Clark Fork Valley Hospital Hospice

“Based on interview and record review, the agency failed to ensure the treatment need for an intraperitoneal indwelling catheter and drainage system was included in the plan of care for 1 (#10) of 14 sampled patients. This deficient practice had the potential to affect the services provided for the patients intraperitoneal drainage system. Findings include: Review of patient #10s Initial Plan of Care, with a certification period 10/30/23 to 1/27/24, failed to include the care and services required for management of the patients intraperitoneal drainage system. During an interview on 12/5/23 at 3:30 p.m., staff member B stated it was the expectation that all patient treatments should be updated on the patients plan of care.”

“Based on observation, interview, and record review, the agency failed to ensure staff maintained sterile technique during a procedure to drain peritoneal fluid with an Aspira indwelling intraperitoneal drainage system (an indwelling intraperitoneal drain is a thin tube placed into the abdomen which is used long-term to remove excess fluid from the abdomen while at home); and failed to ensure staff maintained a sterile technique during the dressing change of the intraperitoneal drainage site for 1 (#10) of 14 sampled patients. This deficient practice had the potential to increase the risk of an infection for this patient. Findings include: 1. During an observation on 12/5/23 at 12:15 p.m., staff member E prepared a sterile site to drain fluid from patient #10s abdomen using the Aspira peritoneal drainage system. Staff member E donned a pair of sterile gloves and then removed the tape which was holding the drainage tubing to the patients abdomen. She then opened an alcohol prep pad which was in the sterile field and used it to clean the tubing hub. She then attached the drainage kit to the patients indwelling peritoneal catheter. Staff member E then proceeded to complete the procedure. Staff member E contaminated the sterile procedure by failing remove the contaminated gloves and don a new pair of sterile gloves after she removed the unclean tape and handling the uncleaned catheter tubing prior to cleaning the drainage hubs and attaching the drainage bags. During an interview on 12/5/23 at 1:30 p.m., staff member E stated she was not certain if she had contaminated the sterile drainage procedure by removing the dirty dressing while wearing the sterile gloves and not changing those gloves before cleaning and connecting the sterile drain hubs. During an interview on 12/5/23 at 3:30 p.m., staff member B stated the procedure for cleaning and connecting the drainage system for a patient with an indwelling peritoneal catheter should be completed using sterile technique to limit the potential for contamination and infection. 2. During an observation on 12/5/23 at 12:45 p.m., staff member E utilized the same contaminated sterile field which was used earlier to drain the patients peritoneal fluid. Staff member E placed two opened packets of gauze for the dressing and an alcohol prep pad on the sterile field. She then donned a pair of sterile gloves and removed the old dressing from patient #10s abdomen. Staff member E then cleansed the site and the catheter tubing with the alcohol prep pad and applied the dressing over the wound site. Staff member E did not remove her contaminated gloves and don a new pair of sterile gloves after removing the dirty dressing. Staff member E failed to maintain a sterile technique while applying the clean dressing. During an interview on 12/5/23 at 1:30 p.m., staff member E stated she was not certain if she had contaminated the indwelling peritoneal catheter insertion site during the dressing change when removed the dirty dressing using the sterile gloves and not changing those gloves to a new pair of sterile gloves before cleaning the site and applying the clean dressing. During an interview on 12/5/23 at 3:30 p.m., staff member B stated the procedure for cleaning and applying a clean dressing over the catheter insertion site for a patient with an indwelling peritoneal catheter should be completed utilizing sterile technique to limit the potential for infection. Review of patient #10s Aspira Drainage System Patient Guide on How to Care For and Dress Your Aspira Drainage Catheter, showed: “;a. Carefully remove the clear dressing, gauze and split catheter pad from your catheter. b. Wash your hands with warm soapy water. Scrub for one full minute. Rinse. Dry using a clean towel or clean paper towels. c. Peel open the pouch with the dressing kit. NOTE: Do not touch any unclean surface such as your skin, clothing, or furniture with your gloves. d. Remove the gloves from the pouch. e. Pick up one glove at the cuff end and place it on your hand. Pick up the second glove with the newly gloved hand and place it on your other hand. f. Remove the blue CSR wrap from the pouch and place it on the clean workspace. Pull on the corner sticking out of the edge of the sheet to open it. g. Lay the sheet flat so you can see the dressing supplies. h. Clean the skin around the catheter exit site with an alcohol pad. i. Place the split catheter pad on the skin around the catheter. j. If you change your dressing every time you drain, coil the catheter on top of the pad. If you change your dressing less often than you drain, lay the catheter down toward your waist. k. Place gauze over the top of the catheter. l. Hold gauze, catheter and split pad in place with one hand. Remove the inner rectangle from the dressing, then remove the printed backing. Place the clear dressing over the catheter and gauze. Make sure the dressing sticks to the skin around the gauze. Remove the paper edge from the dressing and smooth down the dressing edges. Be careful, the clear dressing is very sticky.””

