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Based on interview and document review the facility's nursing staff failed to provide evidence of restraint assessment for one (1) of two (2) restrained patients included in the survey sample. (Patient #8)

The findings included:

An interview was conducted on 10/04/2016 at 10:05 a.m., with Staff Members #1, #2, and #3 during the entrance conference. Staff Member #1 reported the facility did not have any patients currently in restraints. The surveyors requested a list of restrained patient for the past twelve (12) months. At approximately 2:25 p.m. Staff Member #2 presented the facility's restraint log. The surveyor picked a sample of two patients from the log. Patient #1 had been restrained for 13 days in July 2016 and Patient #8 had been restrained for 9 days between 09/24/2016 through 10/02/2016.

Review of Patient #8's electronic medical record (EMR) was conducted on 10/05/2016 from 10:50 a.m. through 11:58 a.m., with Staff Member #7. Patient #8's EMR contained daily physician orders for the continued use of bilateral mitt restraints to prevent the patient from pulling at lines. Patient #8's EMR included "Non-behavioral Restraint" flowsheets utilized to document every two (2) hour required assessments for restrained patients. Patient#8's "Non-behavioral Restraint" flowsheet for 09/30/2016 documented every two hour assessments from "0000 (midnight)" through "0746 (7:46 a.m.)." The next assessment on 09/30/2016 was documented at "2020 (8:20 p.m.)." Patient #8's "Non-behavioral Restraint" flowsheet had an approximate twelve (12) hour gap in restraint assessments. Staff Member #7 navigated Patient #8's EMR for evidence of nursing's assessment related to the patient's restraints. Staff #7 reported he/she was not able to find nursing assessments of the patient's restraints. Staff Member #7 reported the time gap may have been nursing staff attempts to remove restraints at the earliest opportunity. Staff Member #7 reviewed Patient #8's EMR for documentation when the restraints were removed and the reason for replacing the restraints at 8:20 p.m. on 09/30/2016. Staff Member #7 reported he/she was not able to find documentation Patient #8's restraints had been removed and reapplied.

Continued review of Patient #8's EMR was conducted on 10/06/2016 at 8:08 a.m., with Staff Member #7. Staff Member #7 reported he/she had spoken to the two nurses that were responsible for Patient #8's care on 09/30/2016. Staff Member #7 reported the day shift nurse failed to document the patient's restraint assessments. Review of the 10/01/2016 "Non-behavioral Restraint" flowsheet for Patient #8 revealed the nursing staff failed to perform every two hour assessments between "0441 (4:41 a.m.)" and "0803 (8:03 a.m.)." Staff Member #7 verified the findings.

An interview was conducted on 10/06/2016 at approximately 10:30 a.m. with Staff Members #1, #2, #3 and #7. The facility staff was made aware of the findings, a request was made for their policy on restraints and assessments. Staff #2 and #7 reported the facility did not have any additional documentation to address the assessment of Patient #8's restraints for 09/30/2016 and 10/01/2016 gaps in assessments.

Review of the facility's policy titled "Restraint and Seclusion Management: Non-Violent or Self Destructive Behavior in Non Behavioral Health Areas" read in part: "... 18. Monitor and document restraint safety according to patient need ... Monitoring shall be documented at least every 1.5 - 2.5 hours and may need to be more often; Adjust to more often according to patient need ..."

Based on observation, interview and document review it was determined the pharmacy staff failed to:

1. Remove expired medications, which were available for administration to patients in two (2) of four (4) patient care areas. (Pods #6 and #5)

2. Ensure intravenous solutions, which had their protective outer bag removed were not available for administration to patients in one (1) of four (4) patient care areas (Pods #4) and within emergency kits stored in the pharmacy supply storage room.

The findings included:

1. An observation and interview was conducted of Pod #6's Medication administration/preparation area on 10/04/2016 at 10:25 a.m., with Staff Members #1, #2, and #3. The observation revealed a multidose vial of patient specific Humalog insulin. The discard date for the multidose vial of Humalog insulin was documented as "10/02/16." The surveyor handed the vial of Humalog insulin to Staff #1. Staff #1 verified the vial of Humalog insulin had been available for administration to the patient for two days after the documented discard date of 10/02/2016.

An observation and interview was conducted of Pod #5's Medication administration/preparation area on 10/04/2016 at 10:50 a.m., with Staff Members #1, #2, and #3. The observation revealed a box labeled Heparin Lock Flush Solution. The expiration date printed on outside of the box was "Sep 2016." The box contained nine (9) Heparin Lock Flush Solution 5 cc (cubic centimeter) prefilled syringes. The imprinted expiration date on each syringe was "Sep 2016." The surveyor handed the syringes to Staff Member #2. Staff Member #2 verified the expiration date. Staff Member #2 stated, "These should have been discarded on September 30th." Staff Member #2 verified the expired Heparin Lock Flush Solution prefilled syringes had been available for patient administration.

