HospitalInspections.org

Based on observation and interview staff failed to disinfect septums of medication vials prior to puncturing in 1 of 2 staff observations (RN E) and 1 of 2 Pt observations (Pt 1). This has potential to effect all patients receiving IV medications at this facility.


Findings Include:

On 8/8/2015 at 12:10 PM, observed RN E use a needle to puncture vial of Dilaudid (pain medication) for Pt 1. RN E did not disinfect the rubber septum of the vial prior to puncturing.

Per interview on 9/9/2015 at 10:00 AM with Director A, the facility does not have a policy that addresses cleaning of a medication vial prior to puncturing the rubber septum. Director A stated the vial should be swabbed with an alcohol wipe prior to puncturing rubber septum with a needle.

Based on record review and interview, discharge planning staff failed to assess and thoroughly document all ADL assistance needs in 2 of 5 patients (#2, #3). This has potential to effect all inpatients being discharged from this facility.

Findings:

Facility policy "Discharge Evaluation, Discharge Planning and Discharge Documentation" dated 3/2015 states in part: "The evaluation must consider the patient's capability of addressing his/her care needs thru self-care..."

Pt. #2's Case Management Assessment, dated 8/12/2015, documents Pt. #2 required assistance with "Ambulation/ADL's Prior to Admission." The form goes on to list examples of potential needs and the document states "Mark areas where assistance is needed." There are no selected areas of needs documented.

Pt. #3's Case Management Assessment, dated 6/15/2015, includes documentation of required assistance. There are no selected areas of needs documented. Review of the medical record reveals Pt. #3 is a paraplegic patient living in a group home prior to admission, indicating the need for varied services not evaluated in the Case Management Assessment.

During an interview with Director B on 9/9/2015 at 9:30 AM, Director B stated all areas of the Case Management Assessment "should be completed."

Based on record review and interview, facility staff failed to provide a reconciled medication list upon discharge for 4 of 4 discharged patients (#2, #3, #4, #5). This has the potential to effect all inpatients discharged from this facility.

Findings:

Facility policy "Medication Reconciliation" dated 3/2013 states in part: "Upon discharge, a list of the medications currently being administered to the patient and medications taken at home will be compiled and provided to the next provider of care and to the patient (or representative) upon discharge..."

Facility policy "Discharge Evaluation, Discharge Planning and Discharge Documentation" dated 3/2015 states in part: "M. 1. The 'medical information' that is necessary for transfer referrals includes, but is not limited to: ...d. Medication list (reconciled to identify changes made during the patient's hospitalization."

Pt. #2 was discharged from the facility on 9/1/2015 to an inpatient rehabilitation facility. Pt. #2's discharge medication list includes a list of all the medications the patient is currently taking as an inpatient at the facility. Each medication includes a circled yes or no in the column "Continue at Discharge." 21 of 27 medications are marked "yes"; 6 of 27 medications are marked "no." The medication list does not specify which medications are new, changed or stopped from the medications the patient was prescribed prior to the hospitalization.

Pt. #3 was discharged from the facility to home on 7/9/2015. The patient's discharge medication list does not specify which medications are new, changed or stopped from the medications the patient was prescribed prior to the hospitalization. Pt. #3's admission transfer medication list, dated 6/12/2015, included Atenolol 100 mg daily for blood pressure. The facility's discharge medication list does not include Atenolol or instructions for patient to stop, change or take the medication.

Pt. #4 was discharged from the facility to home on 9/3/2015. The patient's discharge medication list does not specify which medications are new, changed or stopped from the medications the patient was prescribed prior to the hospitalization. Pt. #4's transfer admission medication list, dated 7/30/2015, includes Pepcid 20 mg twice daily for acid reflux and Effexor 37.5 mg daily for depression. Neither drug is not listed on Pt. #4's discharge medication list.

Pt. #5 was received inpatient services at the facility from 7/16/2015 to 8/5/2015 at which time Pt. #5 was discharged to home. The admission medication list includes Zantac 150 mg twice daily for acid reflux, Pt. #5's discharge medications include Pepcid 20 mg twice daily for acid reflux. The discharge medication list does not identify this as a new or changed medication. The discharge medication lists 25 medications, 18 of the 25 are marked as "yes" to be continued at discharge. None of the medications are differentiated as new, changed or stopped from pre-admission medications.

The discharge medication lists include a "last dose" column which are left blank. The above findings were confirmed with Director B at the time of the review.

During an interview on 9/9/2015 at 8:55 AM, MD C stated the medical group has a Nurse Practitioner that follows up with patients in their homes and that these visits often reveal "medication discrepancies" post-discharge.