HospitalInspections.org

Based on observation, interview, record review, and policy review, the facility failed to:
- Provide appropriate indwelling urinary catheter (a sterile tubing inserted into the bladder to provide for a continuous flow of urine from the bladder) care for four (#L12, #L14, #SA1, and #SA10) of six patients observed for indwelling urinary catheter care. Failure to provide proper care to patients with an indwelling urinary catheter predisposes these patients to infection.
- Perform hand hygiene during and after wound care in one (#L13) of seven patients observed for wound care. Failure to perform adequate hand hygiene allows for cross contamination of organisms.
- Administer G-Tube (gastric tube, a tube surgically placed into a patient's stomach via the abdomen used for feeding and administration of fluids and medication) medications without possible cross-contamination of organisms for two (#SA2 and #SA3) of 10 patients observed during medication administration. Failure to follow standard precautions promotes possible cross contamination of organisms.
- Remove air from tube prior to administering tube feeding for one (#SA3) of two patients observed for tube feeding. Failure to remove excess air from the tubing allows the air to enter the patient's stomach, possibly creating discomfort.
- Follow the facility's Standard Precautions and Contact Isolation and procedural guides during:
A PICC (Peripherally Inserted Central Catheter, catheter inserted into a large vein for administering medication and fluid) dressing change for one (#SA2) of one PICC dressing change observed. Failure to follow infection prevention precautions could potentially lead to infection of the blood stream.
Tube feeding for one (#SA2) of two patients observed for tube feeding. Failure to follow infection prevention precautions could potentially lead to cross-contamination of organisms.

The facility census was 58.

Findings included:

1. Record review of the document titled, "Indwelling urinary catheter care and management", provided by the facility and taken from 2011 Lippincott Williams & Wilkins showed the following direction:
- To avoid contaminating the urinary tract, always clean by wiping away from-never toward-the urinary meatus.

Record review of a Clinical Fact Sheet for Indwelling Catheters, reference number H-PC F 04-017 A, from the Wound, Ostomy and Continence Nurses Society, provided by the facility included the following prior to insertion of the urinary catheter:
-Interventions to reduce risk of UTI (Urinary Tract Infection), Use strict aseptic technique (free of disease causing organisms) for catheter insertion.

Record review of the procedure for Indwelling Urinary Catheter (Foley) insertion, female, from 2011 Lippincott Williams & Wilkins included the following prior to insertion of the urinary catheter:
- Clean and dry the genital area and perineum (the area between the patient's legs);
- Use the washcloth to clean the patient's genital area and perineum thoroughly with soap and water. Dry the area with the towel.

Record review of the facility's policy titled, "Hand Hygiene", dated 06/2011, showed the following direction:
- Hand hygiene will be performed as follows:
Before and after patient contact;
After removal of gloves;
After situations during which microbial contamination of the hands is likely to occur (i.e. contact with potentially contaminated environmental surfaces);
Between patients.

Record review of the facility's policy titled, "Standard Precautions", dated 11/2010, showed the following direction:
- Remove gloves promptly after use and wash or disinfect hands immediately before touching non-contaminated items and environmental surfaces, and before going to another patient.
- Change gloves and wash or disinfect hands between tasks and procedures on the same patient after contact with materials that may contain blood and or other body fluids.
- Failure to change gloves between patients is an infection control hazard.
- Gloves are indicated when touching contaminated items.
- Ensure that reusable equipment is not used for the care of another patient until it has been appropriately cleaned.
- Handle used linen soiled with blood, body fluids, secretions and excretions in a manner that avoids transfer of microorganisms to other patients and environments.

Record review of the facility's policy titled, "Contact Precautions," revised 05/2010, showed the following direction:
- Removal of Personal Protection Equipment (PPE) shall be done so as not to contaminate the employee. Take precautions to ensure that clothing and hands do not contact environmental surfaces after removal of gloves and gown.
- If use of common equipment is unavoidable, then adequate cleaning and disinfecting is necessary upon removal from the room, before use with other patients.

Record review of the facility's policy titled, "Donning and Removing Personal Protective Equipment (PPE)," revised 11/2010, showed the following direction:
Removing PPE
- Non-sterile Gloves: Outsides of gloves is contaminated.
- Gown
- Front and sleeves of gown are contaminated.
- Unfasten ties with ungloved hands.
- Pull away from neck and shoulders, touching inside of gown only.
- Turn gown inside out.
- Fold or roll into a bundle and discard in trash or linen hamper.
- Conduct Hand Hygiene when all PPE has been removed.

Record review of the facility's policy titled, "Dressing Change - Central Line/PICC Line," last revised 11/2010, showed the following direction:
- The procedure for central line dressing changes will be performed under strict aseptic technique.
- Ask patient to turn face away from the site during procedure.
- Create a clean work area.
- Dispose of old dressing and contaminated gloves appropriately.
- Wash hands using good washing technique, then prepare sterile field and open supplies.
- Don sterile gloves.
- Clean the catheter site with chlorhexidine swabstick. Wipe back and forth from above to below the insertion site.
- Wash hands using good hand washing technique.

Record review of the facility's document titled, "Peripherally Inserted Central Catheter (PICC) dressing change," provided by the facility and taken from 2011 Lippincott Williams & Wilkins showed the following direction:
- Position the patient with his arm extended away from his body to a 45 degree angle so that the insertion site is below heart level to reduce the risk of air embolism.
- Remove and discard your gloves and mask and perform hand hygiene.

