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Based on observation, facility policy review and interview, facility staff failed to follow facility policy with regard to administering medication via Intravenous (a line directly into a vein) push (IVP) for one (Patient #2) of one patient observed receiving medication via IVP. The nursing staff failed to administer drugs in accordance with Federal and State laws and approved medical staff policies and procedures when in 1 of 1 cases (Patient #9) nursing staff failed to affix the prescription dispensing label and the drug add label to a sterile water bottle and in 2 of 5 cases (Patient's #9 and #10) failed to date/time opened bottles of sterile normal saline (a sterile 0.9 salt water solution) and sterile water and failed to ensure the contents of the bottles were discarded within 24 hours after opening.
The census at the time of the survey was 33 (thirty three) patients.

Findings include:

Review of policy, " Bedside Storage of Medications " included: Medications kept at the patient ' s bedside must be properly labeled according to pharmacy medication dispensing/labeling procedures.
Review of policy, " Irrigation Solutions " included: " Drugs that are intended for irrigation purposes must be packaged and administered safely. A brightly-colored auxiliary label will be placed on every bottle bag of solution for irrigation. "

The facility medication guideline states:
RATE OF ADMINISTRATION
IV Injection: Each 40 milligrams (mg) or fraction thereof of Lasix (a diuretic-inhibits reabsorption of fluid) should be given over 1 to 2 minutes.

1. During observation of medication administration to Patient #2 on 04/20/10 at 09:30 AM, showed Staff G, Registered Nurse (RN) administer IV Lasix 40 mg in 30 seconds.
Interview with Staff G after the medication administration revealed, "I probably gave a little too fast. I use my watch to check the time usually".


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2. Bedside observation for Patient #10 on 04/20/10 at 10:15 AM revealed: There is an opened bottle of sterile normal saline with approximately 600 ml (milliliter) left in the bottle by the patient ' s sink and there is no date or time when the bottle was opened.
3. Bedside observation for Patient #9 on 04/20/10 at 10:45 AM revealed: A 1000 ml bottle with a manufacture label stating the contents is sterile water was found bedside on the patient ' s over the bed table. The fluid in this bottle has a light yellow ting to it. There is no prescription label or add medicine label affixed to the bottle. There is no date or time when the 1000 ml bottle sterile water was opened. There are also two opened bottles of sterile normal saline one on the patient ' s bedside table with 425 ml left and one with 300 ml left and neither had the date nor time when it had been opened. A bottle of sterile water is on the patient ' s over the bed table with 600 ml left in the bottle. The nurse had failed to date and time when the bottle was opened.
Interview with charge nurse, employee, S, on 04/20/10 at 10:45 AM revealed: The nurse states that the bottle of sterile water was yellow tinged because the medication Sulfamylon (a topical medication used for wound irrigation) had been added to the water. Nurse, S, confirmed the 1000 ml of sterile water at the bedside had the manufacture label for sterile water only and there was not a pharmacy label with dispensing information or a label showing " add medication " (add medication is any medication added to the sterile water). Nurse, S, confirmed the nurses mix the Sulfamylon in sterile water for wound irrigation, but the nurse who mixed the medication failed to label the sterile water bottle with the pharmacy label and add medication label at the time of mixing.
Interview with nurses, A (the chief nurse executive), Q (a licensed practical nurse), S (the charge nurse) on 04/20/10 at 10:55 AM revealed: none of these nurses could state positively what the hospital ' s policy was in regards to dating and timing bottles of sterile water or sterile normal saline when they are opened. Nurse, A, states he/she believes the bottles of normal saline and sterile water are to be dated and timed at the time of opening and he/she believed the bottles are to be discarded within 24 hours after opening.
Interview with the pharmacist, D, on 04/20/10, at 11:15 AM revealed: The pharmacist stated when the Sulfamylon is dispensed from the pharmacy it is dispensed with a prescription label and a medication added label both of which the nurse is to affix to the bottle of sterile water at the time the nurse adds the Sulfamylon. The pharmacist presented the prescription labeling and the add medication labeling (which is a bright reddish/orange color) that should have been affixed to the 1000 ml bottle of sterile water once the Sulfamylon was added to the water. The pharmacist reviewed the Sulfamylon manufacture packaging with this surveyor and the medication packaging directions includes, " Once a container is opened, any unused solution must be discarded within 48 hours. " The pharmacist states even though the manufacture directions includes the Sulfamylon is good for 48 hours when mixed with the sterile water the hospital ' s policy is to discard the Sulfamylon solution within 24 hours after mixing. The pharmacist also confirmed it is the hospital ' s policy that bottles of sterile water and sterile normal saline are to be dated and timed when opened and unused portions are to be discarded in 24 hours.
Interview with the chief nurse executive, employee A, on 04/22/10 at approximately 1:00 PM revealed: The nurse stated he/she has called the hospital ' s corporate office regarding dating/timing of sterile water and sterile normal saline and how long the fluid in the bottles are good for once opened. The corporate office confirmed the bottles are to be dated and timed when they are opened with the unused portions discarded within 24 hours after opening. The corporate office stated they could not find a written policy that states this, but this is the verbal policy and practice the hospital is to follow.

Based on interview and record review facility staff failed to ensure complete patient admission histories and physicals were on the medical records within twenty four hours of admission for ten (Patients #1, #3, #4, #5, #6, #7, #13, #15, #19 and #21) of fourteen opened and closed medical records reviewed for completed admission history and physicals. The facility census was 33 patients.

