HospitalInspections.org

Based on observations, interviews, and record review, the hospital failed to:

1. Ensure one (1) of 31 sampled patients (Patient 16) would receive fentanyl (a potent opioid to treat pain and to keep patient at a desired sedation level while on mechanical ventilation) continuous intravenous (into the veins, IV) infusion (drip) as ordered by the physician. This deficient practice had the potentials for medication errors and/or adverse event that may or may not affect patient's health condition.

2. Follow facility policy and procedure and manufacturer's instructions for use of glucometer (blood sugar machine) quality control for high and low sugars for a universe of 31 sampled patients. This deficient practice had the potential for inaccurate blood sugar results

3. Ensure there was a clean and sanitary designated area for medication preparation for a universe of 31 sampled patients. This deficient practice had the potential for medication errors and cross-contamination

Findings:

1. On 2/3/2021 at 9:05 AM, during an electronic medical record (eMR) review with the assistance from a registered nurse (RN 4) and a pharmacist (RPh 1), Patient 16 had an admission date of 1/24/2021 at 11:12 AM subsequent to cardiac arrest and resuscitation. Patient 16 was intubated (a process of inserting a tube into a person's trachea, airway, for ventilation) and replied on mechanical ventilation (a machine that helps a patient breathe, or ventilate, when the patient's spontaneous breathing is inadequate to sustain life).

Review of Patient 16's medication orders included an order of fentanyl drip entered electronically by a physician with a start date on 1/24/2021 at 3:06 AM. The order indicated the initiate continuous infusion at 25 micrograms per hour (mcg/hr) and titrate at increment of 25 mcg every 15 minutes for a goal RASS (Richmond Agitation-Sedation Scale, a medical scale used to measure patient's agitation and sedation level) of "-2" (light sedation briefly awakens with eye contact to voice <10 seconds) and the max dose was set at 100 mcg/hr.
Review of the eMR for Patient 16's IV Drips record indicated the infusion rate of the fentanyl drip on 1/25/2021 was maintained at 7.5 ml/hr or 75 mcg/hr consistently; the infusion rate Patient 16's fentanyl drip was changed to 5 ml/hr or 50 mcg/hr on 1/26/2021 at 8 AM.

Review of the eMR indicated Patient 16's fentanyl infusion order was renewed and entered electronically on 2/1/2021 at 3:21 AM to continue the same order and dosing titration parameter or conditions as the aforementioned order dated 1/24/2021.

During a concurrent review of eMR and interview, both RN 4 and RPh 1 indicated that on 2/1/2021 at 5:14 AM, the Patient 16's fentanyl drip was started at 15 ml/hr or 150 mcg/hr. However, this dose was 50 mcg/hr or 50 percent higher than the max dose of 100 mcg/hr per physician order.

Review of Patient 16's RASS score as documented on 2/1/2021 at 5 AM was at "-4" (deep sedation, no response to voice, but movement or eye opening to physical stimulation), which was 2 levels higher than the goal of "-2" as ordered by the physician. Both RN 4 and RPh 1 confirmed Patient's 16's eMR indicated the RASS score had been maintained at "-4" through 2/3/2021 at 6 AM.

Review of Patient 16's electronic IV Drips record on 2/1/2021 at 2 PM indicated Patient 16's fentanyl drip was titrated down by 25 mcg/hr to 125 mcg/hr. Then, 7 hours later at 9 PM, Patient 16's fentanyl drip was abruptly stopped (0 mcg/hr), without titration increment of 25 mcg/hr. On 2/2/2021 at 2 PM with a RASS score of "-4", Patient 16's fentanyl drip was restarted at 5 ml/hr or 50 mcg/hr; later 4:15 PM, the rate was increased to 10 ml/hr or 100 mcg/hr (max dose); then forty-five minutes later at 5 AM, the infusion rate was increased to 15 ml/hr or 150 mcg/hr, with RASS score continued at "-4".

Review of Patient 16's electronic IV Drips record with indicated that on 2/2/2021 between 8 AM to 8 PM, there were at least 5 titrations of the fentanyl drip, from an infusion rate of 5 mcg/hr to 17.5 mcg/hr or 175 mcg/hr. Both RN 4 and RPh 1 acknowledged there were no documented RASS scores to justify those titrations.

On 2/3/2021 at 2:31 PM, during an interview, the intensive care unit director (ICUD) acknowledged the aforementioned titrations did not have justifying RASS scores as per order.