Record review of the document titled, "Gastrostomy tube drug instillation," dated July 09, 2011, provided by the facility and taken from 2011 Lippincott Williams & Wilkins showed the following direction:
Implementation:
- If the prescribed medication is in tablet form, crush the tablets with a mortar and pestle to ready them for mixing in a cup with the diluent. (Request liquid forms of the medication, if available.) Bring the medication and equipment to the patient's bedside.
- Elevate the head of the bed so that the patient is in a Fowler's position (a position in which the head of the patient's bed is raised 30 - 90 degrees), as tolerated;
- Attach the syringe or funnel to the tip;
- Prepare the medication for the gastrostomy tube by mixing the crushed medication in the diluent;
- Release the clamp and instill about 10 ml (milliliters) into the tube through the syringe to check for patency. If the water flows easily, the tube is patent. If it flows in slowly, raise the funnel to increase the pressure. If the water still does not flow properly, stop the procedure and notify the doctor.
- Pour up to 30 ml of medication into the syringe or funnel. Tilt the tube to allow air to escape as the fluid flows downward. Just before the syringe empties, add medication, as needed.
- After giving the medication, pour about 30 ml of water to irrigate the tube.

Record review of the document titled, "Gastrostomy tube drug instillation," dated July 09, 2011, provided by the facility and taken from 2011 Lippincott Williams & Wilkins showed the following direction:
Implementation:
- If the prescribed medication is in tablet form, crush the tablets with a mortar and pestle to ready them for mixing in a cup with the diluent. (Request liquid forms of the medication, if available.) Bring the medication and equipment to the patient's bedside.
- Elevate the head of the bed so that the patient is in a Fowler's position (a position in which the head of the patient's bed is raised 30 - 90 degrees), as tolerated;
- Attach the syringe or funnel to the tip;
- Prepare the medication for the gastrostomy tube by mixing the crushed medication in the diluent;
- Release the clamp and instill about 10 ml (milliliters) into the tube through the syringe to check for patency. If the water flows easily, the tube is patent. If it flows in slowly, raise the funnel to increase the pressure. If the water still does not flow properly, stop the procedure and notify the doctor.
- Pour up to 30 ml of medication into the syringe or funnel. Tilt the tube to allow air to escape as the fluid flows downward. Just before the syringe empties, add medication, as needed.
- After giving the medication, pour about 30 ml of water to irrigate the tube.

2. During an interview on 08/24/11 at 10:45 AM, Staff LP, Registered Nurse (RN), Nurse Manager, stated that indwelling urinary catheter care was to be provided every shift (two times a day) and if the patient was soiled.

3. Observation on 08/24/11 at 9:45 AM showed Staff LT, Certified Nursing Assistant (CNA) provided indwelling urinary catheter care to Patient #L12. During the cleansing, Staff LT placed a soiled washcloth in the water basin and then retrieved an un-used washcloth from the same water basin to continue cleaning the patient's catheter. Staff LT did not retract the patient's foreskin to clean the patient appropriately.

Review of Patient #L12's medical record showed indwelling urinary catheter care was not completed on 08/10/11 thru 8/20/11 and on 08/23/11; and was only completed once on 08/21/11 and 08/22/11.

4. Observation on 08/24/11 at 10:25 AM showed Staff LU, CNA, provided indwelling urinary catheter care to Patient #L14. During the cleansing of the catheter tube, Staff LU used a washcloth to hold the tube and wiped towards the patient, potentially moving bacteria towards the urinary meatus where entry to the bladder could occur.

Review of Patient #L14's medical record showed an indwelling urinary catheter was inserted on 08/07/11. Medical record showed catheter care was not completed on 08/09/11 and 08/11/11 thru 08/23/11; and was only completed once on 08/08/11 an 08/10/11.

5. Observation on 08/22/11 at 3:20 PM showed Staff SAM, CNA, providing indwelling urinary catheter care to Patient #SA1. During the cleansing of the catheter tube, Staff SAM used a washcloth to hold the tube, then wiped up and down the catheter. Staff SAM then placed the soiled washcloth in the water basin, then retrieved an un-used washcloth from the same water basin to continue cleaning the patient's catheter. After he/she was finished cleaning the catheter, Staff SAM removed his/her contaminated gloves and revealed that a second pair of gloves was being worn. Without removing the second set of gloves or performing hand hygiene, Staff SAM completed the process of drying the patient's perineum.

6. Observation on 08/24/11 at 10:08 AM showed Staff SAC, Licensed Practical Nurse (LPN) performed indwelling urinary catheter care to Patient #SA10. During the catheter care, Staff SAC deflated the patient's urinary catheter balloon and advanced the urinary catheter without washing the genital area or cleaning the urinary catheter prior to advancement of the catheter into the patient's bladder. This could result in an introduction of bacteria into the bladder causing a possible bladder or kidney infection. Staff SAF, RN, Nurse Education Manager, was also present during the procedure.

During an interview on 08/25/11 at approximately 2:00 PM, Staff SAF stated that Staff SAC advanced Patient #SA10's urinary catheter without washing the genital area or cleaning the catheter tubing.

7. Observation on 08/24/11 at 9:50 AM showed Staff LI, RN provided wound care to Patient #L13. Staff LI changed gloves several times throughout the wound care but did not perform hand hygiene between any of the glove changes. At the end of the procedure, Staff LI changed gloves without performing hand hygiene and went to a wall-mounted computer to input wound care documentation. The wall-mounted computer was located in a room with four patients and was for use by all staff on all four patients in that room.

8. Observation on 08/23/11 from 8:50AM - 9:50 AM showed Staff SAL, RN, prepared and administered medications per G-Tube to Patient #SA2. Patient #SA2 was on contact isolation precautions, which required the use of an isolation gown and non-sterile gloves when providing care to the patient. Staff SAL used a metal pill crusher to prepare medications at the patient's bedside, using the top of the medication cart as a table. Observation showed Staff SAL placed one souffle cup in the pill crusher, placed the medication in the cup and used the crusher to pulverize the medication for administration. Staff SAL did not place a second souffle cup on top of the pill before crushing, which caused pill particles to stick to the pill crushing plunger device. Staff SAL wiped the particles into the souffle cup using a gloved finger, then used the same crushing technique to crush three additional medications. During medication administration, Staff SAL failed to correctly position the stopcock on Patient #SA2's G-tube, which caused approximately two tablespoons of gastric contents to leak onto the patient's gown and bed sheet. In correcting the stopcock position, Staff SAL's hands were contaminated with gastric fluid. Without removing gloves and performing hand hygiene, Staff SAL continued administering medications. When medication administration was completed, Staff SAL repositioned his/her reading glasses from face to the top of head, contaminating his/her glasses and hair. Staff SAL did not remove gloves or perform hand hygiene before repositioning glasses or before returning to the medication cart to document medication administration in the electronic medical record (EMR).

