interview revealed "This is an area we can certainly improve on."
Interview on 12/03/2015 at 1315 with WCON Director revealed education addressing skin or wound issues and preventive measures is provided during hospital orientation and "use to be done every year during our Blitz (a time that all required annual education is provided)." Interview revealed annual training was removed from the hospital's Blitz because "it (annual training) just got so big, some trainings had to be trimmed." Interview revealed annual education addressing skin or wound issues and preventive measures had not been provided since 2013. Interview revealed education on skin or wound issues and preventive measures was indicated and would be added back to the annual Blitz." Interview revealed "This is an area we can certainly improve on."
3. Record review on 12/03/2015 of the H&P documented by MD #5 on 11/24/2015 at 0120 revealed an 84 y.o. male (Patient #9) who presented to the hospital's ED on 11/24/2015 after falling and hitting his head with complaints of neck pain. Review revealed Patient #9 had a CT (computed tomography: scan of internal organs) scan of the head on 11/24/2015 at 0024 that revealed a subdural hematoma (SDH: collection of blood on the brain). Review revealed a CT scan of the cervical spine (bones in the neck area) was also performed with notable bruising of the neck.
Review on 12/03/2015 of the Braden Skin Assessment on the nursing POC for Patient #9 on 11/24/2015 at 0315 by RN #11 revealed a score of 15 with "Avoid Pressure Points from Lines, Tubes, and Sheets; Avoid Pressure Over Bony Prominences, Turn Patient" as measures indicated for the prevention of skin breakdown or damage. Review revealed a score of 16 on 11/24/1025 at 2000 by RN #12 and remained unchanged until 11/26/2015 at 0758, which was assessed as a score of 17 by RN #13. Review revealed Patient #9's Braden Scale Assessment included slightly limited perception (awareness of surroundings), rare incontinence, slightly limited mobility, adequate nutrition, and a potential for skin damage from friction or shearing. Continued review revealed Patient #9's medical condition became unstable and required transfer to Unit B. Review revealed a Braden Skin Assessment score of 7 and included completely limited perception, total incontinence, no mobility (became confined to the bed), completely unable to move independently, "very poor" nutrition, and remained a potential for skin damage from friction or shearing on 11/26/2015 at 2200 by RN #15. Review revealed Patient #9's Braden Skin Assessment ranged between 7- 9 during continued treatment on Unit B. Review revealed Patient #9 was transferred back to Unit A on 11/29/2015 at 1635 with no change in the assessed score of 9 at that time or evidence of documented continued Braden Skin Assessments through 12/01/2015 at 1314. Review revealed no evidence of a WCON consultation, provision of a "pressure redistributing foam cushion", or of a "specialty bed/low air loss mattress" outlined in the hospital's policies.
Review revealed Patient #9 presented to the hospital risks for skin breakdown with a Braden Skin Assessment score of 18 or less. Review revealed Patient #9's condition progressively worsened and the skin assessment scores indicated higher risks for developing skin breakdown. Review revealed the facility did not implement preventive measures outlined in hospital polices.
Interview on 12/02/2015 at 1010 with WCON #1 revealed specialty bed mattress are indicated for patients with "multiple risk factors (for skin/pressure issues)." Interview revealed patient's requiring the specialty bed mattress are "at greater risk for skin breakdown." Interview revealed any patient with a "Braden Score is 18 less or if skin/wound issues are identified" should be placed receive a specialty bed mattress as a preventive measure to help reduce the risks of the development of a pressure ulcer or other skin/wound issues. Interview revealed a specialty bed would have been contraindicated for Patient #9 if the neck fracture had remained unstable; however, since it was stabilized prior to admission to Unit A, preventive measures should have been implemented as outlined in the hospital's "Specialty Bed/Low Air Loss Mattresses" and "Pressure Ulcer Prevention Guidelines" policies. Interview revealed the need for a specialty bed would not be indicated for any patient receiving care on Unit B since all beds in that area have "low air loss mattresses"; however, interview revealed that according to hospital policy, once Patient #9 was admitted to Unit A, pressure ulcer prevention guidelines should have been implemented, including provision of a foam chair cushion and a specialty bed/low air loss mattress ordered, with consideration for a WCON consultation should have been implemented and "certainly upon his transfer back (to Unit A). Interview revealed the hospital did not follow the hospital's policies. Interview revealed "This is an area we can certainly improve on."
Interview on 12/03/2015 at 1315 with WCON Director revealed education addressing skin or wound issues and preventive measures is provided during hospital orientation and "use to be done every year during our Blitz (a time that all required annual education is provided)." Interview revealed annual training was removed from the hospital's Blitz because "it (annual training) just got so big, some trainings had to be trimmed." Interview revealed annual education addressing skin or wound issues and preventive measures had not been provided since 2013. Interview revealed education on skin or wound issues and preventive measures was indicated and would be added back to the annual Blitz." Interview revealed "This is an area we can certainly improve on."
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on hospital policy and procedures review, medical record review, observation, and interviews, the hospital's nursing staff failed to prepare and administer medications according to medical staff policies and procedures for 1 of 2 patients (#5) receiving intravenous (IV) medications.