During a concurrent interview, ICUD stated Patient 16 was also on midazolam (another potent narcotic used to maintain sedation for patient with mechanical ventilation) that staff needed to keep the patient at RASS "-4". ICUD acknowledged that there was no documented communication to clarify with the physician, and/or the pharmacy department, in regard to the conflict of RASS scores between 2 concurrent medication orders.

Review of Patient 16's midazolam orders indicated an electronically entered order on 2/3/21 at 9 AM, was modified to reflect a goal RASS score of "-4". Patient 16's original midazolam order was initiated on 1/29/2021 at 6:04 PM to start dose at 2 mg/hr, titrated by 1 mg/hr every 15 minutes for goal RASS of "-2", and a max dose of 10 mg/hr. On 2/3/2021 at 9 AM, Patient 16's midazolam order was modified to reflect a goal RASS score of "-4."




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2. On February 1, 2021 at 1:59 p.m., during initial tour of the facility with Registered Nurse (RN) 1, Risk Manager (RM) and Chief Quality Officer (CQO), RN 1 stated the test strip vial and two quality control (QC) solution vials for the glucometer were not dated when first opened. The manufacturer's expiration dates for QC 1 vial was April 30, 2022 and for QC 2 vial was July 31, 2022.

Concurrently, RN 1 stated the QC solutions should have been dated when first opened to ensure accurate blood sugar results from the patients.

A review of Patient Care policy - Blood Glucose Testing, dated May 21, 2019, indicated the following:
1. The glucometer measures the glucose in whole blood and is used for diagnostic purposes.
2. The quality control (QC) must be performed every day that patient tests are performed.
3. Every 24 hours, a low and high-level glucose control must be performed prior to testing patient samples.
4. Upon opening the liquid QC, it is good for 3 months or the printed expiration date on the vial, whichever comes first.
5. When new vials of liquid QC are opened, document the open date in the "opened" prompt provided on the label to include the date.
6. Count out 3 months and document the expiration date in the "expiration" prompt provided on the label to include the date.
7. Requirement for QC solution and strip vial upon first opening with your initials and open date on the test strip vial and QC solution bottles - QC bottles are good for 3 months after opening.

A review of the manufacturer's instruction for use for the glucometer, undated, indicated the following:
1. Testing control solutions with known glucose (sugar) levels establishes that the operator and the system are performing acceptably.
2. Control results must be within the defined acceptable ranges before valid patient testing is allowed.
3. Write the date the bottle was opened on the bottle label.
4. The control solution is stable for 3 months from that date or until the "use by" date on the bottle label, whichever comes first.
5. The glucometer has two control solutions, one for the low range and one for the high range.

3. On February 1, 2021 at 3:01 p.m., during tour of the facility with charge nurse (CN), RM and CQO, CN stated there was no designated area in the medication room for medication preparation for the nurses. CN stated the nurses prepared the patient medications in the patients' rooms.

A review of Pharmacy policy - Medication Administration, dated May 17, 2018, indicated there should be areas utilized to prepare medications for administration, which shall be clean and free of clutter or debris, in order to reduce or effectively eliminate the potential for contamination and/or medication error.

Based on observation, interview, and records review, the hospital failed to ensure that the Condition of Participation for Pharmaceutical Services was met by failing to:

1. Ensure pharmacists would review the transactions from the Pyxis (automated drug dispensing cabinet, ADC, device that allows nurses in hospitals quick, electronic activated and tracked access to stored medications) for therapeutic appropriateness, at least retrospectively, for 10 out of 19 non-profiled (a programmed system in which anyone with access could retrieve any medication for any patient as long as the medication was stocked in the specific unit) Pyxis machines (automated drug dispensing cabinet, ADC) located throughout the hospital (Refer to A-0500); and

2. Ensure the Personal Protection Equipment (PPE, i.e. mask, hair covers, gloves, gowns, and shoe covers) donning (act of putting on PPE) and doffing (act of removing PPE) area adjacent to the only segregated compounding area (SCA, a designated, demarcated area with no specific ISO [an international standardized rating of a cleanroom based on how much particles exit per cubic meter] classification level of cleanliness), located in the pharmacy, had enough space and not cluttered with racks and cart full of supplies (Refer to A-0501); and