9. Observation on 08/25/11 from 9:05 AM - 10:15 AM showed Staff SAI, RN prepared and administered medications per G-Tube to Patient #SA3. Staff SAI used a metal pill crusher to prepare medications in the patient's room at a wall-mounted medication cabinet. Staff SAI placed one souffle cup in the pill crusher, placed the medication in the cup and used the crusher to pulverize the medication for administration. Staff SAI did not place a second souffle cup on top of the pill before crushing, which caused pill particles to stick to the pill crushing plunger device. Staff SAI wiped the particles into the souffle cup using a gloved finger, then used the same crushing technique to crush four additional medications. Staff SAI proceeded to mix crushed medications with tap water. Staff SAI injected 30 ml of air into Patient #SA3's G-tube and listened for evidence of tubing placement, but did not attempt to aspirate stomach contents prior to medication administration. Staff SAI used an irrigation kit to flush the G-tube with tap water between medications, and placed the irrigating bottle on Patient #SA3's over bed table between uses. When medication administration per G-tube was completed, Staff SAI did not perform hand hygiene before returning to the medication cart and documenting the administration of medications in the EMR. Without changing gloves or performing hand hygiene, Staff SAI reached into his/her pocket to retrieve keys to a locked medication cabinet and removed medications from the cabinet. After removing medications, Staff SAI returned the keys to his/her pocket without decontamination, then reached into the wall-mounted medication cabinet and retrieved additional supplies to finish preparing IV medications for administration. Staff SAI wore the same contaminated gloves to administer medications through the central IV. Without removing gloves or performing hand hygiene, Staff SAI returned to the medication cart to chart administration of medications and tube feeding. Staff SAI then reached into his /her pocket, retrieved keys, and locked the medication cabinet. Staff SAI then left the room to care for another patient, failing to sanitize the medication cart, mounted wall cabinet shelf or exterior, doors of locked medication cabinet, over bed table, or administration pumps for IV fluids and tube feedings that had been contaminated during care. Approximately 15 minutes after Staff SAI left Patient #SA3's room, Staff SAJ, CNA, noted that Patient #SA3's IV tubing was leaking fluid onto the bed linens. Staff SAI returned to the room, identified that the stopcock of Patient #SA3's IV tubing was not closed off correctly, removed the tubing of the antibiotic that had been infusing, laid the uncapped tubing on Patient #SA3's bed, corrected the leakage problem, and reattached Patient #SA3's antibiotic tubing without cleansing the hub of the central IV line.

10. Online review of instructions for use of this type of pill crusher showed the following guidance: NOTE: Please read the instructions included with the pill crusher before using the product. The instructions state that you place the pills into a souffle cup, place a cup on top of the pills to prevent cross contamination of medications, place the cups with the pills into the pocket, squeeze the handle, rotate the cup, squeeze the handle again, repeat until the pills are pulverized to a fine powder. The amount of "squeezes" that it takes to pulverize the pills varies with the type of medication. A common aspirin would probably be crushed in 1-2 squeezes. Some medications especially vitamins and supplements have a very tough outer shell and take more work to crush. For this product to work properly it must be used with the souffle cups that are sold below or they may be purchased locally.
(http://www.google.com/search?q=metal+pill+crusher&rls=com.microsoft:*&ie=UTF-8&oe=UTF-8&startIndex=&startPage=1&rlz=1I7ADRA_en).

11. During an interview on 08/23/11 at 11:10 AM, Staff F, Nurse Educator, stated that nurses were taught to place pills between two souffle cups when crushing medications to prevent cross contamination "because you don't know what's on there."

12. During an interview on 08/23/11 at 1:30 PM, Staff SAN, Infection Control Nurse, stated the following:
- Nursing staff were expected to perform hand hygiene before and after retrieving items from a pocket; and before and after touching reading glasses, hair, contaminated items, surfaces, etc.

13. Observation on 08/23/11 at 10:00 AM showed Staff SAL, RN, changed Patient #SA2's PICC line dressing. Patient #SA2 was on contact isolation precautions. Staff SAL applied isolation gown, non-sterile gloves and mask, and proceeded to remove the PICC line dressing from Patient #SA2's right upper arm. Staff SAL placed the sterile dressing kit on the patient's over bed table, which was wet with fluid that had spilled on the table during irrigation of the patient's feeding tube. After removing the old dressing, Staff SAL removed the contaminated non-sterile gloves and disposed of them. Without performing hand hygiene, Staff SAL opened the sterile dressing kit, applied sterile gloves from the kit, and cleaned the insertion site. Staff SAL did not position the patient's arm at a 45? angle as instructed by Lippincott policy and did not have a clear view of the site, which was located on the inner, posterior aspect of the patient's upper arm. After cleaning the PICC insertion site, Staff SAL applied the chlorhexidine-impregnated sponge dressing. Due to the positioning of the patient's arm, Staff SAL could not see the insertion site. While applying the transparent dressing, Staff SAL discovered that the dressing was misplaced and attempted to flatten it. When the dressing was completed, the impregnated sponge was not lying flat against the patient's skin, which diminished its effectiveness for preventing infection at the insertion site. Staff SAL then applied labeling tape to the patient's dressing. Without removing gloves and performing hand hygiene, Staff SAL reached into his/her pocket, retrieved an ink pen, labeled the dressing, and returned the pen to his/her pocket. Staff SAL then disposed of use supplies from the patient's over bed table and tidied the patient's room. Without removing contaminated gloves, Staff SAL removed the isolation gown by placing his/her gloved hands inside the neckline of the gown and pulling the gown away to break the tied closure at the neckline, then removed his/her gown and gloves. Staff SAL repeated this process of removing an isolation gown three times during the time period of 8:50 AM and 11:00 AM while providing care to Patient #SA2.

