Fmc - Mercy

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 36083 Based on documents review, observations, and interviews, the facility did not ensure administration of the medication to the right patient for 1 of 3 patients observed for medication administration (Patient #2). At the time of the survey, the facility reported a census of 75 patients. Findings include: 1. The policy titled, Medication Preparation and Administration, dated 2/6/23, noted for its purpose, “To administer medications with the goals of staff and patient safety, optimal therapeutic response, and infection control.” The policy indicates that all medications in syringes not being administered immediately shall be labeled appropriately with the name of the medication, route, dose, name of patient, date, time and initials of the person who prepared the medication. The policy directs staff members to follow the principles for medication administration including the right drug and the right patient. 2. The document titled, Adverse Events Report, from 4/10/23 to 4/10/24, included 2 occurrences of medication errors, which indicated facility’s history of occurrences related to medication errors. 3. On 4/10/24, at 12:20 PM, observations of multiple labeled syringes of pre-drawn medications were stored in a locked drawer by the medication preparation area. 4. On 4/10/24, at 1:30 PM, Patient Care Technician (PCT) A, was in the process of administering Patient #2’s heparin through the venous (blue) catheter port. After giving the medication, PCT A showed the empty syringe labeled as 2.3 ml (milliliters) of heparin for Patient #8, and not for Patient #2. 5. On 4/10/24, at 1:31 PM, PCT A verified to have administered the medication to Patient #2, which was prepared for a different patient, saying, “I got the wrong one, it’s for [Patient #8]” while pointing to Patient #8, who had ongoing treatment at another dialysis station. 6. On 4/15/24, at 4:30 PM, the Interim Clinic Manager (ICM) acknowledged the the potential adverse effect of administering medications prepared for different patient. The ICM also acknowledged the importance of thorough verification of the right medication and the right patient before administration.”

“QAPI-INDICATOR-MEDICAL INJURIES/ERRORS CFR(s): 494.110(a)(2)(vi) The program must include, but not be limited to, the following: (vi) Medical injuries and medical errors identification. This Standard is not met as evidenced by: 36083 Based on documents review, observation, and interviews, the facility failed to ensure reporting of occurrences in order to investigate and address for 2 of 2 incidents in the sample observed and reviewed (total chlorine breakthrough and medication error). At the time of the survey, the facility reported a census of 75 patients. Findings include: 1. The policy titled, Patient Safety Event Reporting and Documentation, dated 2/6/23, provides the guidelines for staff on identifying, reporting, and documenting patient related near misses, safety events, and serious safety events. The policy indicates that promotion of a culture of safety will create best practice guidelines by identifying human, technical and environmental factors that impact patient safety. The policy also indicates staff are encouraged to report events with the understanding that event review is focused on opportunities for learning and improving the quality and safety of patient care. The policy directs staff to complete reporting in a timely manner and according to facility’s event reporting procedure. The policy lists examples of events to be reported including exposure to contaminants, and medication errors. 2. The document titled, Hourly TCL Logs, from 4/1/24 to 4/10/24, showed that on 4/2/24 at 6:00 AM, the total chlorine result from post worker carbon tank was 0.1 ppm (parts per million), which directed staff to activate the breakthrough policy. 3. On 4/10/24, at 1:30 PM, Patient Care Technician (PCT) A, was observed in the process of administering Patient #2’s heparin through the venous (blue) catheter port. After the medication administration, PCT A showed the empty syringe that indicated it was 2.3 ml (milliliters) of heparin for Patient #9, and not for Patient #2. PCT A verified to have administered the medication to Patient #2, which was prepared for a different patient, saying, “I got the wrong one, it’s for [Patient #9].” 4. However, the facility’s adverse events log from 4/1/24 to 4/10/24, lacked indication that occurrences were reported regarding the 0.1 ppm total chlorine results on 4/2/24 and the medication error on 4/10/24. 5. On 4/15/24, at 1:44 PM, PCT C indicated an incident of a “high” total chlorine result from the port post primary carbon during tests on 4/2/24. PCT C also indicated activation of the facility’s breakthrough policy. On 4/15/24, at 4:00 PM, the Biomedical Staff (BS) verified the incident regarding the total chlorine result of 0.1 ppm on 4/2/24 has not been reported according to facility policy. 6. On 4/15/24 at 4:45 PM, when asked about expectations regarding reporting of incidents regarding high total chlorine tests and medication/heparin administration errors, the Interim Clinic Manager (ICM) indicated these should be reported in a timely manner. On 4/16/24 at 1:15 PM, PCT A indicated reporting the medication error involving Patient #2 on 4/10/24, immediately prior to the interview saying, “I just reported it today.” PCT A acknowledged the incident report should have been made as soon as it happened on 4/10/24 (6 days ago). 7. On 4/17/24 at 1:13 PM, the Medical Director (MD) stated the purposes for reporting incidents is for facility to review root cause, development and implementation of action plan to address or prevent reoccurrence, and for tracking and trending. The MD also indicated incidents should be reported as soon after occurrence.”