HospitalInspections.org

Based on observation, record review and interview facility staff failed to wear proper Personal Protective Equipment (PPE) for 1 of 1 patient (Patient #14), in a total sample of 3 patient observations.

Findings include:

Review of facility's policy titled, "Standard Precautions/Transmission Based Precautions," #6.170 dated 06/2024 revealed, " ... B.1. Contact Precautions: Use Contact Precautions: ... PPE- Wear gloves and isolation gown before entering the room for direct patient care or whenever clothing may contact surfaces in the room ... Perform hand hygiene after removal of PPE."

Review of Patient #14's "History and Physical" dated 10/12/2024 revealed, admission to facility for multiple wounds with Multidrug-resistant organism of Enterobacteria requiring contact precautions.

During observations of patient care on 10/22/2024 at 8:44 AM signage outside of Patient #14's room revealed, "Contact Precautions (In addition to Standard Precautions) Everyone Must: Clean hands when entering and leaving room. Doctors and Staff Must: Gown and glove at door. Use patient dedicated or disposable equipment. Clean and disinfect shared equipment." A rack containing Personal Protective Equipment including but not limited to isolation gowns and gloves was hanging on the outside of the door. Certified Nursing Assistant (CNA) N was observed entering room without cleaning hands or donning any PPE, retrieving a completed meal tray and bringing it to the opposite end of the hall to place in a metal meal tray cart. CNA N did not clean hands upon completion of this task.

During an interview on 10/22/2024 at 9:32 AM with CNA I who when asked if PPE must be worn when entering a contact isolation room to pick up a meal tray responded "Yes, we have to wear PPE in contact isolation rooms even when only picking up a tray."

During an interview on 10/23/2024 at 10:16 AM, Chief Nursing Officer Z stated, "The staff are expected to put a gown and gloves on when entering a room for any reason."

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Based on interview and record review, the facility staff failed to administer medications within the time parameters per facility policy in 4 out of 10 patient (Patient #2, 3, 4, 7) medication administration logs reviewed in a total universe of 10 patient records reviewed.

Findings Include:

Review of facility policy #9.360 titled, "Standard Administration Times" last reviewed 03/2020 revealed, "Medications must be administered within 60 minutes of their scheduled administration time unless otherwise specified (60 minutes prior to or after the scheduled administration time) ...1. Standard medication administration times: a. Daily ...0900 b. Twice daily or every 12 hours ... 0900-2100 ...d. Three times daily ...0900-1500-2100 ...bedtime ...2100 ...L. Every 6 hours ...0600-1200-1800-2400 ...m. Every 8 hours ...0600-1400-2200 ...2. Per feeding tube administration differences ... b. Twice daily or every 12 hours 0900-2100 c. Three times daily 0600-1400-2000."

Review of Patient #2's medical record revealed a 67-year-old who was admitted to the facility for respiratory failure on 06/14/2024 and is currently a patient at the facility. A review of Patient #2's physician ordered scheduled medications included the following:
-Hydrocodone/acetaminophen (pain medication) 10 mg-325 mg, Give 1 tablet by mouth Daily. Make sure to give at least 30 minutes prior to therapy. Therapy to start at 10:00 AM.

Review of Patient #2's "Administration History" for Hydrocodone/acetaminophen revealed:
-9/22/2024 medication given at 10:30 AM, after therapy start time.
-10/6/2024 medication charted as not given. There was no reason why the medication was not administered documented.
-10/12/2024 medication given at 10:09 AM, after therapy start time.
-10/19/2024 medication given at 10:02 AM, after therapy start time.

Review of Patient #3's medical record revealed a 47-year-old who was re-admitted to the facility for traumatic brain hemorrhage post craniotomy on 9/23/2024 and is currently a patient at the facility. A review of Patient #3's physician ordered scheduled medication included the following:
-Gabapentin (anticonvulsant; may also be used to treat chronic pain) 100 MG, Give 100 mg per tube Three times a day per tube.

Review of Patient #3's "Administration History" for Gabapentin revealed:
-9/28/2024 missed dose at 2:00 PM. There was no reason why the medication was not administered documented.
-10/19/2024 missed dose at 6:00 AM. There was no reason why the medication was not administered documented.

Review of Patient #4's medical record revealed, a 33-year-old who was admitted initially to the facility for ventilatory dependent respiratory failure on 9/4/2024 and continues to be a current patient at the facility. A review of Patient #4's physician ordered scheduled medication included the following:
-Cefazolin Sodium/Dextrose (antibiotic) 2 grams, Infuse 2 gm over 30 minutes Intravenously Every 8 hours.

Review of Patient #4's "Administration History" for medication Cefazolin revealed:
-09/06/2024 afternoon dose given at 1:37 PM, night dose given at 11:56 PM (10 hours between doses).
-09/09/2024 morning dose given at 5:05 AM, afternoon dose given at 3:19 PM (10 hours between doses).

Patient #7 is a 55-year-old who was admitted to the facility for respiratory failure on 10/10/2024 and is currently a patient at the facility. A review of Patient #7's physician ordered scheduled medication included the following:
-Heparin Sodium (anticoagulant), Inject 5000 unit subcutaneously Every 8 hours
-Pregabalin (nerve pain medication) 100 MG, Give 100 mg by mouth Three times a day

Review of Patient #7's Administration History of Heparin revealed:
-10/11/2024 morning dose given at 5:13 AM, next dose given at 3:14 PM (10 hours between doses).
-10/16/2024 missed dose at 6:00 AM. There was no reason why the medication was not administered documented.

Review of Patient #7's Administration History of Pregabalin revealed:
-10/22/2024 morning dose given at 8:18 AM, missed dose at scheduled time of 3:00 PM, evening dose given at 10:19 PM (14 hours between doses).

During an interview on 10/22/2024 at 9:53 AM, Patient #7 was asked if he receives his medications on time. Patient #7 stated that the medications are brought late a lot. Typically, 45 minutes to an hour late, and often more than hour late. Patient #7 said that the staff tell him that they are busy.

During an interview on 10/22/2024 at 10:43 AM, Patient #2 was asked if he was provided his medication on time. Patient #2 stated, he is supposed to receive his pain medication before his therapy at 10:00 AM and almost every time it's an hour late or longer which makes it difficult or impossible to go to therapy. Patient #2 said he has had to cancel therapy because of it multiple times which is very frustrating.