During an interview on 08/23/11 at 1:30 PM, SAN, Infection Control Nurse, stated the following:
- Nursing staff were expected to perform hand hygiene between removal of non-sterile gloves and application of sterile gloves and before and after retrieving items from a pocket.
- Procedures outlined in the facility's policies and the Lippincott policies differed regarding nursing processes, but stated that it was acceptable practice to remove the isolation gown without removing gloves. However, if gloves were not removed first, isolation gowns should be removed by grabbing the front of the gown and pulling to break the neck ties. Placing gloved hand inside the neckline was not an acceptable practice.

14. Observation on 08/23/11 at 10:50 AM showed Staff SAL, RN, hung a bottle of Glucerna (tube feeding) for Patient #SA2. After completing the procedure, Staff SAL picked up a permanent marker that had fallen onto the floor, labeled the bottle of tube feeding with date and time, and helped the patient reapply his/her oxygen cannula.

15. Observation on 08/24/11 at 9:50 AM showed Staff SAI, RN, administered a tube feeding bolus to Patient #SA3. Staff SAI did not prime the tubing to remove air before beginning the administration of tube feeding.

During an interview on 08/25/11 at 2:15 PM, Staff SAI stated that nursing staff weren't required to prime the tube feeding pump before administering tube feeding, and stated, "I don't think air in the tubing is a problem."


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Based on interview, record review and policy review the facility failed to obtain weights prior to and after dialysis treatment (cleanse the blood of toxins in patients who have kidney failure) for five (#L16, #L3, #L4, #L11, #L14) of five current patients, and one (#L7) of one discharged patient and failed to document the times of Heparin (blood thinner) administration for one (#L16) of one current patient. The facility census was 58.

Findings included:

1. Record review of the facility's policy titled, "Pre/Post Dialysis Treatment Data Collection" dated 09/09, showed direction for Data collection may include, but is not limited to, the following: Weight.

2. During an interview on 08/22/11 at 2:15 PM, Staff #LB, Registered Nurse (RN), Director of Quality Management, stated that dialysis is a contracted service and the staff are provided by the dialysis service. The dialysis service sends the same Registered Nurses each day.

3. Review of current Patient #L16's dialysis treatment record on 08/24/11 at 2:30 PM during his/her dialysis treatment showed no weight recorded prior to the treatment.

Further review of current Patient #L16's dialysis treatment record on 08/24/11 showed that Heparin (medication used to thin blood) was ordered to be administered 1,000 units prior to treatment, and 500 units every hour with exception of last hour before disconnecting patient from the treatment, then administering 1,000 units more to the Central Venous Catheter (vein and artery access to administer dialysis treatment) to dwell until the next dialysis treatment. Heparin was documented as patient having 1000 units prior to dialysis treatment, and then 3,000 units total. The nurse did not document the Heparin doses at the actual time given.

During an interview on 08/24/11 at 2:30 PM, Staff LV, Dialysis Registered Nurse, stated that he/she documents the dosage of heparin given before the dialysis and then the total amount given during the treatment. He/she stated that the dialysis machine was programmed to give the dosage hourly, and he/she drew the total amount of Heparin into a syringe, connected the heparin syringe to the dialysis machine and programmed the machine.

4. Review of current Patient #L3's dialysis treatment record showed no documentation of weights prior to and after dialysis treatments.

5. Review of current Patient #L4's dialysis treatment record showed no documentation of weights prior to dialysis treatments.

6. Review of current Patient #L11's dialysis treatment record showed no documentation of weights prior to dialysis treatments.

7. Review of current Patient #L14's dialysis treatment record showed no documentation of weights prior to dialysis treatments.

8. Review of discharged Patient #L7's medical record showed no documentation of weight prior to and after dialysis treatments.

9. During an interview on 08/24/11 at 2:30 PM, Staff LV, Dialysis Registered Nurse, stated that it was the responsibility of the floor staff to obtain the patient's weight before and after dialysis treatment. He/she confirmed there should be a weight prior to and after the dialysis treatments to determine if there should be adjustments made to the dialysis treatment.

Based on observation, interview, record review, and policy review, facility staff failed to:
- Verify dosage of a high-risk medication for one (#L1) of 10 patients observed during medication administration. Failure to have a second nurse verify a high-risk medication dosage puts the patient at risk of receiving an incorrect dose.
- Maintain aseptic (without contamination) technique when administering intravenous (IV - a line inserted directly into a vein) medications for three (#L11, #L10, and #SA3) of 10 patients observed during medication administration. Failure to wipe the IV hub with alcohol prior to administering medications puts the patient at risk for a blood stream infection.
- Follow hospital policy with regard to preparation and administration technique for two (#SA2 and #SA3) of 10 patients observed during medication administration. When G-tube medications are not administered appropriately, there is the potential for the tube to become clogged and require replacement.
- Follow facility policy and manufacturers guidelines with regard to administering medication via intravenous push (IVP) for one (#SA3) patient of 10 patients observed during medication administration. When medications are not administered appropriately, there is the potential for the patient to have a medication reaction.
- Administer medication within the required time frames of 30 minutes prior until 30 minutes after the scheduled administration time for seven (#L10, #SA5, #SA7, #SA8, #SA6, #SA2, and #SA3) of 10 patients observed during medication administration. When medications are not administered as ordered by a physician it can be potentially harmful or fail to achieve the desired treatment affect for the patient.

The facility census was 58.

