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Based on observations in the Emergency Department (ED), interviews with staff, and review of hospital policies, it was determined that the hospital staff failed to label and/or discard a multi-dose vial of medication that had been opened and partially used.

One of the unlocked supply carts observed in the ED contained a 20 milliliter (ml) multi-dose vial of 2% lidocaine (a medication used to numb the skin for procedures such a suturing lacerations) that had been opened and half used. This vial of medication had not been labeled with the date of opening at first use. The Chief Nursing Officer (CNO) and the ED charge nurse were present at the time of this finding and stated that multi-dose vials of injectable medication are to be used for only one patient and any remaining medication in the vial is to be discarded.

The hospital policy for use of multi-dose vials of medication, 'Procedure for Medication Administration' (policy #NS017-CLI), stated that if multi-dose vials are used the container will expire 28 days after opening and that the date of expiration must be written on the vial. This policy also stated that if multi-dose vials are used for more than one patient, the vials "must not enter the immediate treatment area and if multiple dose vials are found in the patient care area (ex: outpatient exam rooms), they must be dedicated for single patient use and discarded after use." Per interview with the ED charge nurse, vials of lidocaine are typically used when physicians suture lacerations. At the end of the procedure, the lidocaine vials are to be discarded.

Based on observation in the Emergency Department (ED) and interviews with staff, it was determined that the hospital staff failed to lock and/or secure supply carts containing needles, sutures, iodine/skin cleaning solutions, etc. that were stored in ED hallways.

Observations in the ED were conducted on 4/8/2016. During those observations, 2 supply carts containing packages such as IV catheters, suture needles, scalpels, and blood sample tubes were found to be unattended and unlocked in the ED hallway. This finding was confirmed with the Director of Regulatory Compliance, the ED charge nurse, and the CNO. The charge nurse was asked about this finding and stated that the carts should be locked while being stored and left unattended in the hallways where visitors may have access.

Failure of staff to lock supply carts in such a manner to ensure safety against theft, damage, contamination, or deterioration places potential risk that availability of those supplies will be limited when needed, thus endangering the safety of patients.

Based on observations in the Emergency Department (ED), interviews with staff, and review of policies it was determined that the hospital staff failed to maintain use of personal protective equipment (PPE) in a patient treatment room that had been used for a patient who had been infected with lice while the room was being terminally cleaned.

Observations in the ED on 4/8/16 revealed that the staff failed to don the appropriate personal protective equipment (PPE) while a patient treatment room was being terminally cleaned after staff cared for a patient (patient #29) who was infested with lice. Patient #29 had been discharged from ED room #2 the morning of 4/8/16. An environmental services department (EVS) staff member was observed wearing a disposable jumpsuit, hair covering and booties while terminally cleaning the room. An ED nurse and another EVS staff member were observed entering and exiting ED room #2 while contaminated linens and curtains were in the process of being removed and the room terminally cleaned. The ED nurse and the other EVS staff member entering the room did not don any PPE prior to entering Room #2. The ED nurse was observed placing supplies into supply carts stored inside Room #2 prior to the completion of room #2 being clean. This finding was also observed by the Director of Regulatory Compliance, and she in turn requested that staff entering Room #2 don PPE prior to entering the room during the cleaning process.

Review of the hospital policy for standard precautions and isolation guidelines (policy #MC.143), stated that patients found with lice should be placed on contact or standard isolation precautions (varies if head or body lice are found). The CNO and the Director of Regulatory Compliance were asked during survey to provide a policy that outlines the EVS cleaning process for a patient room that had been used for a patient with suspected or known lice. Surveyors were instructed during the exit conference on 4/8/16 that no policy was found.

Failure of hospital staff to comply with policies, procedures and guidelines of isolation techniques places other patients and staff at risk for acquiring infections.

Patient #20 presented to ED 3/22/2016 for abdominal pain, distention, and decreased colostomy output. During the ED visit Patient #20 was assessed to have a right arm PICC line in place from the outside sending facility. There were no IV medications given through the PICC during the ED visit or upon discharge. Patient was discharged to home. The PICC line was not removed prior to patient discharge. Per policy #MC.141 an intravascular catheter should be removed when it is no longer essential. When patient#20 arrived home it was noted by case management notes that patient #20 still had the PICC line in place. Case management arranged for a private ambulance to take patient to Urgent Care for removal of the PICC line.

Failure to assess the need for the PICC line at the time of discharge could have led to further issues, complications, or risk of infection for patient #20.