“Based on interview and record review, the agency failed to ensure a plan of care was developed for the hospice aide to follow when providing care for 1 (#3) of 14 sampled patients. Findings include: During an interview on 12/5/23 at 1:04 p.m., staff member D stated the hospice aide care plan had not been developed prior to the aide providing care to patient #3. Staff member D stated the nurse would have given verbal instructions to the aide for the care to be provided. Review of patient #3’s medical record showed aide home visits were completed on 5/4/23, 5/1/23, 5/18/23, 5/25/23, and 6/1/23. Patient #3’s aide care plan showed it was developed on 6/7/23. The agency failed to develop an aide care plan prior to home visits.”

“Based on observation, interview, and record review, the agency failed to ensure staff safely disposed of a controlled narcotic of a used fentanyl patch for 1 (#10) of 14 sampled patients. This deficient practice had the potential to increase the patients risk for improper use of controlled narcotics. Findings include: Review of patient #10s Initial Plan of Care, with a certification period 10/30/23 to 1/27/24, showed: “;Problem: Risk for injury - environmental safety related to opioid abuse. Goal(s): Potential home safety hazards will be corrected... Intervention(s): [Skilled Nurse] to reconcile controlled medication count at each [Skilled Nurse] visit. - Assign to: Skilled Nurse; Supply limited quantity of controlled medications. - Assign to: Physician; Educate patient/caregiver to store narcotics in original container inside lockbox. [Sister] will be the only person allowed to administer to patient...” During an observation on 12/5/23 at 1:00 p.m., staff member E removed patient #10s fentanyl patch from his back, folded the patient in half, and then disposed of the patch in the patients bedroom garbage can. Staff member E then left the garbage for the patient to take out. During an interview on 12/5/23 at 1:30 p.m., staff member E stated patient #10 had a history of opioid misuse and they kept his controlled medications in a locked box at the house and his sister was the only person with access to the locked box. Staff member E stated she disposed of the used fentanyl patch in the garbage in the patients room and then the patient would take that garbage outside to the garbage bin. She stated she was not concerned about the way she disposed of the fentanyl patch, stating there was no medication remaining on the used fentanyl patch after three days of use ¹. During an interview on 12/5/23 at 3:30 p.m., staff member B stated a used fentanyl patch could still have residual amount of medication remaining on the patch to cause harm if ingested. She stated throwing the patch in the patients garbage and leaving the garbage for the patient to take out later increases the patients risk for misuse of the medication and creates other environmental risk factors. Staff member stated staff should follow the agencys policy and procedure for the destruction of the used fentanyl patch. Review of the agencys Policy and Procedure titled Controlled Drugs in Patients Home, with a revision date of 9/2023, showed: “;...5. Disposal of narcotics shall occur in the patient’s home unless the client or immediate family refuses. Medications permanently disposed of in safe manner according to the Home Medication Disposition Record. Tubings, cassettes, or other narcotic delivery systems will be emptied of medication, if possible, and placed in a biohazard container. The attending nurse and family member or authorized caregiver shall sign the disposal record...” Review of the agencys Home Medication Disposition Record, showed: “;Follow your medication prescriber’s instructions and use all medications as instructed. If you do not use all of your prescribed or over-the-counter medication, you can take a few small steps to make a huge impact in safeguarding lives and protecting the environment by disposing of unused medicines properly: 1. Do Not Flush prescription drugs down the toilet unless the label or accompanying patient information specifically instructs doing so. 2. Be Proactive and Dispose of Unused Medication In Household Trash. When discarding unused medications, ensure you protect children and pets from potentially negative effects: • Pour medication into a sealable plastic bag. If medication is a solid (pill, liquid capsule, etc.), crush it or add water to dissolve it. • Add kitty litter, sawdust, coffee grounds (or any material that mixes with the medication and makes it less appealing for pets and children to eat) to the plastic bag. • Seal the plastic bag and put it in the trash. • Remove and destroy ALL identifying personal information (prescription label) from all medication containers before recycling them or throwing them away...” Citation: ¹ Commissioner, O. of the. (5/18/2023). Make sure fentanyl patches are stored, used and disposed of properly. U.S. Food and Drug Administration. https://www.fda.gov/consumers/consumer-updates/accidental-exposures-fentanyl-patches-continue-be-deadly-children#:~:text=How%20to%20Dispose%20of%20Fentanyl,the%20medicine%20in%20the%20patch. ¹ How to Dispose of Fentanyl Patches: ...Even after a patch is used, there is enough fentanyl left to cause illness, overdose or death in babies, children, pets and others who are accidentally exposed to the medicine in the patch. Thats why the drug comes with special instructions on how to dispose of used or leftover patches. The FDA recommends promptly disposing of used patches by folding them in half with the sticky sides together, and then flushing them down a toilet. Patches should not be placed in the household trash, where children or pets can find them. Children may find lost, discarded or improperly stored patches and ingest them or stick them on themselves or others. The FDA has included fentanyl patches on a list of medicines that should be flushed down a toilet because they could be especially harmful, and possibly fatal, in a single dose if used by someone other than the person for whom the medicine was prescribed.”