Findings Included:
1. Record review of the facility policy titled, "High-Risk Medication", dated 11/2011, showed the following direction:
- At a minimum, the following medications will be on the High Alert Medication List: Insulins.
- If a High-Alert medication requires a second nurse verification, that verification must be documented in the patient's medical record.
- Insulin: Before administering any of these agents, use a second nurse to independently check the drug, dose.

Record review of the facility's document titled, "2011 Annual Infection Prevention and Control Plan", dated January 2011, showed the following goal:
Blood Stream Infection desired rate of 1.0/1000 line days.

Record review of the facility's documents titled, "Infection Control", dated 08/24/11 showed a Blood Stream Infection rate of 3.56/1000 line days at the Lindell campus and 2.53/1000 line days at the St. Anthony's campus (both higher than their desired rate of 1.0/1000 line days).

Record review of the facility policy titled, "Medication Management", dated 06/2011, showed the following direction:
- Medications will be administered within 30 minutes before or after the scheduled time.
- The 7 "R's" of administering medications will be followed with each medication administration:
"Right" patient
"Right" medication
"Right" dose
"Right" time
"Right" route
"Right" reason
"Right" documentation.
- Wipe injection port with alcohol.

Record review of the facility's policy titled, "Administration of Medications," last revised 06/2011, showed the following direction:
General Guidelines for Administration of Medication:
- The individual administering the medication(s) must document all medications immediately after administration in the patient's medical record.
Medications via Feeding Tube:
- Crush tablets using a pill-crushing device such as a mortar and pestle to a find powder and mix well in 30 milliliters (ml) of warm water unless crushing is contraindicated.
- Rinse medication cup with 10-20 ml water and pour into syringe. Pour into the syringe to rinse and to ensure that all medication has been given.
Medications via IV Push per Saline Lock:
- Wipe injection port with alcohol.
- Administer IV Push medications no faster than 1 ml per minute or slower if recommended by the drug reference or physician order.

Record review of the document titled, "Gastrostomy tube drug instillation," dated July 09, 2011, provided by the facility and taken from 2011 Lippincott Williams & Wilkins showed the following direction:
Implementation:
- Perform hand hygiene and put on gloves;
- If the prescribed medication is in tablet form, crush the tablets with a mortar and pestle to ready them for mixing in a cup with the diluent. (Request liquid forms of the medication, if available.) Bring the medication and equipment to the patient's bedside.
- Elevate the head of the bed so that the patient is in a Fowler's position (a position in which the head of the patient's bed is raised 30 - 90 ?), as tolerated;
- Attach the syringe or funnel to the tip;
- Prepare the medication for the gastrostomy tube by mixing the crushed medication in the diluent;
- Release the clamp and instill about 10 ml into the tube through the syringe to check for patency. If the water flows easily, the tube is patent. If it flows in slowly, raise the funnel to increase the pressure. If the water still does not flow properly, stop the procedure and notify the doctor.
- Pour up to 30 ml of medication into the syringe or funnel. Tilt the tube to allow air to escape as the fluid flows downward. Just before the syringe empties, add medication, as needed.
- After giving the medication, pour about 30 ml of water to irrigate the tube.

Record review of the document titled, "Impaired swallowing and aspiration precautions," dated April 02, 2011, 2011, provided by the facility and taken from 2011 Lippincott Williams & Wilkins showed the following direction:
Managing a patient with a feeding tube
- Assess placement of the feeding tube before feeding and every 4 hours for a patient with a continuous feeding. Aspirate contents from the tube, note appearance and color and determine pH. Testing pH and noting aspirate characteristics are the most reliable means of determining tube placement. Note that listening to stomach sounds as air is injected into the tube is no longer considered an accurate method for confirming placement.

2. Review of current Patient #L1's medical record showed he/she was admitted on 06/22/11 for wound treatment and had a history of diabetes. On 08/21/11 at 9:00 PM, Patient #L1 received Insulin four units. That dose of Insulin was not verified by a second nurse per facility policy.

During an interview on 08/22/11 at 3:10 PM, Staff LD, Registered Nurse (RN) Supervisor, stated that the Insulin given to Patient #L1 on 08/21/11 at 9:00 PM should have had a second nurse verify the dose.

3. Observation on 08/23/11 at 9:20 AM showed Staff LQ, RN administered medications to Patient #L11. Staff LQ administered the patient's oral medications first, inserting each pill into the patient's mouth and holding the patient's water glass and drinking straw to assist the patient. After completing the administration of the patient's oral medications, Staff LQ wore the same contaminated gloves to administer medications through the central IV (Intravenous - catheter inserted into a larger vein for administering medication and fluid). Staff LQ failed to wipe the IV hub (port) with alcohol prior to administering the IV medications.

During an interview on 08/23/11 at 10:35 AM, Staff LQ, RN, stated that he/she had not read the policy on when the IV hub should be wiped.

During an interview on 08/23/11 at 10:35 AM, Staff LO, RN Education Manager stated that the rule is to "scrub the hub".

4. Observation on 08/23/11 at 9:55 AM showed Staff LR, RN administered medications to Patient #L10. Staff LR failed to wipe the central IV hub with alcohol prior to administering the IV medication.

Review of Patient #L10's medical record showed he/she had the following medications that were due to be administered on 08/23/11 at 9:00 AM and were not administered until 9:50 AM:
- Citalopram (antidepressant) 20 mg (milligrams) po (by mouth) bid (twice a day);
- Amlodipine (treat high blood pressure and chest pain) 10 mg po daily;
- Metronidazole (antibiotic to treat infection) 500 mg IVPB (intravenous piggy-back [administer through the patient's vein]) q (every) 12 h (hour);
- Senna/docusate (laxative) 1 tab (tablet) po daily;
-Brimonidine tartrate (treat glaucoma) ophth (ophthalmic [eye]) drop, 1 drop ou (both eyes) q 12 h;
- Acetaminophen (pain medicine) 325 mg po daily;
- Aspirin, children's 81 mg po daily;
- Ferrous sulfate (iron supplement) 325 mg po bid;
- Metoprolol tartrate (treat high blood pressure and chest pain) 12.5 mg po bid.
Staff LR documented the reason the medications were late as "attending to other patient needs".

