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Based on observation, interview, record review and policy review, the facility failed to follow their policy for personal protective equipment (PPE) for two (#10 and #15) out of two patients observed and failed to follow facility policy for hand hygiene during medication administration for one (#3) out of four patients observed. This had the potential to affect all patients in the facility. The facility census was 30.

Findings included:

Record review of the facility policy titled, "Standard Precautions", showed direction for facility staff when applying PPE under gowns, to put the gown on, close the gown securely so the back is completely covered, and tie both waist and neck strings.

1.Observation on 04/04/11 at 2:30 PM, showed Staff D, Registered Nurse (RN), administer medication to Patient #10. Patient #10 is on contact isolation (requires use of PPE clothing protection) for VRE. Staff D was wearing a PPE gown, but the gown was not tied around the waist, exposing Staff D's uniform to potential contact with the infectious environment such as the patient's bed or table.

During an interview on 04/04/11 at 3:00 PM, Staff D stated that he/she did have the gown on, but didn't have it tied around the waist. Staff D also stated that gown was too small for him/her.

2. Observation on 04/06/11 at 11:05 AM, showed Staff M, Housekeeper, cleaning Patient #15's room. Patient #15 was on contact isolation for VRE. Staff M was wearing a PPE gown, but the gown was not tied at the waist, exposing Staff M's uniform to potential contact with the infectious environment, such as the patient's bed or table.
During an interview on 04/06/11 at 11:05 AM, Staff C, Director of Quality stated that isolation gowns should be tied at the waist to prevent the spread of disease and that he/she would discuss with Staff M that the gowns should be tied while in contact isolation rooms.

Record review of the facility policy titled, "Hand Hygiene" revised on 01/10, showed direction for facility staff to perform hand hygiene using either soap and water, or an alcohol based hand sanitizer after removing gloves.

3. Observation on 04/05/11 at 9:50 AM, showed Staff E, RN, administer medication to Patient #3. Patient #3 was on contact isolation for Methicillin Resistant Staphylococcus Aureus (MRSA) (an organism resistant to penicillin antibiotics) wound infection. Staff E removed his/her gloves three times during the medication administration and reapplied gloves. Staff E did not perform hand hygiene after glove removal and before reapplying gloves.

During an interview on 04/05/11, following Patient #3's medication administration, Staff E stated that hand hygiene should be done after removing gloves, and that he/she should have used hand sanitizer after removing his/her gloves.








29047

Based on observation, interview, record review, and policy review, the facility failed to ensure medications were administered within 30 minutes of the scheduled time for four (#16 #15, #14, #12) of eight patients observed receiving medications; and failed to follow the facility policy when medications were administered late. The facility census was 30.

Findings included:

Record review of the facility's policy titled, "Medication Administration" revised 02/19/10, showed direction for facility staff to administer medications at the time ordered or within 30 minutes before or 30 minutes after the time designated.

Record review of the facility's policy titled, "Medication Errors" revised 11/2009, showed the following:
-Categories of Medication Errors include the wrong time;
-Medication errors may be identified and reported by any person noting an error;
-An incident report must be completed;
-The attending physician is notified for category C and above (C defined as an error occurred that reached the patient, but did not cause the patient harm);
-All medications administered to a patient must be charted in the patient's permanent medical record and would include medications given in error.

1. Observation on 04/04/11 at 2:55 PM, showed Staff J, Registered Nurse (RN), administer Nystatin (antifungal) oral (by mouth) suspension and Ultram ( pain medication), 25 milligrams (mg) to Patient #15.

Review of Patient #15's medical record on 04/04/11 at 4:10 PM, showed:
-A physician order dated 03/24/11 for Ultram, 25 mg three times daily;
-A physician order dated 03/31/11 for Nystatin oral suspension, three times daily;
-A document titled, "Medication Administration Record" (MAR). The MAR showed that the medications were scheduled to be administered at 2:00 PM, and were charted as given at 2:00 PM, not at 2:55 PM, as observed;
-No documentation that the physician had been notified.

2. Observation on 04/04/11 at 3:10 PM, showed Staff J administer Ferrous Sulfate (iron supplement), 325 mgs and Trusopt (used to treat glaucoma) eye drops to Patient #14.

Review of Patient #14's medical record on 04/04/11 at 4:15 PM, showed:
-A physician order dated 03/18/11 for Trusopt, to instill one drop in each eye three times daily;
-A physician order dated 03/20/11 for Ferrous Sulfate, 325 mgs three times daily;
-The MAR showed that the medications were scheduled to be administered at 2:00 PM, and were charted as given at 2:00 PM, not at 3:10 PM as observed;
-No documentation that the physician had been notified.

