HospitalInspections.org

During the on-site follow-up on 04/08/16, the following new deficiency was cited.

Based on observation and interview, it was determined the Governing Body failed to administer its duties to assure patients were provided health care in a safe environment in that single dose 100 milliliter bags of 0.9% Sodium Chloride was used multiple times on multiple patients. Patient safety and protection from likely sources of infection from cross contamination could not be assured. The lack of policies and staff knowledge in the safe preparation and administration of intravenous medications placed all patients who had an intravenous access at risk of exposure to likely sources of infection. See C-0241, C-0270, C-0271, C-0278.

During the on-site follow-up on 04/08/16, the following new deficiency was cited.

Based on observation and interview, it was determined the Governing Body failed to assure: policies were developed; staff was knowledgeable and monitored for the safe preparation and administration of intravenous (IV) medications. Observation on 04/06/16 at 1600 revealed four of four partially used 0.9% Sodium Chloride Injection, 100 milliliter (ml), single dose bags stored in the IV Start/blood draw totes. Patient safety and protection from likely sources of infection from cross contamination could not be assured and placed all patients who had intravenous access at risk of exposure to likely sources of infection and cross-contamination between patients. The findings were:

A. Observation on 04/06/16 at 1600 in the Emergency Department revealed two of two (one red and one brown) plastic storage totes were at the nursing station. The contents of the red and brown storage totes included two partially used 0.9% Sodium Chloride for Injection, 100 ml single dose bags in each tote.
B. In an interview with the Infection Control Nurse, the Director of Nursing, Registered Nurse #1, and Licensed Practical Nurse #1 on 04/06/16 at 1635, they confirmed the facility practice of using single dose bags of 0.9% Sodium Chloride Injection, 100 milliliter (ml), was to withdraw an intravenous flush for use multiple times on multiple patients in the Emergency Department, on the Medical Surgical Unit, and the In-patient Rehab Unit. Surveyor #1 asked the Director of Nursing how many times each IV bag would be used for flush and she replied "until the bag is empty".
C. The Director of Nursing stated there was not a policy for IV flush or single use IV medications on 04/07/16 at 0900. The Director of Nursing provided a copy of a policy "IV Therapy" on 04/07/16 at 0906. The purpose listed was "to provide guidelines for the initial and maintenance of IV access." The equipment listed included "Normal Saline Flush." The follow up stated "If saline lock is ordered, the lock will be flushed every shift."