Fmc - of Spoon River

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 49555 Based on document review, observation, and interview, it was determined the Facility failed to ensure staff demonstrated compliance with current aseptic techniques with the use of multidose vials. Findings include: 1. The policy titled “Medication Preparation and Administration” (published 2/6/2023) was reviewed on 11/26/2024 at approximately 2:00PM. The policy noted “ ...Always use a sterile syringe and needle when entering a vial ...If either vial is multi-use a different syringe must be used for entry into each vial ...Cleanse the diaphragm of a vial with alcohol prior to accessing the vial. If the vial is a multidose vial, cleanse the diaphragm with a new alcohol pad each time the vial is accessed with a needle using friction and 70% alcohol. Allow to dry before inserting a device into the vial.” 2. On 11/25/2024 at approximately 10:30 AM and 11/26/2024 at approximately 9:30 AM, the Registered Nurse (RN) (E #2) was observed turning a multi-use medication vial upside down and then lightly swiped the vial diaphragm against an alcohol pad that was lying on the counter for approximately two seconds. E #2 then inserted a needle into the diaphragm and drew up medication. E #2 did not allow the diaphragm to dry before inserting the needle into the vial. 3. On 11/25/2024 at approximately 10:50 AM, the RN (E #2) was observed cleansing the rubber diaphragm of a previously opened injectable multi-use medication vial with alcohol. E #2 inserted the needle into the vial and drew up the remaining liquid inside of the vial. E #2 then removed the lid of a new injectable multi-use medication vial, cleansed the diaphragm with alcohol and inserted the previously used needle and syringe into the newly opened multi-use vial to draw up the remaining medication needed for administration. E #2 did not use a new needle or syringe to draw up medication from the newly opened vial. 4. An interview was conducted on 11/27/2024 at 10:00 AM with the Nurse Manager (E #1). E #1 verbally agreed medication vials should be cleaned using adequate friction, allowed to dry prior to inserting a needle, and a new syringe and needle should be used for entry into each multi-use vial.”

“INVENTORY CONTROL CFR(s): 494.50(b)(1) 9.2 Inventory control Reprocessing supplies should be used on a first-in, first-out basis, and outdated supplies should be identified and discarded. This Standard is not met as evidenced by: 50645 Based on observation, document review, and interview, it was determined the Facility failed to ensure all inventory of patient care supplies were discarded when expired. Findings include: 1. A tour of the treatment and storage areas was completed on 11/25/2024 between 10:30 AM and 11:15 AM. During the tour, the following supplies were found outdated and were available for patient use. a. Two boxes of Filter needles 18 Gauge X 1 ½ inch, one hundred counts per box. The manufacturer’s expiration date was 5/2024 on one box and 8/2024 on the second box. b. Forty-two 21 Gauge X 1-inch needles expired on 12-31-22. c. Three Yankauer suction tubing packages expired on 5/2024. d. Three unopened vials of Calcium Chloride 10% 1 gram/10 milliliters expired on 5/2024. 2. The policy titled “Expiration Dates Sterile Supplies” (published 07/04/2012) was reviewed on 11/27/2024 at approximately 11:11 AM. The policy noted, “ ... Sterile items will be checked before use to ensure that they have not expired. Appropriately dispose of sterile items that have reached the expiration date. Expiration dates of sterile supplies contained in emergency boxes or code carts should be noted and logged as per facility protocol.” 3. On 11/25/2024 at approximately 11:45 AM, an interview was conducted with the Nurse Manager (E #1). E #1 verbally agreed the supplies were expired and the expired supplies were removed from the treatment area.”