During an interview on 08/23/11 at 9:55 AM, Staff LR stated that the medications were given late because he/she was busy with another patient. Staff LR stated that they did not do incident reports when medications were given late.

5. During an interview on 08/24/11 at 2:33 PM, Staff LA, RN, Chief Clinical Officer, stated that medications were to be administered between 30 minutes before and 30 minutes after the scheduled time.



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6. Observation on 08/23/11 from 9:00 AM to 11:00 AM showed Staff SAE, RN, administered medications to Patient #SA5.

Review of Patient #SA5's medical record showed the following medications not administered at the scheduled time of 9:00 AM:
-Amlodipine (to lower blood pressure) 2.5 mg (milligrams) administered at 10:14 AM;
-Collagenase (ointment used in wound care) topical ointment not applied;
-Bacitracin (antibiotic ointment) topical ointment not applied;
-Sodium Bicarbonate (antacid) 650 mg administered at 10:25 AM.

7. Observation on 08/23/11 from 9:00 AM to 11:00 AM showed Staff SAE, RN, administered medications to Patient #SA7.

Review of Patient #SA7's medical record showed Staff SAE, RN, documented administering the following medications at 9:00 AM to Patient #SA7 when the nurse was not available to administer the medications:
- Gabapentin (reduces nerve pain) 600 mg;
- Citalopram (antidepressant) 40 mg;
- Aspirin (reduces pain, fever, inflammation and clotting time) 81 mg;
- Furosemide (helps remove excess fluid) 80 mg;
- Levothyroxine (used to treat low thyroid activity) 50 mcg (micrograms);
- Fenofibrate 48 mg, (treats high cholesterol);
- Metoprolol succinate XL (lowers blood pressure) 25 mg;
- Pregabalin (anticonvulsant drug used for nerve pain) 50 mg
The medications were documented as administered late at 10:26 AM when the time of administration was scheduled at 9:00 AM.

8. Observation on 08/23/11 from 9:00 AM to 11:00 AM showed Staff SAE, RN, administered medications to Patient #SA8.

Review of Patient #SA8's medical record showed Staff SAE, RN, documented administering the following medications at 9:00 AM to Patient #SA8 when the nurse was not available to administer the medications:
-Potassium Chloride (potassium replacement) 20 mEq (milliequivalents);
-Divalproex (used to preventing migraines or treating epilepsy or mania) 125 mg;
-Enoxaparin (an anticoagulant, slows blood clotting time) 40 mg;
-Aspirin (reduces pain, fever, inflammation and clotting time) 325 mg;
-Furosemide (helps remove excess fluid) 20 mg;
-Prednisone (reduces inflammation) 15 mg;
-Vancomycin (antibiotic) 1 gm, IVPB (Intravenous Piggy Back-administered through a vein);
-Lansoprazole (antacid) 30 mg;
-Zinc oxide/menthol ointment (used to prevent and treat minor skin irritations).

9. Review of Patient #SA6's medical record showed a nurse administered the 9:00 AM medication Oxycodone SR (pain medication) 20mg late at 11:12 AM.

10. During an interview on 08/24/11 at approximately 3:00 PM, Staff SAE, RN stated that the above times he/she documented administering 9:00 AM medications for Patients #SA7 and #SA8 was not correct and the incorrect administration times were documented in error as he/she was with the surveyor in Patient #SA5's room at the time. He/she confirmed the medications were administered sometime after 11:00 AM on 08/23/11. He/she confirmed administering medications late to Patients #SA5, #SA6 and #SA7 on 08/23/11. He/she confirmed hospital policy was medications were supposed to be administered between 30 minutes prior to the scheduled time and up to 30 minutes after the scheduled time. He/she confirmed the medication administration policy required staff to document the actual time of medication administration. He/she confirmed incident reports were not completed for medications given late.


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11. Observation on 08/23/11 from 8:50 AM - 9:50 AM showed Staff SAL, RN, prepared and administered the following medications scheduled for 9:00 AM administration to Patient #SA2 per G-tube.
- Finasteride (used to treat enlarged prostate gland) 5 mg;
- Carvedilol (used to treat high blood pressure and congestive heart failure) 3.125 mg;
- Aspirin (used as a low-dose blood thinner) 81 mg;
- Lansoprazole (orally-disintegrating) (blocks acid production in the stomach) 30 mg.

Record review of Patient #SA2's MAR showed the list of medications to be administered to #SA2 included Lansoprazole (orally-disintegrating) 30 mg. However, the package of the medication actually administered to Patient #SA2 read Lansoprazole Delayed Release, 30 mg. (Orally Disintegrating tablets were recalled by Teva Pharmaceuticals in April, 2011 due to the reported frequency of the medication not dissolving and clogging syringes used during administration and the tubes they are administered through. Please see: http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm251575.htm)

Record review of Patient #SA2's medical record showed the following:
- Finasteride 5 mg was administered at 9:33 AM;
- Carvedilol 3.125 mg was administered at 9:43 AM;
- Aspirin 81 mg was ad ministered at 9:37 AM;
- Lansoprazole 30 mg was administered at 9:35 AM.

Patient #SA2 was admitted to the facility with a diagnosis of respiratory failure and was transferred to the High Acuity Unit (HAU) for close observation on 08/21/11 following episodes of vomiting and aspiration of gastric contents. Patient #SA2 was on contact isolation precautions, which required the use of an isolation gown and non-sterile gloves when providing care to the patient.