The findings include:

Review on 12/03/2015 of the hospital's "Standard Precautions" policy revised January 12, 2015 revealed "Policy: Healthcare workers...will treat all blood, body fluids, secretions, excretions, mucous membranes, and non-intact skin as potentially infectious. Appropriate barriers including Personal Protective Equipment (PPE) will be used to avoid direct contact...Equipment:...gloves, gown, mask, eye shield; goggles...General Information A. Standard Precautions 1. Standard Precautions are designed to reduce the risk of transmission of microorganisms (potentially infectious bacteria)...Standard Precautions put a barrier between the healthcare worker and the blood or other potentially infectious material (OPIM) of any patients...2. Use Standard Precautions for the care of all patients. 3. Personal protective equipment (PPE) is available in all patient care areas...Procedure A....1. Gloves a. Wear gloves when exposure to or contact with body substance or OPIM is planned or anticipated..."

Review on 12/02/2015 of Patient #5's History and Physical (H&P) dated 11/28/2015 at 0048 revealed a [AGE] year old (y.o.) female presented to the hospital's Emergency Department requesting detoxification (medical treatment of substance use involving no substance use until the bloodstream is free of toxins). Review revealed a diagnosis of Hyponatremia (low sodium: chemical that helps regulate the amount of water in and around cells within the body); Severe Hypokalemia (low potassium: a chemical that is critical to the proper functioning of nerve and muscles cells); Acute Alcohol Intoxication (condition in which more alcohol is consumed than the liver can filter out of the body); Starvation (lack of food); and Chronic Hepatitis C (condition caused by the hepatitis C virus). Review of the Medication Administration Record (MAR) revealed a scheduled dose of Reglan (used to treat nausea, vomiting, loss of appetite, and heartburn) 10 mg intravenous (IV: route used to administer medication directly into the bloodstream) before meals.

Observation on 12/02/2015 at 1150 of Patient #5's medication pass by RN #7 revealed RN #7 did not don gloves prior to accessing the patient's saline lock (intravenous (IV) catheter that is threaded into a vein, flushed with saline, and then capped off for later use). Observation revealed RN #7 did not aspirate to verify blood return prior to flushing with normal saline (NS) and stated, "This (IV lock) is a little stiff (referring to administration of the initial NS flush). Can you feel that? You've had this (IV lock) for a while haven't you?" Observation revealed RN #7 did not aspirate to verify blood return prior to administration of the scheduled dose of Reglan 10 mg or the second flush of NS immediately following the Reglan 10 mg administration.

Interview on 12/02/2015 at 1200 with RN #7 revealed "I typically wear gloves with central lines (a catheter [small, flexible tube] inserted into a vein with the tip positioned near the heart) but not on peripheral (a catheter placed into a vein in order to administer medication or fluids) lines." Interview revealed I try to practice good hand hygiene." Interview revealed, "No, I did not (aspirate) before either flush or the Reglan." Interview revealed, "I watched the site for any indications of swelling as I flushed the lock and during administration of the Reglan." Interview revealed hospital staff did not follow the hospital's "Standard Precautions" policy.

Interview on 12/02/2015 at 1210 with Nurse Manager #1 revealed "Yes, you would normally wear gloves anytime there is potential exposure to blood or body fluids and to protect the patient." Interview revealed gloves should be worn when accessing any IV due to the potential blood exposure. Interview revealed IV lock placement should be verified via gentle aspiration to ensure placement prior to all medication administration. Interview revealed staff did not follow the hospital's "Standard Precautions" policy or access the IV correctly.