3. Ensure the implementation of the cleaning procedure in the sterile compounding area. The environmental services (EVS) staff failed to document their weekly and monthly terminal cleaning activities in January 2021 (Refer to A-0501); and

4. Ensure the competency assessment records included the evaluation of the staff's knowledge of the cleaning agent(s) to be used and the dwell time (amount of wet contact time on the surface to kill bacteria, fungi, and viruses). (Refer to A-0501); and

5. Ensure their sterile compounding quality assurance policy and procedure included the viable sampling plans, (Refer to A-0501); and

6. Ensure the segregated compounding area (SCA, a designated, demarcated area with no specific ISO [an international standardized rating of a cleanroom based on how much particles exit per cubic meter] classification level of cleanliness) and the top exterior of the compounding aseptic isolator (CAI, a type of intravenous [into the veins, IV] medications preparation hood, which is an unit designed to maintain an aseptic or ISO-5 compounding environment to insure sterility [germ-free] of the compounded IV medications) located in the pharmacy was free of residues or debris (Refer to A-0501).

The cumulative effect of these systemic deficient practices resulted in the failure of the hospital to deliver pharmaceutical services which safeguarded the health of the patients.

Based on interview and record review, the hospital failed to ensure pharmacists would review the transactions from ten (10) out of 19 Pyxis machines(automated drug dispensing cabinet, ADC) that were running on a non-profile system (meaning anyone with access could retrieve any medication for any patient as long as the medication was stocked in the specific unit) for therapeutic appropriateness, at least retrospectively, if not prior to medication administration. Those 10 non-profiled Pyxis located in the following hospital departments including: emergency department (ED), operation rooms (OR), post anesthesia care unit (PACU), catheterization laboratory (CATH, examination room in a hospital with diagnostic imaging equipment used to visualize the heart and/or treat any abnormality found). This deficient practice had a potential for avoidable medication errors that may affect patient's health condition.

Findings:

On 2/2/2021 at around 10:50 AM during an interview, a hospital pharmacist (RPh 1) stated the hospital had a total of 29 Pyxis, in which, 19 Pyxis were non-profile (meaning anyone with access could retrieve any medication for any patient as long as the med was stocked in the specific unit). Of those 19 Pyxis, 9 were specific to individual assigned anesthesiologists; the remaining 10 units were located within the ED, OR, PACU, and CATH. Both the director of pharmacy (DOP) and RPh 1 stated the pharmacy did not have a process to review those 10 non-profile Pyxis to ensure the transactions were appropriate and free of medication errors.

On 2/3/2021 at 8:35 AM during an interview, RPh 1 stated the hospital did not have a policy and procedure to review non-profile Pyxis transactions nor reconciliation process with patients' medication orders. RPh 1 acknowledged the potentials for medication errors and drug diversion.

Review of the guideline published by the American Society of Health-System Pharmacists (ASHP, a nationally recognized professional association which published numerous authoritative guidelines in pharmacy practice and referred by the industry as the standard of practices), "Minimum Standard for Pharmacies in Hospitals", dated 4/13/2012, indicated "All medication orders shall be prospectively reviewed by a pharmacist and assessed in relation to pertinent patient and clinical information before the first dose is administered or made available in an automated dispensing device, except in emergent situations ... There shall be a procedure for retrospective review of these orders." The guideline further suggested, "Use of [ADC] shall be structured so as to not hinder the pharmacist's review of (and opportunity to intervene in) medication orders before the administration of first doses ..."

Based on observations, interviews and record reviews, the hospital failed to:

1. Ensure the Personal Protection Equipment (PPE, i.e. mask, hair covers, gloves, gowns, and shoe covers) donning (act of putting on PPE) and doffing (act of removing PPE) area adjacent to the only segregated compounding area (SCA, a designated, demarcated area with no specific ISO [an international standardized rating of a cleanroom based on how much particles exit per cubic meter] classification level of cleanliness), located in the pharmacy, had enough space and not cluttered with racks and cart full of supplies.

2. Ensure the implementation of the cleaning procedure in the sterile compounding area. The environmental services (EVS) staff failed to document their weekly and monthly terminal cleaning activities in January 2021.

3. Ensure the competency assessment records included the evaluation of the staff's knowledge of the dwell time (wet contact on the surface to kill microbials) for a cleaning agent(s) specified in a hospital policy.

