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Based on observation and interview, the facility failed to ensure that supplies and medications are readily available for emergency use. Findings include:

During observation of the hospital on 08/27/2010 between 1300 and 1600, the following medication/ supplies were noted to be outdated and available for use.

1. Emergency Department
A. Clean storage room
Two bags of IV 10% Dextrose-outdated 5/10
One bag of IV 5% Dextrose 0.9% Normal saline-outdated 7/10

B. Trauma 1 & 2
Five Central line catherzation kits-outdated (1) 2/09, (3) 8/09, (1) 10/09
Three Central line dressing kits-outdated (1) 3/09, (2) 6/09
One Cricothyrotomy Catheter Set-outdated 3/10

The following supplies were noted to be opened and not dated .
1. Emergency Department
A. Clean storage room.
Three bottles of Nu-gauze wound packing strips- One opened 9/09 and two with no dates as to when they were opened.
One bottle of Iodoform wound packing strips, with no date as to when it was opened.

The findings were verified by the Emergency Department Manager at the time of the observations.

2. Acute Care Unit
A. Medication Area
One bottle of Morphine SR 15mg tabs-no expiration date
One bottle morphine ER 30mg tabs- no expiration date
Four Fentanyl 100mcg patches-outdated 6/10

The above findings were verified by the Acute Care/ ICU Manager at the time of the observations.

3.. OB Department
A. Medication Area
One bottle potassium hydroxide-no expiration date
Five bags 5% Dextrose- outdated 1/10
Ten tablets of Simethicone 80mg-outdated 7/10

The above findings were verified by the OB Manager at the time of the observations.

The above findings were discussed with the Chief Operating Officer (COO) on 08/28/2010 at 1600. COO not able to produce policy in regards to who's job it is to check for outdated medications and supplies in the facility. Document provided by the COO titled Job Description Position: Staff Pharmacist under primary functions of position reads "Responsible for drug distribution and storage throughout the hospital."

The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See C-231

Base on observation and interview, the facility failed to maintain equipment in safe operating condition. Findings include:

On 8/26/2010 at approximately 9:00 am while on tour with the facility manager, it was noticed that the reduced pressure backflow assembly did not have a recent test sticker on the assembly. When the facility manager was asked how often the assembly was tested, it was stated that they weren't tested since they moved into the new facility (which was in September of 2008). It is estimated that there are about 10 reduced pressure backflow assemblies within the hospital. Michigan Plumbing Code, Section 312.9.2 requires that all reduced pressure backflow assemblies shall be tested at the time of installation, immediately after repairs or relocation and at least annually.

During the facility tour on 8/26/2010 between 8:00 AM and 12:00 PM it was observed that the chemical dispensing units are attached to mop sink faucets in housekeeping rooms throughout the hospital (with the exception of the kitchen housekeeping closet). This set-up results in shut off valves being located downstream of the built in atmospheric vacuum breaker (AVB) subjecting the AVB to constant pressure which could cause it to fail prematurely. This set up could also result in hot water leaching into the cold water system and vise versa.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on August 30, 2010, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated August 30, 2010 for Life Safety Code.

Based on record review and staff interview it was determined that the Specialized services for Occupational Therapy and Physical Therapy were not ordered by a physician.
Findings include:

On 8/28/10 at approximately 1130, the medical records for 2 of 2 swing bed patients (pt. # 7 and pt. #8) revealed that there was not a physician's order (as required) for the Occupational Therapy and Physical Therapy services being provided. These findings were verified with the Chief Operating Officer and the Nursing Supervisor at time of record review.