Review of the Pharmacy's policy titled "Expired Medications" read in part: "Medication expiration dates shall be monitored to prevent distribution or administration of out dated products. Stock will be rotated to minimize expired medications ... 1. The manufacturer's assigned expiration date will be used unless unless storage or processing requires a change. An expiration date in MM/YY (month /year) format is considered expired on the final calendar day of that month."

2. An observation and interview was conducted of Pod #4's Medication administration/preparation area on 10/04/2016 at 11:20 a.m., with Staff Members #1, #2, and #3. The observation revealed one (1) bag of 50 ml (milliliter) Sodium Chloride Intravenous (IV) solution without the manufacturer's protective outer wrapper stored in a drawer. Staff Member #1 and Staff Member #2 explained to the surveyor that IV solutions could be kept outside of the manufacturer's protective wrapper for 30-days. Staff Member #2 acknowledged the bag of 50 ml Sodium Chloride had not been dated when the outer wrapper was removed. Staff Member #2 reported it would be impossible to determine the 30-day discard date.

Review of the Pharmacy's policy titled "Expired Medications" read in part: "... 2. For use in the pharmacy, IV bags removed from their outer wrapper will be labeled with a 90-day expiration date ..."

According to the manufacturer's (Baxter) "... recommends only removing the overwrap from the VIAFLEX plastic container just before the drug or solution is to be administered. However, where there are pharmacy space limitations or the need to remove a single bag from an overwrap containing several bags, containers may be stored at room temperature for no more than the following time periods: 50 mL or less [for] 15 days [and] 100 mL or greater [for] 30 days ..."


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3. On 10/4/16 at a approximately 11:25 A.M. the following observations were made in the Storage Supply Room/ Night Pharmacy Room:
In the night pharmacy supply cart were six (6) thin plastic bags or "kits" each containing a 100 ml (milliliter) IV bag of sodium chloride, two vials of Dilantin, a filter and a syringe. The bags of sodium chloride had been removed from their protective outer cover bags and placed in the "kits". The "kits" were not dated as to when the IV sodium chloride would expire after removal from the protective outer cover.

Staff Member #4 stated, "I forgot to put the expiration date on the outside of the bags we used to put all the needed items in."

Based on observations, document review and interview it was determined the facility staff failed to ensure they identified potential areas of infection control in the environment such as chipped wooden arms on chairs, chipped and worn hand rails, chipped wooden bedside table and cabinets in patient rooms for four (4) of four (4) observed pods, rolling wooden cabinet covers in the medication preparation areas for six (6) of six (6) pods, leaving belongings from a discharged patient in a room designated as clean, transporting linens while holding next to the staff's body and failing to clean equipment used in patient rooms and returning them to a common area (vital sign machines, flow carts (computer stands)).

The findings include:

On 10/4/16 during the initial tour of the facility between 10:30 and 11:45 A.M. the following observations were made:
Pod 6: The upper medication cabinets had lockable rolling covers made of wood. The paint from the wood was peeling and left exposed wood that could not be properly disinfected. One room designated as clean had chipped (the chipped items left exposed bare wood)wooden cabinets that were used to store patient belongings, a chipped bedside table with labels from a previous patients stuck on the outside of the drawers and a chair for patient and visitor use with chipped and bare wood exposed. Bare wood is a porous surface and can not be disinfected.

Pod 5: The upper medication cabinets had lockable rolling covers made of wood. The paint from the wood was peeling and left exposed wood. Staff Member #8 was observed taking a vital sign machine and a flow cart into the room of a patient and returned the equipment to the common nurses station without disinfecting the equipment and was observed removing clean linen from the cart, holding next to [his/her] uniform, taking it to the isolation PPE (Personal Protective Equipment) cart laying the linen on top of the cart, donning PPE and holding the linen next to the PPE gown as [he/she] walked into a patient's room.

Pod 4: The upper medication cabinets had lockable rolling covers made of wood. The paint from the wood was peeling and left exposed wood. One room designated as clean had chipped (the chipped items left exposed bare wood) wooden cabinets that were used to store patient belongings and contained items from a previously discharge patient, a chipped bedside table and used patient items stored under the sink. There was a sign under the sink that directed staff to not store basins and items under the sink.

Pod 3: The upper medication cabinets had lockable rolling covers made of wood. The paint from the wood was peeling and left exposed wood. Three rooms designated as clean had chipped (the chipped items left exposed bare wood) wooden cabinets that were used to store patient belongings, a chipped bedside table and a chair for patient and visitor use with chipped and bare wood exposed and one room (773) had a tear of approximately 6 inches in the vinyl covering of a chair. One room had an IV pole in the room with what appeared to be mop strings (red and white and green) stuck in the wheels of the rolling poll.

Handrails in the hallway by the visitor/patient lounge/waiting area had exposed chipped wood. Staff Member #1 was asked if the area was used by patients and [he/she] responded, "Yes."

The Procedure for Environment and Safety/Hazard Surveillance Rounds (ESC Rounds) was provided and it documents that monthly rounds will be conducted and deficiencies that place patients, visitors or staff in a unsafe environment will be addressed immediately by the Manager/Director, Safety Office, Safety & Security and/or Facilities Engineering.