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Based on observation and interview the facility failed to conduct active surveillance, identify, develop, or implement measures specific to prevention of device-associated bloodstream infections (BSI), methods to reduce transmission of infection in the hospital, and failed to follow basic aseptic technique for five Patient ' s (#1, #2, #3, #6 and #9) of 16 patients. The facility census was 16.

1. Observation on 05/25/10 at 12:10 a.m. showed Staff D, RN (Registered Nurse), Charge Nurse, changing the IV (intravenous - within the vein) medication bag and restarting the medication for Patient #1. Alcohol wipes are used to wipe the IV ports before connection and aseptic technique (set of specific practices and procedures performed under carefully controlled conditions with the goal of minimizing contamination [introduction of infectious organisms] by pathogens [infectious agent or germ]) requires the alcohol to dry before connection or access. The nurse did not allow the alcohol to dry and immediately reconnected the tubing allowing any contaminates to infiltrate the medication going into the patient ' s vein. The blood glucose meter (an instrument that calculates the amount of sugar in the blood) was taken into the patient's isolation room, the nurse tech performed the test, removed the isolation mask, gown and gloves, picked up the meter, left the room and returned to the nurses' station where it was again picked up, taken into a different patient ' s room, etc. This practice was observed many times during observations on 05/25/10 and 05/26/10.

2. Observation on 05/26/10 at 8:45 a.m., showed Staff M, RN, administering an IV push (syringe is connected to the IV access device and the medication is injected directly into the Patient ' s vein) to Patient #6. The nurse used an alcohol wipe to clean the IV access port but did not wait for the alcohol to dry before connecting the tubing. Patient #6 is under isolation precautions (special measures, practices, and procedures used in the care of patients with contagious or communicable diseases).

3. Observation on 05/26/10 at 09:27 a.m. showed Staff D, RN, Charge Nurse, administering an IV push to Patient #2. An Alcohol wipe was used to clean the port but the nurse did not wait for the alcohol to dry before connecting to the port with a syringe and injecting the medication. Patient #2 is under isolation precautions.

4. Observation on 05/26/10 at 10:10 a.m. showed Staff D, RN, Charge Nurse, administering medication through a PICC (peripherally inserted central catheter) line to Patient #3. The nurse swiped the access port with an alcohol pad but immediately attached the syringe and injected the medication without allowing the alcohol to dry.
5. Observation on 05/26/10 at 10:45 a.m. showed Staff F, RN, administering medication by IV push to Patient #9. The nurse wiped the access port with an alcohol pad but immediately attached the syringe and injected the medication without allowing the alcohol to dry.
6. During an interview on 05/26/10 at approximately 11:10 a.m. with Staff A, RN, DON (Director of Nursing-Acting), it was stated that he/she acts as the Infection Control Officer. Staff A states that observation of staff practices are not commonly observed on a routine basis and that asepsis technique is the expected practice. Staff A agrees that the alcohol wipe should be allowed to dry before the port is accessed and medication is administered.
7. During an interview on 05/26/10 at 11:51 a.m. Staff G, RN, Staff Educator, stated that observation of nursing practices was not used as a surveillance technique to identify educational opportunities for nursing staff. Staff G stated that that there is no nursing inservice schedule written down for the facility and that all nursing skill competencies are completed annually in the same month - mostly by electronic completion or at the skills fair.

Based on record review and interview the facility failed to analyze the cause(s) of medication errors or investigate for the root cause analysis of administering medication without an order, administering the wrong medication, documenting on an incident report, notifying the physician and/or family of medication error(s), and following facility policy for the potential of affecting 16 of 16 patients. The facility census was 16.
1. Closed record review on 05/26/10 of Patient #4 revealed a medication error to include the incorrect IV (intravenous, within the vein) solution. The nurse identifying the incorrect IV solution and submitting an incident report was not the nurse making the error. The nurse that made the error was identified but no incident report was filed by this nurse or by nursing administration.
2. Closed record review on 05/26/10 of Patient #4 revealed a medication error to include the wrong dose of medication and an omitted medication. The nurse did not administer a medication ordered for the Patient but started an IV solution with the correct medication at the incorrect infusion rate - 50mL/hr (milliliters per hour) rather than the 100mL per hour as ordered by the physician. A bolus (single, large dose of medication) medication order was omitted. The physician and/or family were not notified of this error.
3. In an interview on 12/26/10 at 11:51 a.m. with Staff A, RN (Registered Nurse), DON (Director of Nursing-Acting) it was stated that no root cause analysis was initiated and no incident report was submitted for the nurse administering the incorrect IV medication. Staff A, RN, DON, stated, " I dropped the ball " and agreed the facility should have investigated and evaluated the incident. Staff A, RN, DON, acknowledged that the physician and/or family had not been notified after these events were identified and according to policy that should have happened in each instance.