Findings included:

1. Record review of the facility Medical Staff Rules and Regulations adopted 01/28/10 directed in section C. Medical Records, in part, the following:
-The attending practitioner shall be responsible for the preparation of a complete and legible medical record.
-At a minimum, each patient shall receive a history and physical examination completed no more than twenty four hours after admission.
-The history and physical must be placed in the patient's medical record within twenty-four (24) hours of admission.
-All clinical entries in the patient's medical record shall be accurately dated, timed, and authenticated.

2. Record review of open Patient #1's admission history and physical revealed staff admitted the patient on 03/26/10 with diagnoses including acute respiratory failure on ventilator weaning, anemia, diabetes mellitus type 2, past transurethral resection of the prostate (removal of prostate tissue) and methicillin resistant staphylococcus aureus of the sputum and urine (bacteria that is resistant to antibiotics).

Record review of the patient's admission history and physical revealed the physician authenticated the document on 03/29/10 (three days after admission)

3. Record review of open Patient #3's admission history and physical revealed staff admitted the patient on 03/19/10 with diagnoses including respiratory failure, chronic inflammatory demyelinating polyneuropathy (an acquired immune-mediated inflammatory disorder of the nervous system), monoclonal gammopathy (abnormal blood protein), past history of Hepatitis B (viral infection in the liver), osteoporosis (weakened, porous bones), glaucoma (group of eye diseases in which there is optic nerve damage) and past history of pneumonia with sepsis (infection of the lungs and infection in the blood).

Record review of the patient's admission history and physical revealed the physician authenticated the document on 03/21/10 (two days after admission).

4. Record review of open Patient #4's admission history and physical revealed staff admitted the patient on 03/29/10 with a requirement for mechanical ventilation after motor vehicle accident and resultant bone, abdominal and chest injuries and pneumothoraces (collapsed lungs).

Record review of the patient's admission history and physical revealed the physician authenticated and dated the document but failed to time the authentication.

5. Record review of open Patient #5's admission history and physical revealed staff admitted the patient on 04/09/10 with diagnoses including sacral decubitus ulcer (bed sore at base of the spine) and a requirement for physical therapy.

Record review of the patient's admission history and physical revealed the physician electronically dated, timed and authenticated the document on 04/12/10 (three days after admission).

6. Record review of open Patient #6's admission history and physical revealed staff admitted the patient on 03/22/10 with diagnoses including epidural abscess (inflammation and a collection of pus between the dura mater of the brain and skull, or between the dura mater of the spinal cord) after surgery and drain, a requirement for intravenous antibiotics, a requirement for physical and occupational therapy.

Record review of the patient's admission history and physical revealed the physician dated, timed and authenticated the document on 03/24/10 (two days after admission).

7. Record review of open Patient #7's admission history and physical revealed staff admitted the patient on 03/23/10 with diagnoses including right frontal craniotomy for aneurysm and hemorrhage, history of hypertension, respiratory failure requiring mechanical ventilation, a requirement for antibiotics for infection in the cerebrospinal fluid, high blood pressure, tracheitis (bacterial infection of the trachea) and a requirement for physical and occupational therapy.

Record review of the patient's admission history and physical revealed the physician dated, timed and authenticated the document on 03/25/10 (two days after admission).

8. Record review of open Patient #13's admission history and physical revealed staff admitted the patient on 03/29/10 with diagnoses including hip fracture with surgical repair, stroke after hip fracture repair, chronic lung disease, and history of lung cancer, high blood pressure, and diabetes.

Record review of the patient's admission history and physical revealed the physician dated, timed and authenticated the document on 04/06/10 (eight days after admission).

9. Record review of closed Patient #15's admission history and physical revealed the patient was admitted on 03/27/10 with diagnoses including empyema (collection of pus in the cavity between the lung and the membrane that surrounds it called the pleural space), after chest tube placement.

Record review of the patient's admission history and physical revealed the physician dated, timed and authenticated the document on 03/29/10 (two days after admission).

During an interview on 04/21/10 at 2:34 PM, the Director of Health Information Management (HIM) reviewed the patient's admission history and physical and stated the physician failed to date, time and authenticate the document within twenty four hours to complete the document.

During the same interview on 04/21/10 at 2:34 PM, the Director of HIM stated the facility interpretation of the requirement for the history and physical to be done within twenty four hours of admission was the staff transcribed the physician's dictation and placed the unauthenticated copy on the medical record without editing and correction by the physician.

10. Record review of closed Patient #19's admission history and physical revealed staff admitted the patient on 03/31/10 with diagnoses including pneumonia with respiratory failure, anemia, thrombocytopenia (low blood fragments called platelets), deconditioning and malnutrition.

Record review of the patient's admission history and physical revealed the physician dated, timed and authenticated the document on 04/06/10 (six days after admission).

During an interview on 04/21/10 at 2:45 PM the Director of HIM reviewed the patient's admission history and physical and stated the physician failed to date, time and authenticate the document within twenty four hours to complete the document.

11. Record review of open Patient #21's admission history and physical revealed staff admitted the patient on 04/16/10 with diagnoses including acute renal failure pulmonary fibrosis, recent Candida pulmonary infection and malnutrition.

Record review of the patient's admission history and physical revealed the physician dated, timed and authenticated the document on 04/19/10 (three days after admission).






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