4. Ensure their sterile compounding quality assurance policy and procedure included the viable sampling plans (an environmental sampling plan that check for microbial contamination of an area).

5. Ensure the segregated compounding area (SCA, a designated, demarcated area with no specific ISO classification level of cleanliness) floor and the top exterior of the compounding aseptic isolator (CAI, a type of intravenous [into the veins, IV] medications preparation hood, which is an unit designed to maintain an aseptic or ISO-5 compounding environment to insure sterility [germ-free] of the compounded IV medications) located in the pharmacy was free of residues or debris;

These deficient practices had the potential of exposing patients to avoidable microbial contamination for those who were requiring compounded intravenous (IV) medications, which may have affected the patients' health conditions.

Findings:

1. On 2/2/2021 at 9:45 AM during an inspection of the pharmacy, there was a segregated compounding area (SCA) at the corner and separated from the rest of the pharmacy by a red demarcation line on the floor. (See attached photo print-out provided by the hospital). In an area next to the red demarcation line, there was a blue sticky floor mat approximately 2 feet by 3 feet in size, on the floor. The mat was half covered by a wire shelving rack and a cart full of intravenous medications and compounding supplies.

During a concurrent interview, the director of pharmacy (DOP) stated the blue mat was where the pharmacy staff would don and doff PPE prior to and after performing sterile compounding in the SCA. The DOP acknowledged the designated area was cluttered and did not have enough space for PPE donning and doffing.

2. On 2/2/2021 at around 10 AM during an inspection of the segregated compounding area (SCA) in the pharmacy with the director of pharmacy (DOP), DOP presented current and past cleaning documentation of the SCA done by environmental services (EVS).

Review of the EVS cleaning log for January 2021, the columns titled "weekly" and "Monthly" were blank.

During a concurrent interview, DOP indicated EVS staff did not document the required weekly and monthly cleaning of the SCA in January 2021.

3. On 2/2/2021 at around 10 AM, DOP presented staff competency evaluation record. A review of the "Competency Assessment: Cleaning and Disinfecting the IV Room and Segregated Sterile Compounding Area" did not indicate which specific cleaning agent(s) were to be used. The assessment also did not check for the staff's knowledge of the dwell time (the amount of time to maintain wet contact on the surface to achieve microbial deactivation/killing). During a concurrent interview, the DOP acknowledged that the staff competency assessment did not document the staff's knowledge of which cleaning agent to use and the contact time required.

Review of the hospital policy and procedure, Sterile Compounding Area Cleaning, approved on 1/21/2020, indicated the hospital did not specify cleaning agents to be used and the corresponding contact time required. During a concurrent interview at around 10:20 AM, DOP stated the hospital policy should list the specified cleaning agents to be used and the products' required dwell time for staff as guidance.

4. On 2/2/2021 at around 10:20 AM, DOP presented the IV hood certification reports done in 5/2020 and 11/2020, and the hospital policy, Sterile Compounding Quality Assurance, dated 1/21/2020. During a concurrent interview, when the surveyor asked DOP for the hospital's viable sampling plans for the SCA, the DOP indicated the vendor had a diagram of the sampling area. DOP further stated the hospital did not include viable sampling plans of the IV hood.

Review of the current United States Pharmacopeia (USP - establishes quality standards for drug compounding) chapter <797>, " ...Sampling Plan-An appropriate environmental sampling plan shall be developed for airborne viable particles based on a risk assessment of compounding activities performed."

5. On 2/2/2021 at around 10:30 AM during an inspection of the segregated compounding area (SCA) in the pharmacy with the director of pharmacy (DOP), the SCA had a CAI for staff to perform sterile compounding (an act of preparing compounding IV medications). On the floor near the CAI, DOP acknowledged there were black sticky residuals on the floor.

At around 10:45 AM during an observation, the surveyor asked the pharmacy technician working in the SCA to wipe across the top exterior of the CAI with a paper towel. Afterward, the technician presented the paper towel and there were brown, grey residuals. DOP confirmed there was dust collection on top of the CAI.

Review of the hospital's EVS cleaning log - Pharmacy IV room indicated the daily cleaning included " ... sweep and mop floor, ... clean outside hood including stainless steel surfaces underneath the hood". The signature next to date "2/1/2021" on the cleaning log indicated a EVS last cleaned the area on 2/1/2021.