Based on record review and interview the facility failed to follow up with medication errors as an opportunity for feedback to the nursing staff making the errors and the opportunity to implement preventative measures and mechanisms for improvement and nursing staff education. This has the potential of affecting 16 of 16 patients in the facility.
1. Closed record review on 05/26/10 of Patient #4 revealed three medication errors to include: Omission of medication ordered; incorrect medication administered; and medication administered at the incorrect infusion rate.
2. Record review of personnel files did not indicate the nurse(s) making the medication errors were ever interviewed, counseled, or educated as a part of an activity to provide feedback in an effort to improve or prevent future medication errors.
3. In an interview on 12/26/10 at 11:51 a.m. with Staff A, RN (Registered Nurse), DON (Director of Nursing-Acting) it was stated that no feedback was given to the nurse(s) and that it should have been followed up on.
4. In an interview on 12/26/10 at 1:10 p.m. with Staff L, Human Relations Manager, it was acknowledged that the personnel files reviewed had no documentation regarding counseling, medication errors, or documentation of incident reporting even though the nurse had been identified by Staff A, RN, DON as making medication errors. Staff L also stated that any documentation regarding those issues would be found in the personnel records reviewed.

The facility failed to administer medications within 30 minutes before or after the scheduled medication time, failed to follow their policy of administering medications within 30 minutes before or after the scheduled medication time, failed to administer IV pushes over the amount of time specified for a specific medication by accepted national standards of practice, and failed to notify the physician that medication was not administered as ordered for seven Patient's (#1, 2, 3, 4, 6, 8 and 9) of 16 Patients. The facility census was 16.

1. Observation on 05/25/10 at 12:10 p.m. with Charge Nurse, Staff D, RN (Registered Nurse), for medication administration the nurse stated that medications could be given one hour before to one hour after the prescribed time by the physician. Charge Nurse, Staff D, RN, proceeded to give Patient #1 two medications - one prescribed for an 11:00 a.m. administration time and one prescribed for a 1:00 p.m. administration time. It should be noted that charge Nurse, Staff D, RN, is supervising, training, and overseeing the other six nurses in the unit who are administering medication.

2. Closed record review of the medical chart documentation for Patient #4 on 05/25/10 from 3:17 p.m. to 4:06 p.m. revealed the day nurse (unknown identity) did not give a 500mL (milliliters) bolus (the administration of a drug, medication or other substance in the form of a single, large dose) as ordered by the physician and during the same shift started an IV (intravenous - within a vein) at a rate of 50mL/hr not the ordered 100mL/hr as ordered by the physician and allowed it to run at an incorrect rate. No documentation in the Patient ' s chart as to whether the physician was notified. This closed record review also revealed that approximately 500 mL of Lactated Ringer had been infused to Patient #4 without an order for Lactated Ringer (A solution containing sodium chloride, potassium chloride, calcium chloride, and sodium lactate in distilled water). This medication was not ordered and has the potential of severe outcomes if used in patients with diabetes, heart problems, kidney problems, liver problems, high levels of potassium, high levels of sodium, acid/base problems (e.g., acidosis, alkalosis), swelling, allergies (especially drug allergies), and drug interactions.

3. Observation on 05/26/10 at 08:45 a.m. for a medication pass with Staff M, RN, administered an injection of Hydromorphone (a morphine derivative used to treat pain) 1 mg/0.5mL IV Push to Patient #6 over a period of 10 seconds instead of the accepted national standard of practice of 1-2 minutes an injection of Hydromorphone (common name, Dilaudid).