During an interview on 04/04/11 at 4:10 PM, Staff J, stated that:
-He/she did not realize the medications were admininistered that late;
-The facility protocol would be to circle the time the medication was to be given and put the time the mediation had actually be given with the reason why the medication was late;
-Medications should be administered 30 minutes before and/or after ordered;
-He/she had been off the floor with a patient which delayed the medication pass;
-He/she would need to change the times on the MAR.

3. Observation on 04/05/11 at 11:05 AM, showed Staff L, RN, administer Protonix (used to decrease acid in gastrointestinal tract) 40mgs, injected (IV) intravenously (intravenous line is a plastic catheter that is placed through the skin into a vein), to Patient #16.

Review of Patient #16's medical record on 04/05/11 at 3:00 PM, showed:
-A physician order dated 03/31/11 for Protonix 40 mgs, IV daily at 10:00 AM;
-That the MAR indicated the medication was scheduled to be administered at 10:00 AM and was charted as given at 10:00 AM, not at 11:05 AM as observed;
-No documentation that the physician had been notified.

During an interview on 04/05/11 at 4:00 PM, Staff L stated that:
-Medications can be administered one hour before or after they are ordered;
-If a medication is administered late, the facility protocol would be to circle the time the medication was to be given, and put the time the medication had actually been given with the reason why the medication was late;
-The Protonix was not administered late.

4. Observation on 04/06/11 at 10:55 AM, showed Staff L administer the following medications to Patient #12:
-Aspirin, 81 mgs (pain medication);
-Pepcid, 20 mgs (used to treat heartburn/indigestion);
-Potassium chloride, 40 milliequivalents (mEq) (Potassium supplement);
-Plavix, 75mgs (is used to prevent strokes and heart attacks in patients at risk for these problems);
-Lasix, 40mgs (diuretic);
-Zinc Sulfate, 220mgs (mineral supplement);
-Multivitamin (vitamin supplement);
-Amitiza, 8 micrograms (mcg) (used to relieve stomach pain, bloating, and straining and produce softer and more frequent bowel movements);
-Colace, 100mgs (stool softener);
-Prednisone, 5mgs (decreases inflammation);
-Vitamin C (vitamin suppliment).

Review of a document on 04/06/11, provided by Staff G, Director of Pharmacy, and produced by the Med Dispense Station (an automated medication dispensing system), showed the following medications were dispensed for administration to Patient #12 on 04/05/11 between 10:50 AM and 10:53 AM:
-Aspirin, 81mgs;
-Pepcid, 20mgs;
-Potassium chloride, 40 mEq;
-Plavix, 75 mgs;
-Lasix, 40mgs;
-Zinc Sulfate, 220mgs;
-Multivitamin;
-Amitiza , 8 mcgs;
-Colace, 100mgs;
-Prednisone, 5mgs;
-Vitamin C.

Review of Patient #12's medical record on 04/06/11 at 1:40 PM, showed that the medications scheduled to be administered on 04/06/11 at 10:00 AM, were charted as given at 10:00 AM, not between 10:50 AM and 10:53 AM, and there was no documentation in the medical record that the physician had been notified of the medication being administered late.

During an interview on 04/06/11 at 2:10 PM, Staff L stated that:
-He/she had been informed that medications can be administered 30 minutes before or after they are ordered;
-He/she had been working with a patient that caused late administration of the medications;
-If a medication is administered late, the facility protocol would be to circle the time the medication was to be given and put the time the medication had actually be given with the reason why the medication was late.

During an interview on 04/05/11 at 3:30 PM, Staff C, RN, Quality Manager stated that:
-The policy does say to fill out an incident report and notify the physician if medications are given late;
-Nursing is not filling out incident reports for late medications, because he/she reviews all of them;
-Physicians are not being notified that medications are given late.

Based on observation, interview, record review, and policy review, the facility staff failed to follow accepted standards of practice from the on-line reference used by the facility, when administering three intravenous push (IVP - injected through a plastic catheter that is placed through the skin into a vein) medications to one (Patient #16) out of three patients receiving IVP medications observed. The facility also failed to ensure medications were administered according to the physician orders for two (#8 and #13) out of three current patient's and for one (#22) out of one discharged patient. This had the potential to affect all patients in the facility. The facility census was 30.

