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Based on policy and procedure review, medical record review and staff interview, the nursing staff failed to perform dressing changes as ordered by the physician for 1 of 5 patients with wound dressing orders.(Patient #2)

The findings include:

Review of policy and procedure "Wound Program Standards and Best Practice Guidelines" (revised 07/16) revealed "... Wound care completed per orders and documented correctly? ..."

Medical record review on 10/14/2016 at 1100 revealed Patient #2 was a 72 year old male patient admitted on 10/04/2016 with a diagnosis of hypoxic respiratory failure and Atrial Fibrillation with rapid ventricular response (irregular heart rate). Review revealed wound dressing orders dated 10/4/2016 at 1800 stating, "Clean coccyx wound with wound cleanser, apply hydrogel (wound medication), cover with dry gauze and foam dsg (dressing) secure with medipore tape/transparent tape change daily and prn (as needed)". Review of a "Wound Documentation" form revealed, the dressing was changed on 10/4/2016 at 1430. Further review revealed the wound dressing orders were changed on 10/5/2016 at 1500 and stated, "D/C (discontinue) hydrogel dsg to sacral wound (sacral and coccyx are very close in proximity) & (and) use silver aginate (wound medication) instead." Review of the "Wound Documentation" revealed documentation of the wound dressing changes on 10/10/16 (no time provided) and 10/13/2016 at 1000. The review revealed no other dressing changes documented. Review revealed the wound dressings for Patient #2 were not documented as being performed daily as ordered (7 days missing).

Interview on 10/14/2016 at 1115 revealed Registered Nurse (RN) #1, a staff nurse, had not yet changed the dressing on 10/14/2016. Interview revealed RN #1 had discussed the lack of documentation with dressing changes with the rounding Physician Assistant (PA). And, the situation was going to be "addressed with staff". Further interview revealed, RN #1 thought the wound looked as if it were getting "worse".

Interview on 10/14/2016 at 1115 with RN #2, the Charge Nurse, revealed the charge nurses have a report and were aware of the patients with wounds, but they did not verify that the dressings were being changed.

Interview on 10/14/2016 at 1115 with RN #3, the Manager, revealed "if it is not documented, it is not done". The interview revealed the policy was not followed.

Based on Manufacturer recommendation, observation and staff interview the facility staff failed to ensure expired supplies were not available for patient care use and failed to discard expired glucometer solutions in 4 of 5 glucometers on the nursing unit. (Glucometers A0227, D0220, A0215 and A0575)

The findings include:

1. Observation during unit tour on 10/12/2016 at 1100 revealed a drawer in the lab supply room with eight (8) dark green top lab tubes with a manufacturer expiration date of 9/2016. Further observation revealed one hundred and twenty (120) yellow and red top lab tubes with a manufacturer expiration date of 9/2016 and 4 tubes with a manufacturer expiration date of 5/2016. Observation in the supply room revealed a bin with five (5) 1.5 ounce tubes of Medihoney gel (wound medication) with a manufacturer expiration date of 7/2016. The observation revealed patient care supplies available for immediate patient use beyond the manufacturer's expiration date.

Interview on 10/12/2016 at 1150 with Supply Tech #4, revealed it was his third week with the facility. The interview revealed he was responsible for checking the expiration dates and to make sure supplies were in stock and "up to date". Interview revealed he picked up the lab tubes when ordered and replenished the supply in the lab room. The interview also revealed stock in the supply room should be checked intermittently to make sure the supplies were not expired. Supply Tech #4 verified that the lab tubes and wound gel were expired and should have been removed and not available for use.

Interview with Registered Nurse (RN) #3, the Nurse Manager, revealed the process for checking expiration dates was recently implemented. The charge nurse was responsible for checking expiration dates and, the process was not working due to not having a consistent Charge Nurse. The interview revealed the process for checking expiration dates would be reevaluated.

2. Review on 10/12/2016 of the manufacturer insert for the "Medisense Glucose and Ketone Control Solutions" (revised 01/15) revealed "... DATE When you open a new bottle, write the date of opening on the bottle label. ... Precautions and Warnings Do not use solution 90 days after opening or if they are expired (check the expiration date printed on each bottle and the box they were packaged in). ..."

Observation during tour on 10/12/2016 at 1100 revealed five (5) glucometers for patient use on the counter in the nurse's station:

(A) Observation revealed glucometer #A0227 had an open bottle high control solution in the case with no open date written on the label and a manufacturer expiration date of 12/2017. Glucometer #A0215 had an open bottle of low control solution in the case with no open date written on the label and a manufacturer expiration date of 12/2017.

(B) Glucometer #D0220 had an open bottle of low control solution in the case with "discard after 9/27/2016" written on the label and a manufactured expiration date on 12/2017. Glucometer #A0575 had two (2) open bottles of low control solution, both with "do not use after 9/27/16" written on the label. One of the solutions had a manufacturer expiration date of 11/2016 and the other had a manufacturer expiration date of 12/2017.

Observation revealed four (4) of the glucometer cases had expired control solution in them or had no open date written on the label as per manufacturer recommendation.

Interview on 10/12/2016 at 1115 with RN #5, a staff nurse, revealed the glucometer control testing was performed on the night shift. The interview revealed staff were taught to label the bottles with the date the bottle was opened and with the date the controls expired. RN #5 verified that the control solutions were expired based on the discard date written on the bottles and, she could not determine the date that the unlabeled bottles were opened. The interview confirmed that the manufacturer recommendations were not followed.

Interview with RN #3, the Manager, revealed the process for checking expiration dates was recently implemented and was not working due to not having a consistent Charge Nurse. The interview revealed the process for checking expiration dates would be reevaluated.

NC00120955