| 10169 |
BROAD CREEK CARE CENTER |
425351 |
801 LEMON GRASS COURT |
HILTON HEAD ISLAND |
SC |
29928 |
2010-12-13 |
425 |
J |
|
|
GN4K12 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Extended Survey, the facility failed to ensure that expired medications were not stored with medications readily available for resident use resulting in expired Heparin Lock Flush available for use. Seventy Five of 79-3 millimeter Heparin Lock Flushes, were observed in the medication room with expiration dates prior to the survey, an additional 30 were found 12/13/2010 in the bio-hazard container with an expiration date of 8/1/2010 and 2 used Heparin 3 millimeter syringes were found in the sharps container on 12/13/2010 with expiration dates of 8/1/2010 and 11/1/2010. One of one resident sampled with a Peripherally Inserted Central Catheter (PICC), Resident #11, had a IV flush daily with a Heparin Lock Flush ordered. The findings included: Resident #11 was originally admitted on [DATE] and was readmitted after a hospital stay on 11/16/2010 with [DIAGNOSES REDACTED]. Resident #11 was admitted back to the facility on [DATE] with a PICC line and was ordered by the physician to "Flush PICC with 5cc Normal Saline before and after each use, followed by 3cc Heparin Once a Day at 8PM, start date 11/16/2010". On 12/8/2010, during observation of the facility's medication room, expired supplies were noted to be in the same area as the supplies used for resident care. The medication room contained 14-3 ml. Heparin Lock Flush syringes expired 8/1/2010; 60-3 ml. Heparin Lock Flush expired 11/1/2010 and 1-3 ml. Heparin Lock Flush syringes expired 10/20/2010. The Heparin Lock Flushes were observed to be in an open brown cardboard box, sitting on a cart to the right as you entered the medication room. At 10:45 AM on 12/8/2010, expired items (Heparin Lock Flushes) in the medication room were verified by LPN #1 who then removed them from the medication room. LPN #1 stated all nurses were responsible for ensuring any expired meds were removed from the medication room, but there was no system in place to determine when it should be checked or how often it was to be done. During an interview with the Pharmacist on 12/8/2010 at 3:55 PM, he stated that it was the responsibility of the facility's Pharmacy Consultant to ensure that all expired medications and supplies were removed from the facility. The Pharmacist also stated that the pharmacy had not sent Heparin Flushes to the facility in over a year. During the interview with the facility's Pharmacist the surveyors requested the invoices for Heparin delivered to the facility. The Pharmacist stated that he was unable to locate any. When asked how he tracked the lot numbers of the Heparin, he stated that they did not charge for it so they did not track the lot numbers. When asked by the surveyors whose responsibility it was to monitor the facility's medications he stated that the Pharmacy contracted with a consultant who was responsible for that. During an interview with Registered Nurse #1 on 12/8/2010 at 4:00 PM, she stated that the Heparin Flushes she used currently were located on a cart to the right of the door as you walked into the medication room. The container identified by RN #1 was the one noted to hold the expired Heparin Lock Flushes. During an interview with the Nursing Home Administrator on 12/8/2010 at 4:15 PM, the Administrator stated that the Pharmacy Consultant was responsible for monitoring the medication room and medication carts for expired medications. She also stated that the consultant had been to the facility for review on 11/17/2010, and that she had no idea where the expired Heparin in the facility came from. The NHA verified that the Pharmacy had not sent Heparin to the facility in over a year at 5:25 PM on 12/8/2010. On 12/13/2010, an additional box of 30-3 ml. Heparin Lock Flush expired 11/1/2010 was observed in the bio-hazard box by a surveyor and 1 used-3 ml. Heparin Lock Flush syringe expired 8/1/2010 and 1 used 3-ml Heparin Flush syringe expired 11/1/2010 was retrieved by that surveyor from the sharps container located on the medication cart. In an interview with the Interim Director of Nursing (DON) on 12/13/2010, The DON stated that the bio-hazard material had been picked up on 12/1/2010 and provided documentation of that pick-up. She also stated that the medication cart sharps container was emptied approximately every 3 weeks because the facility did not use many sharps. On 12/13/2010 during an interview with the Pharmacy Consultant, the Consultant confirmed she was responsible for ensuring expired medications were removed from the medication room. She stated she was in the facility monthly for medication review and checked the medication room and carts at that time. She stated she was unaware the Heparin was in the building. On 12/13/2010 at 4:15 PM, during an interview with the facility's Pharmacist, he stated that he did not have lot numbers of Heparin Flushes received prior to September 16, 2010. When asked how he would recall medications from facility's when the Federal Drug Administration recalled medications by lot number, he stated that he would recall the medication by name, not lot number. When asked if his process would include medication lot numbers not included in the recall he stated that it would. Immediate Jeopardy was cited at F425 with a scope and severity of "J" related to expired Heparin Lock Flushes (75 of 79) stored in an area readily available for resident use. The Immediate Jeopardy existed when a resident (Resident #11) was admitted and was using the IV flushes daily per physician order [REDACTED]. In addition 2 used syringes of the IV Heparin Lock Flush were found in a sharps container and noted to have dates that were expired. On 12/8/2010 at 5:25 PM the survey team met with the Administrator and Director of Nursing to inform them of the determination of Immediate Jeopardy with a start date of 11/16/2010 related to the system failure identified with using expired Heparin to flush a PICC line; the failure to follow the facility policy for the care and maintenance of a central line and the failure to follow the South Carolina Board of Nursing policy related to the extended role of practice of the LPN. The Immediate Jeopardy was not removed at the time the survey team exited from the facility 12/13/2010 and is ongoing. First Follow-Up Visit During an unannounced onsite visit on 12/29/2010 at 11:30 AM, it was determined based on interviews, observations, review of records, and review of facility policies, that the Allegation of Compliance submitted by the facility on 12/13/2010 with an addendum submitted on 12/23/2010 had been implemented by the facility and was in practice as of 12/18/2010, removing the immediacy of the deficient practice. The citation at F-425 remained at a lowered scope and severity of " D". The facility will be in compliance at F-425 when an acceptable Plan of Correction is submitted and a follow up visit is conducted, to determine that the facility has implemented their Plan of Correction as stated. |
2014-04-01 |