1. Review of the last CMS survey findings
Hot Topics 2
Review of the last CMS survey findings

2. Medication Issues Unlabeled medications Unsecured medications
Storage of medications
Timeliness of administration of controlled substances
Commingling of medications
Insulin bottles
Needles & Syringes
IV bags in warmer
Other Issues

3. Unlabeled Medications
Syringe was found in a drawer without a label stating what the medication was in syringe.
Action:
In policy PCS it states that medications removed from original packaging/container must be labeled with concentration and name of medication
Correct procedure:
Morphine
2mg/mL

4. Unsecured Medications
WOWs with drawers historically set a facility up for issues with regulatory agencies. The most common reason is a universal code which allows any nurse access to the drawers in the WOW.
Many times even family members or patients discover the code when standing near the nurse as she opens the WOW.
Therefore a WOW is not considered secure.

5. Storage of Medications
Medications are not to be stored outside of pharmacy except under very specific circumstances, like self- administered medications.
CONTROLLED SUBSTANCES MANY NEVER BE STORED OUT SIDE OF PHARMACY.
See policy C in pharmacy policies
“all controlled substances located in patient care areas will be maintained in a secured area”.
Any solutions with additives (KCL) should in a secured area
If removing solutions check use by date
If sol/additives found return to secure area
If outdated then discard immediately

6. Timeliness of administration of medications
Administration of controlled substances should occur immediately upon removal from the Omnicell. If the patient is sleeping or not present in their room when the nurse arrives—immediately return the medication to the Omnicell.
Remember meds should not stored outside pharmacy and should never be left at the bedside for the patient to take (ie: with breakfast)

7. Co-mingling of medications
See policy C in Pharmacy policies “Controlled Substances, Control, Storage, and Documentation in the Patient Care Areas”
“All Schedule II, III, or IV drugs must be stored in individual pockets separate from other controlled and uncontrolled medications”.

8. Insulin vials
Remember insulin is considered a high risk medication and should be labeled as such.
Insulin is only stable for 28 days after opening. A label should be attached to the vial when received from pharmacy. Double check the dates to assure the dating is correct.
Even though insulin is a multi-dose vial it is not intended for use between patients. Single dose (discard after 1 dose is removed) if in
an area where no patient medication
storage is available.
High
Risk Alert
Date:____

9. Needles, Syringes, IV flushes
Needles, Syringes, and IV flushes fall under the same rules as medication storage. There is no storage of these items on the WOW, in rooms, in drawers, on the back of the keyboard, or in pockets.

10. Other issues
Our previous dietary manual did not contain Bariatric diets, so a new diet manual is available at each nursing station.
Refrigerator temperatures: this log is kept by dietary but nursing needs to be aware of their responsibility for patient safety and nutrition.
If the temperature range is too hot milk and
other milk products should not be served to
patients. If nursing notes the temperature
is out of range please notify the dietary
department. Range is 36-40°F

11. IV bags in fluid warmers
According to Bbraun
“Product that has been exposed to (40°C [104°F] and not used within four (4) weeks (our policy states 28 days) must be discarded and not returned to storage”.
B/Braun Sharing Expertise retrieved from frequently asked questions E3.
11/17/15
Date on outside of protective wrapper

12. Negative Pressure Room for TB
Airborne Isolation required
Transmission is related to number of droplet nuclei in the air, making air exchange an extremely important factor in preventing further transmission to others Including You.
NURSES MAY NEVER UNPLUG OR TURN DOWN THE HEPAFILTER ON A TB PATIENT.
Engineering is required to
monitor the negative pressure
Tissue test can assure negative pressure is present (see Negative pressure education on tracker trainer)

13. Negative Pressure Cont.
Be aware: I noticed in the education on tracker trainer the spell check corrected my abbreviation of AII to All. Not all rooms are set up for hepafilter use. AII stands for Airborne Infection Isolation. So the sentence is discussing only airborne isolation rooms not all rooms in the facility.
Don’t forget the tissue test—what is it checking for? How do you do it? It is in the education on tracker trainer.

14. Laryngoscope Just information for you to know:
Laryngoscope handles are not sterile they are clean, they are taken out, cleaned and sterilized, but then they are opened so the batteries can be put back into the handle. Be aware if you pick one up and were to drop to the floor, just indicate you will send to SPD to re-clean.
Remember extra batteries and bulb are
on the cart.

15. Syringes & Clear biohazard bags
With EVS inspecting all waste from the floors the most common findings are syringes and clear biohazard bags.
Currently we are disposing of ALL syringes, with or without blood or a needle, into the sharps containers.
Even if a clear biohazard bag is empty, because of the biohazard sign imprinted on it, it is required to go into a biohazard container. Remember these bags should only be used for specimens and nothing else.

16. Surveys
Each time a survey is completed and a finding is noted we must educate regarding that finding.
Patient safety and accuracy should be our first priorities, the surveyors look for areas where patient safety is compromised.
Whenever there is a decision made to practice in a manner outside of what is considered safe practice we will be cited.
Let’s all work together toward a survey where no findings occur.