4. Observation on 05/26/10 at 9:27 a.m. for medication administration with Staff E, LPN (Licensed Practical Nurse) and Staff D, RN, Charge Nurse for the IV push. Staff D, RN Charge Nurse, prepared the IV port by wiping with an alcohol pad but did not allow the alcohol to dry before accessing the port and administering Famotidine (antacid), 20mg to Patient #2 over 40 seconds rather than the accepted standard of practice for this medication administration of no less than two minutes. Observation of Staff E, LPN, showed five medications administered at the following times: Medication scheduled for 9:00 a.m. administered to patient at 10:07 a.m.; medication scheduled for 8:00 a.m. administered to patient at 10:07 a.m.; medication scheduled for 9:00 a.m. administered to patient at 10:07; medication scheduled for 9:00 a.m. administered to patient at 10:07; and medication scheduled for 9:00 a.m. administered to patient at 10:07. Staff E, LPN, stated he/she wasn't sure what the time allowance was for medication administration - he/she thought it might be one hour before and one hour after the scheduled medication time -"but that could be wrong".

5. Observation on 05/26/10 at 10:10 a.m. revealed Staff H, LPN, and Staff D, RN, Charge Nurse for medication administration to Patient #3. Staff D, RN, Charge Nurse, prepared the IV port with an alcohol wipe but did not let the alcohol dry before accessing the IV port and administering Methylprednisolone (used to treat inflammation of the skin, joints, lungs, and other organs) 40mg over a 30 second period instead of the one to several minutes as is the accepted standard of practice for this medication.

6. Observation on 05/26/10 at 10:40 a.m., for medication administration with Staff H, LPN, to Patient #8 showed two medications administered at 10:45, one medication scheduled 10:00 a.m. and one medication scheduled for 11:00 a.m.

7. Record Review of the electronic MAR (medication administration record) on 05/26/10 at 11:00 a.m. revealed Staff N, RN, administered medication to Patient #6. An IV (intravenous medication) push (a syringe is connected to the IV access device and the medication is injected directly into the IV line) scheduled for 7:00 a.m. was administered at 6:11 a.m. and a medication scheduled for 9:00 a.m. was administered at 8:22 a.m.

8. Record Review of the electronic MAR on 05/26/10 at 11:10 a.m. revealed Staff H, LPN administered medication to Patient #3 at 8:44 a.m. for a scheduled 8:00 a.m. administration.

9. Record Review of the electronic MAR on 05/26/10 at 11:20 a.m. revealed Staff P, RN administered four medications to Patient #9: Medication administration scheduled for 7:00 a.m. administered to patient at 6:01 a.m.; medication administration scheduled for 9:00 a.m. administered to patient at 8:18 a.m.; medication administration scheduled for 7:00 a.m. administered to patient at 6:01 a.m.; medication administration scheduled for 7:00 a.m. administered to patient at 6:01 a.m.

10. Record review of:

Heartland Long Term Acute Care Hospital Policy: Medication Administration, Policy Number: Rx#27 Effective: March 2009 states, in part, under SUPPORTIVE DATA:
? Scheduled medications may be given up to 30 minutes before or 30 minutes after the time the medication is due.
? Most current regimens and frequencies are well established and cannot be altered to less frequent doses without compromising patient care.
MEDICATION ADMINISTRATION:
Key Points
6. When parameters are outside of the guidelines for medication administration, do not give the medication and contact the physician for an order to administer or discontinue the medication.
ANTIBIOTICS (SEE WORKSHEET BELOW FOR ADDITIONAL INFORMATION):
Key Points
1. Pharmacy to schedule the antibiotic dose for the next administration hour. For example, an order is received at 9:35 AM, the antibiotic is schedule for a 10:00 AM administration time. If multiple antibiotics are started, the pharmacist will stagger the antibiotic start times based on infusion rate requirements.
2. Within 30 minutes of the administration time, allows the nurse flexibility in case the patient is away from the procedure for a test, surgery, etc.