Findings included:

Record review from the online reference used by the facility staff, and provided by Staff G, Director of Pharmacy on 04/06/11, showed direction for staff to administer Dilaudid (pain medication) intravenously (IV - in the vein) slowly over two to three minutes (rapid intravenous administration has been associated with an increase in side effects, especially respiratory depression and hypotension).

Record review from the online reference used by the facility staff, provided by Staff G on 04/06/11, showed direction for staff to flush the IV line before and after administration of Protonix (decreases acid in the gastrointestinal tract) and to administer Protonix IV slowly over at least two minutes.

1. Observation on 04/04/11 at 2:45 PM, showed Staff K, Registered Nurse (RN) administer Dilaudid, 1milligram (mg) IVP, over 30-45 seconds to Patient #16.

During an interview on 04/04/11 at 3:00 PM, Staff K stated that he/she:
-Thought the medication had been administered over about one minute;
-Thought the Dilaudid could be administered over one minute;
-Would have to check with the pharmacist to see how fast Dilaudid could be adminnistered IVP.

2. Observation on 04/05/11 at 11:05 AM, showed Staff L, RN, administer Dilaudid 1mg, IVP over 10 seconds, and Protonix 40mg, IVP over 10 to 15 seconds to Patient #16. Staff L did not flush the IVP line before and after the administration of Protonix.

During an interview on 04/05/11 at 11:20 AM, Staff L stated that he/she:
-Probably pushed the Dilaudid too fast;
-Should have pushed the Dilaudid over one minute;
-Was not sure about the timing of administration of Protonix;
-Usually just pushed it in without timing it.

During an interview on 04/05/11 at 2:15 PM, Staff O, Pharmacist, confirmed that the standard of practice would be to administer Dilaudid IVP over two to three minutes, and that Protonix should be administered IVP over at least two minutes, and that the IV line should be flushed before and after the administration of Protonix.

During an interview on 04/05/11 at 2:10 PM, Staff G, Director of Pharmacy stated that the standard of practice for IVP medications would be to administer the medication over at least two minutes.





29047

Record review of policy #M01-N, titled, "Medication Administration" dated 12/01/98, revised on 02/19/10, showed that the six rights of medication administration should be followed when administering medications, including verifying the right dose (page 3, 20.3). Further review of the policy showed that the medication should be checked for accuracy three times before it is administered to the patient (page 3, 21).
3. Record review of Patient #8's medical record showed that on 03/28/11, a physician ordered Vicodin (narcotic pain reliever), one tablet by mouth, to be given every four hours as needed for pain rated 6-8.
Further review of Patient #8's medical record showed that the following medications were administered to the patient, but were not administered according to the physician's order:
-04/02/11 at 8:20 PM, the patient received Vicodin for a documented pain score of 0;
-04/04/11 at 6:15 AM, the patient received Vicodin for a documented pain score of 0;
-04/04/11 at 9:00 PM, the patient received Vicodin for a documented pain score of 5.

4. Record review of Patient #13's medical record showed that on 03/31/11, a physician ordered Morphine (narcotic pain reliever), two mgs IV, every three hours as needed for pain rated 6-10. On 04/05/11 at 1:00 PM, the patient received Morphine for a documented pain score of 0.

5. Record review of Patient #22's medical record showed the following physician orders:
-03/01/11, Percocet (narcotic pain reliever), one tablet per tube, every four hours as needed for pain rated less than 5;
-03/01/11, Percocet, two tablets per tube, every four hours as needed for pain rated greater than 5;
-03/01/11, Risperdal (a sleep aid), 0.5 mgs per tube, as needed at bedtime.

Further review of patient #22's medical record showed that the following medications were administered to the patient, but were not administered according to the physician's order:
-On 03/01/11 at 8:00 PM, the patient received two Percocet tablets for a documented pain score of 5;
-On 03/02/11 at 11:00 AM, the patient received two Percocet tablets for a documented pain score of 3;
-On 03/02/11 at 6:45 PM, the patient received two Percocet tablets for a documented pain score of 3;
-On 03/03/11 at 3:45 AM, the patient received Risperdal;
-On 03/05/11 at 8:50 PM, the patient received two Percocet tablets for a documented pain score of 2;
-On 03/06/11 at 5:05 AM, the patient received two Percocet tablets for a documented pain score of 2.

During an interview on 04/06/11 at 1:20 PM, Staff B, Chief Nursing Officer, stated that medications should be administered as ordered by the physician and that if a nurse failed to administer medications according to the physician's orders, it would be considered a medication error.