Based on observation, interview, and record review, the facility failed to ensure that the Condition of Participation for Infection Prevention and Control and Antibiotic Stewardship Program was met by failing to:

1. Implement mitigating procedures (process to reduce or eliminate risks or hazards) to prevent the spread of COVID 19 (a highly communicable respiratory disease) according to Acute Communicable Disease Control (ACDC local health department agency providing guidance with infection control) and Centers for Disease Control (CDC government agency providing national infection control guidelines) when a pharmacy staff (PB) was allowed to continue working in the pharmacy and patient care areas, despite being positive for COVID 19 for a universe of 145 admitted patients. This failure had the potential to result in the spread of COVID 19, putting the health and safety of the vulnerable and already health-compromised patients in jeopardy. (Refer to A 0749)

2. Ensure that a Certified Nursing Assistant (CNA 1) doffed (removed) gloves and performed hand hygiene upon exiting the patient room for one of 31 sampled patients (Patient 1). (Refer to A 0749)

3. Provide a clean and sanitary environment, free of materials that can harbor harmful microorganisms, in the medication room. (Refer to A 0749)

The cumulative effect of these systemic practices resulted in the failure of the hospital to deliver care in compliance with the Condition of Participation for Infection Prevention and Control and Antibiotic Stewardship Program, which could affect the health and safety of the vulnerable and health-compromised patients.

Based on observation, interview, and record review, the facility failed to:

1. Implement mitigating procedures (process to reduce or eliminate risks or hazards) to prevent the spread of COVID 19 (a highly communicable respiratory disease) according to Acute Communicable Disease Control (ACDC local health department agency providing guidance with infection control) and Centers for Disease Control (CDC government agency providing national infection control guidelines) when a pharmacy staff (PB) was allowed to continue working in the pharmacy and patient care areas, despite being positive for COVID 19 for a universe of 145 admitted patients. This failure had the potential to result in the spread of COVID 19, putting the health and safety of the vulnerable and already health-compromised patients in jeopardy.

2. Ensure that one out of sampled staff (CNA 1) doffed (removed) gloves and performed hand hygiene upon exiting the patient room for one of 31 sampled patients (Patient 1). (Refer to A 0749)

3. Provide a clean and sanitary environment, free of materials that can harbor harmful microorganisms, in the medication room .

On 2/2/21 at 4:40 PM, the survey team called an immediate jeopardy (IJ) situation in the presence of the chief executive officer (CEO), risk manager (RM), and quality manager (QM). The facility failed to implement proper mitigation strategies to prevent the spread of COVID 19 when PB who tested positive twice for COVID 19 was allowed to continue to work, updating, and delivering refills to the Pyxis in 10 nursing stations. The facility failed to consult the local health department for proper isolation or quarantine procedures, which had the potential to expose patients and other staff to COVID-19.

The CEO, RM, and QM were informed of the IJ situation regarding failure to implement proper mitigation strategies to prevent the spread of COVID 19.

On 2/3/2021 at 6:00 PM, the IJ situation was lifted after verifying an acceptable plan of action (POA) while onsite. The POA indicated that the hospital reviewed its exposure plan and updated its policy to reflect contact tracing (notifying contacts of exposure to COVID-positive individual/s) of asymptomatic staff, and a documented process should an exception is made due to critical staffing needs. The employees who test positive for COVID 19 will be removed from the schedule until cleared by employee health and consistent with the Health Officer Order (HOO - local health enforcement agency). The hospital will communicate with Los Angeles County Department of Public Health (DPH - local health department) about employees who test positive for COVID 19, and will follow up with the ACDC program. The hospital has developed a contingency staffing plan (supplementing staffing from outside staffing agencies) and will document attempts to address any potential staffing surge (sudden increase in number of patients in relation to staffing capacity). The hospital began employee testing of exposed staff and will notify employees who were in close contact by electronic mail.

Findings:

1. During interview with Pharmacy Director (PD) on 2/2/2021 at 11:00 AM, PB initially tested for COVID-19 at a drive-thru site on 1/16/21 when his son, who lives in the same household, tested positive for COVID-19. On 1/18/21 around 12:00 PM, PB received his positive test result while at work and reported it to PD. PD referred PB to facility's Employee Health Services (EHS), who administered another COVID-19 test to PB, and result from that test came back positive on 1/19/21. Per PD, EHS referred PB to facility's Infectious Disease (ID) on 1/19/21 who recommended that PB be fit tested and should be wearing a respirator. According to EHS, ID cleared PB on 1/19/21 to continue working while socially distanced from other staff. EHS did not have documentation that ID cleared PB to work in patient care areas.