Staff SAL used a metal pill crusher to prepare medications for administration at the patient's bedside. Observation showed Staff SAL placed one souffle cup in the pill crusher, placed the medication in the cup and used the crusher to pulverize the medication for administration. Staff SAL did not place a second souffle cup on top of the pill before crushing, which caused pill particles to stick to the pill crushing plunger device. Staff SAL wiped the particles into the souffle cup using a gloved finger, and then used the same crushing technique to crush three additional medications. During administration of medications, Staff SAL failed to correctly position the stopcock on Patient #SA2's G-tube, which caused approximately two tablespoons of gastric contents to leak onto the patient's gown and bed sheet while he/she prepared the next medication.

Patient #SA2 was slouched down in bed with only his/her shoulders and head elevated to 30? at the time G-tube medications were administered. Staff SAL failed to correctly position Patient #SA2 in bed to prevent stomach contents from entering the lungs prior to administering medications according to policy.

12. Observation on 08/25/11 from 9:05 AM - 10:15 AM showed Staff SAI, RN, prepared and administered medications per G-Tube to Patient #SA3. Staff SAI used a metal pill crusher to prepare medications in the patient's room at a wall-mounted medication cabinet. Staff SAI placed one souffle cup in the pill crusher, placed the medication in the cup and used the crusher to pulverize the medication for administration. Staff SAI did not place a second souffle cup on top of the pill before crushing, which caused pill particles to stick to the pill crushing plunger device. Staff SAI wiped the particles into the souffle cup using a gloved finger, then used the same crushing technique to crush four additional medications. Staff SAI injected 30 ml of air into Patient #SA3's G-tube and listened for evidence of tubing placement, but did not attempt to aspirate stomach contents prior to medication administration. When medication administration per G-tube was completed, Staff SAI did not remove gloves and perform hand hygiene before preparing IV medications for administration. Staff SAI wore the same contaminated gloves to administer Patient SA3's medications through the central IV.

Medications scheduled for 9:00 AM administration were:
- Linezolid (antibiotic) 600 mg;
- Twocal HN (nutritional supplement) 220 ml;
- Levetiracetam (used to prevent seizures) 1000 mg;
- Topiramate (used to prevent seizures) 100 mg;
- Sodium bicarbonate (antiacid) 1300 mg
- Metoprolol tartrate (used to treat high blood pressure) 25 mg;
- Citalopram HBR (antidepressant) 30 mg;
- Furosemide (used to prevent fluid retention and prevent swelling) 10 mg;
- Pantoprazole sodium (used to treat/prevent gastroesophageal reflux) 40 mg.

Record review of Patient #SA3's medical record showed the following:
- Linezolid 600 mg was administered at 9:39 AM;
- Twocal HN 220 ml was administered at 9:40 AM;
- Pantoprazole sodium 40 mg was administered at 9:36 AM.

Staff SAI was observed administering pantoprazole sodium per IV push in less than 15 seconds. Online review for (Protonix) pantoprazole sodium (http://www.drugs.com/pro/protonix.html) showed the following:
"Two Minute Infusion - Protonix IV for Injection should be reconstituted with 10 ml of 0.9% Sodium Chloride Injection, USP, to a final concentration of approximately 4 mg/ml. The reconstituted solution may be stored for up to 24 hours at room temperature prior to intravenous infusion and does not need to be protected from light. Protonix IV for Injection should be administered intravenously over a period of at least 2 minutes."

Approximately 15 minutes after Staff SAI left Patient #SA3's room, Staff SAJ, CNA, noted that Patient #SA3's IV tubing was leaking fluid onto the bed linens. Staff SAI returned to the room, identified that the stopcock of Patient #SA3's IV tubing was not closed off correctly, removed the tubing of the antibiotic that had been infusing, laid the uncapped tubing on Patient #SA3's bed, corrected the problem, and reattached Patient #SA3's antibiotic. Staff SAI failed to cleanse the hub of the central IV line before reattaching the antibiotic and resuming administration.

During an interview on 08/25/11 at 2:15 PM, Staff SAI stated that pantoprazole sodium (Protonix) should be administered over a two minute period and stated he/she didn't recall how fast it was given to Patient #SA3, but believed it was given over "almost a two minute period." Staff SAI confirmed that some medications were given past the approved administration time for Patient #SA3 and stated that when he/she needed assistance administering medications in a timely manner, he/she would "usually" ask a supervisor for help, and would "usually" call the physician once the medication was given to notify them that the medication was administered late. Staff SAI stated, "The type of drug does not matter. I would call the physician after giving the medication."

13. Online review of instructions for use of the type of pill crusher used by both Staff SAL and Staff SAI showed the following guidance: "NOTE: Please read the instructions included with the pill crusher before using the product. The instructions state that you place the pills into a souffle cup, place a cup on top of the pills to prevent cross contamination of medications, place the cups with the pills into the pocket, squeeze the handle, rotate the cup, squeeze the handle again, repeat until the pills are pulverized to a fine powder. The amount of "squeezes" that it takes to pulverize the pills varies with the type of medication. A common aspirin would probably be crushed in 1-2 squeezes. Some medications especially vitamins and supplements have a very tough outer shell and take more work to crush. For this product to work properly it must be used with the souffle cups that are sold below or they may be purchased locally."
(http://www.google.com/search?q=metal+pill+crusher&rls=com.microsoft:*&ie=UTF-8&oe=UTF-8&startIndex=&startPage=1&rlz=1I7ADRA_en).

During an interview on 08/23/11 at 11:10 AM, Staff F, Nurse Educator, stated that nurses were taught to place pills between two souffle cups when crushing medications to prevent cross contamination "because you don't know what's on there." Staff F also stated that nurses were taught to dissolve medications in water and then draw the solution into a syringe, attach the syringe to the G-tube, and let the medications enter by gravity. Staff F agreed that this was contrary to the information provided to nursing staff via the Lippincott policy.

Based on interview, policy review, and review of training materials, the facility failed to implement a training program for administration of blood transfusions and intravenous medications during nursing orientation and other continuing education programs, and also failed to document clinical competencies through demonstrations and supervised practice of nursing staff. This failure had the potential to affect all patients who accessed care at the facility. The facility census was 58.

Findings included:

1. Review of the facility's Nursing Orientation Manual showed evidence that nursing staff received training on blood transfusion reactions, use of intravenous (IV) pumps, and IV admixture (adding medications to an IV solution), but failed to include training on blood transfusion practices, IV medication administration technique, and other areas of specific training as required by C&S Letter 100-27.

2. During an interview on 08/23/11 at 1:10 PM, Staff SAF, Nurse Education Manager, stated that he/she was unaware that the requirements for staff training had been changed. Staff SAF stated that training documents were "in the works" for blood administration, but not to the extent required by this regulation.

Based on interview and record review the facility failed to have a procedure for reporting errors related to late administration of medications. This failure could result in not identifying a medication administration problem and could potentially affect all patients in the facility. The facility census was 58.

Findings included:

1. Record review of the facility policy titled, "Medication Management", dated 06/2011, showed the following direction:
- Medications will be administered within 30 minutes before or after the scheduled time.

Record review of the facility's policy titled, "Event Reporting System," last revised 11/2010, showed the following direction:
- An "event" is defined as any occurrence or situation not consistent with the routine operation of the facility and which may have caused or may have the potential for causing injury to patients.
- Enter the event into the Event Reporting System (ERS) at the time of the event but no later than 24 hours after it occurs or is discovered.

Record review of a facility's undated employee training document titled, "Kindred Hospital Dayton Event Reporting System (ERS)," showed the following direction:
- Examples of Events needing an "Event Report" include Medication Variance.

Record review of the facility's policy titled, "Medication Misadventures," last revised 11/09 showed the following direction:
- A medication misadventure is an iatrogenic hazard (one that can be avoided by proper and judicious care) or incident:
- A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional or patient. Such events may be related to administration.
- Medication errors include dispensing errors and medication administration errors.

2. During an interview on 08/24/11 at approximately 3:00 PM, Staff SAE, Registered Nurse (RN) stated that medication incident reports were not required to be completed for medications given late.



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3. During an interview on 08/23/11 at 9:55 AM, Staff LR, RN stated that they did not do incident reports when medications were given late.

4. During an interview on 08/24/11 at 2:33 PM, Staff LA, RN, Chief Clinical Officer, stated that he/she was not aware yet if the facility was monitoring late medications.


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5. During an interview on 08/25/11 at 2:15 PM, Staff SAI, RN, stated that nursing staff weren't required to complete an incident report when medications were given late. Staff SAI confirmed that some medications were given past the approved administration time for Patient #SA3 and stated that when he/she needed assistance administering medications in a timely manner, he/she would "usually" ask a supervisor for help, and would "usually" call the physician once the medication was given to notify them that the medication was administered late. Staff SAI stated, "The type of drug does not matter. I would call the physician after giving the medication." Staff SAI stated he/she did not complete an incident report for medications that were not administered in a timely matter for Patient #SA3.

6. During an interview on 08/25/11 at 8:55 AM, Staff SAD, Chief Clinical Officer, stated that staff were trained to complete incident reports when medications were administered more than 30 minutes before or 30 minutes after a scheduled administration time, but there was no requirement by policy. During an interview on 08/25/11 at 10:15 AM, Staff SAD, acknowledged that the "Medication Misadventures" policy required staff to report late medication administration. Staff SAD stated that incident reports for late medication administration for Patients #SA2 and #SA3 were not completed, but should have been done.

7. Record review of the Event Log Report for the time period of 08/22/11 through 08/24/11 showed that four reports were entered into the system on 08/22/11. There were no event reports for Patients #SA2 or #SA3.

Based on interview, record review, and policy review the nurses failed to administer medication as ordered for one (#L1) of 10 patients observed during medication administration. Failure to administer medications as ordered potentially results in delayed/absence of treatment or rejection of an implanted organ and delayed treatment. The facility census was 58.

Findings included:

1. Record review of the facility policy titled, "Medication Management", dated 06/2011, showed the following direction:
- The 7 "R's" of administering medications will be followed with each medication administration:
"Right" patient
"Right" medication
"Right" dose
"Right" time
"Right" route
"Right" reason
"Right" documentation.

2. Review of current Patient #L1's medical record showed he/she was admitted on 06/22/11 for wound treatment and had a history of a liver transplant and diabetes. A physician's order for Tacrolimus (organ anti-rejection medication that is extremely important to take per physician's order to prevent rejection of the transplanted organ) 1 milligram (mg) po (by mouth) daily and was scheduled to be administered at 9:00 AM. The nurse failed to administer Patient #L1's Tacrolimus on 08/17/11 at 9:00 AM. On 08/17/11 at 1:50 PM, the nurse documented that the Tacrolimus was not given due to the patient was off the unit. The nurse failed to document when the patient left the unit and when the patient returned but the pre-transfer assessment was done at 8:55 AM and the ambulance transport document showed en-route vital signs taken at 11:33 AM. The nurse failed to administer Patient #L1's Tacrolimus on 08/22/11 at 9:00 AM. On 08/22/11 at 11:22 AM, the nurse documented that the Tacrolimus was not given due to the patient was off the unit. The nurse failed to document when the patient left the unit and the ambulance transport document showed the patient returned to Kindred Hospital at 1:31 PM. On 08/22/11 at 6:03 AM Patient #L1's blood sugar was 193. A physician's order was written to administer Insulin (medication to lower blood sugar) three units if the patient's blood sugar measured 181 to 220. The nurse failed to administer three units of Insulin to Patient #L1.

During an interview on 08/22/11 at 3:10 PM, Staff LD, Registered Nurse (RN) Supervisor, stated that the Tacrolimus was not given to Patient #L1 on 08/17/11 or 08/22/11 as ordered. Staff LD stated that Patient #L1 should have received Insulin three units on 08/22/11 at 6:03 AM.