During interview with PB on 2/2/2021 at 9:54 AM, PB stated that aside from restocking the pharmacy and working in the dispensing area, he updated and delivered medications to refill the automated dispensing cabinets (electronically locked machines for storing and dispensing medication for patients) in 10 nursing stations in patient care areas. PB stated that he offered to stay home to quarantine (isolating self after exposure and having a confirmed positive COVID 19 test) but instead cleared and allowed by EHS to continue working.

During interview with PD on 2/2/2021 at 11:00 AM, PD stated that when PB has to go on vacation, she or the clinical manager covered PB's purchasing role. The PD stated that hospital only tested staff with symptoms of COVID 19 and did not advice pharmacy staff to get tested. No staff in patient care areas were advised to get tested for potential exposure from PB, and no pharmacy staff reported that they got tested after exposure to PB.

During interview with PB on 2/2/2021 at 3:12 PM, PB stated that when he was on leave, a pharmacy technician would cover for him. PB stated he continued to work full time, Monday to Friday, from 7:00 AM to 3:30 PM, and did not take any day off from the time he tested positive for COVID 19.

During interview with Infection Preventionist (IP) on 2/3/2021 at 12:50 PM, IP stated he notified ACDC of PB's positive test result via electronic mail but did not receive a response from ACDC for guidance on PB's permission to continue to work. IP did not follow up confirmation and recommendation by ACDC on the work status of PB.

During record review of ACDC COVID-19 guidelines provided by RM for Monitoring Health Care Professionals, Workplace Exposures: HCP (healthcare personnel - persons working in healthcare settings) with high risk workplace exposures to COVID 19 should be excluded from work and should follow quarantine instructions. They should be instructed to monitor themselves daily for symptoms consistent with COVID 19 and to immediately contact their established point of contact (e.g. occupational health program) if symptoms develop. HCP can return to work after 10 days if they have never had symptoms. Exceptions for staffing shortages may be made. Return to Work Protocol for HCP with confirmed COVID 19 HCP with mild to moderate illness who are not severely immunocompromised can return to work: At least 10 days after symptom onset AND At least 24 hours since last fever without fever reducing medication AND improvement in symptoms. Asymptomatic HCP who are not severely immunocompromised should be excluded from work until 10 days have passed since the date of their first positive COVID 19 diagnostic test, assuming they have not subsequently developed symptoms.

PB remained asymptomatic throughout this period but IP did not clarify with ACDC which category PB falls under.


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2. On February 1, 2021 at 1:29 p.m., during initial tour of the facility with Risk Manager (RM) and Chief Quality Officer (CQO), Certified Nursing Attendant (CNA) 1, was observed leaving Patient 1's room wearing gloves, performing hand hygiene with worn gloves on and returning to Patient 1's room, to assist the patient.

Concurrently, RM stated he could not believe what he saw, CNA1 leaving patient's room with gloves on and then performing hand hygiene with alcohol based hand rub onto the gloves and re entering Patient 1's room.

A review of Infection Control policy Personal Protective Equipment (PPE), dated September 15, 2020, indicated the following:
" ...3. If an HCP is expected to have hand contact with potentially infectious materials or contaminated surfaces, HCP will wear gloves.
4. Single use gloves cannot be washed or decontaminated for reuse.
5. Gloves must be changed between patients or moving from contaminated area to cleaner areas on the same patient.
6. HCP must remove PPE prior to leaving the work area or when the PPE becomes contaminated ..."

3. On February 1, 2021 at 3:01 p.m., during initial tour of the medication room with Charge Nurse (CN), RM and CQO, the following were observed:
a. Two Corrugated boxes with shipping labels for storage of needles and syringes.
b. Hand washing sink with mineral deposits and rust stains on the faucet and a chip in the basin.
c. Tape and tape residue throughout the medication room's carts, cabinets and shelves.

Concurrently, CN stated was not aware corrugated boxes should not be in the patient care area, was not aware of the mineral deposits in the sink faucet and was not aware of the tape/tape residue observed in the medication room. CN stated there was no designated area in the medication room for medication preparation for the nurses. CN stated the nurses prepared the patient medications in the patients' rooms.