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Based on observation, interview and review of the hospital's policies and procedures, it was determined the facility failed to ensure that all medications available for patient use in the Physical Therapy (PT) Department were not expired.

This had the potential to negatively affect all patients served at the facility.

Findings include:

Facility Policy
Division VII: General Miscellaneous and Professional
Chapter H: Monitoring Monthly of Expiration Dates

All drugs in the hospital will be checked for appropriate dating and integrity at least on a monthly basis....

If an out of date, contaminated or damaged drug is discovered, it is pulled from the shelf immediately and returned to the pharmacy where it is placed in the expired drug area, and a replacement for the product is ordered and returned to the shelf for use.

During a tour of the PT Department on 3/7/12 at 8:10 AM, the surveyor observed the following expired (exp) medications:
Betamethasome Dipropionate Cream 0.05% (percent) x (times) 1 tube exp 1/21/10
Polysporin Powder x 1 bottle exp 11/08
Arthritis Formula 0.025% Topical Analgesic Cream x 1 tube exp 4/01
Kovia Ointment 30 g(grams) x 2 tubes exp 9/09
Mercurochrome 2 % Solution 1 oz (ounce) x 19 bottles exp 2/09

During an interview on 3/7/12 at 8:40 AM, Employee Identifier # 6, Director of PT, observed and confirmed the aforementioned findings.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.

Findings include:

Refer to Life Safety Code violations.

Based on observation, review of facility policy and procedures and staff interviews, it was determined the facility failed to ensure all medical supplies available for patient use in the Surgery, Obstetrics (OB), Nursery and Physical Therapy (PT) Departments were not expired. This had the potential to negatively affect all patients served at the facility.

Findings include:

Facility Policy
Division III Emergency Drug Protocol and Procedures
Revised: May 6, 2010

Sub-Section 1a: Crash Cart Utilization and Inventory Maintenance

Monitoring the Crash Cart
1) The stock in the crash cart is to be audited monthly by the following department: pharmacy, respiratory therapy and central supply.....On the first of every month, a delegate from each department is to check the assigned area of all crash carts to remove any out of date items, ensure proper levels of each item and document the inspection of each cart on the audit log....

1. During a tour of the Surgical Services Department on 3/6/12 at 11:30 AM, the surveyor observed the following Intravenous (IV) catheters in the Hyperthermia Cart had expired:

(4) 20 Gauge (g) 1 1/4 inch IV catheters expired 7/2007
(4) 22g 1inch IV catheters expired 7/2007
(2) 24g 3/4 inch IV catheters expired 7/2007.

During an interview on 3/6/12 at 11:35 AM, Employee Identifier (EI) # 1, Director of the Operating Room, observed and confirmed the aforementioned findings.


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2. During a tour of the Obstetrical Unit on 3/6/12 at 10:50 AM and 1:00 PM, the surveyor observed the following expired supplies:
Room 324 at 10:50 AM:
Red top Laboratory (Lab) tubes x (times) 8 expired (exp) 12/10
Red top Lab tubes x 3 exp 3/11
Purple top Lab tubes x 3 exp 10/11
Purple top Lab tubes x 7 exp 2/11
Purple top Lab tubes x 10 exp 7/11

OB Crash Cart at 1:00 PM
Adult ECG (Electrode Cardiogram) Electrode pads x 1 pack exp 12/07
Smallbore Extension Set x 3 exp 5/08
Tuberculin (TB) Syringe 28g 1/2 inch x 6 exp 1/07
22 G 1 inch IV catheter x 4 exp 4/08
24 G 3/4 inch IV catheter x 4 exp 4/08
18 G 1 1/4 inch IV catheter x 4 exp 10/07
14 G 2 inch IV catheter x 4 exp 5/06
16 G 1 1/4 inch IV catheter x 5 exp 5/06
20 G 1 1/4 inch IV catheter x 4 exp 2/08
Ultrasite Horizon Pump Y-Type Blood Set x 1 exp 4/11
IV Administration Set x 2 exp 8/09
Neonatal/Pediatric ECG Electrodes x 3 exp 9/09

3. During a tour of the Nursery on 3/6/12 at 11:45 AM, the surveyor observed the following expired supplies:
Microbore Extension Set x 6 exp 9/11

Nursery Crash Cart:
TB Syringe 28 G 1/2 inch x 5 exp 6/07
Blue Top Lab tubes x 3 exp 10/11
Green Top Lab tubes x 2 exp 12/11
18 G 1 1/4 inch IV catheter x 4 exp 2/09
24 G 3/4 inch IV catheter x 4 exp 9/09
22 G 1 inch IV catheter x 4 exp 1/11
20 G 1 1/4 inch IV catheter x 4 exp 10/11
Plastic Bell Circumcision Device 1.2cm (centimeters) x 2 exp 3/09
Plastic Bell Circumcision Device 1.3cm x 2 exp 4/10
Discofix 3-Way Stopcock x 3 exp 3/07
Micro A.B.G. (Arterial Blood Gas) Sampler x 3 exp 4/08

During an interview on 3/6/12 at 11:35 AM, EI # 5, Nurse Manager, observed and confirmed the aforementioned findings.

4. During a tour of the PT Department on 3/7/12 at 8:10 AM, the surveyor observed the following expired supplies:
Plain Packing Strip x 2 bottles exp 11/11.

During an interview on 3/7/12 at 8:40 AM, EI # 6, Director of PT, observed and confirmed the aforementioned findings.

Based on observation, review of medical records, review of facility policy and interview with facility staff the facility failed to follow infection control precautions per facility policy and physicians order in 1 of 1 patient with a physician order of contact precautions. This affected Medical Record (MR) # 10 and had the potential to negatively affect all patients at the facility.

Findings Include:

Facility Policy:
Isolation Precautions
Patient Care Services
Original Date: 1982
Revised Date: 10/09
Contact Precautions
...Nursing personnel will apply a gown and gloves (prior to room entry and remove gown and gloves prior to leaving the patient room) for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment...
...The unit clerk is to enter the order for isolation thru the computer system. It is the responsibility of the nurse to assure that Isolation is set up for use and that the Precaution Label is completed properly and affixed to the patient room door.

MR # 10 was admitted to the facility on 3/5/12 with diagnosis of Severe Cellulitis.

On 3/7/12 at 8:50 AM, the surveyor entered the patient's room to observe the therapist perform wound care. There was no "precautions label" affixed to the patient's door per the facility policy. There was no isolation set up with gowns and gloves available for the surveyor or therapist use per facility policy.

Review of the MR on 3/7/12 at 9:30 AM revealed a physician's verbal order noted by a Registered Nurse (RN) on 3/6/12 at 10:30 AM as follows: "...Contact Precautions..."

During an interview with Employee Identifier # 7, the Staff Registered Nurse, when the surveyor asked about the physician's order for "contact precautions", he/she stated, "we usually get an Isolation Kit from Central and place it outside the door, I don't know why it's not there".

Based on review of the surgery log and staff interview, it was determined the facility failed to ensure the surgery log contained the name of the scrub tech, the circulating nurse and the name of the person who administered the anesthesia for 1 of 1 surgery logs reviewed. This had the potential to affect all patients requiring surgical services at the facility.

Findings include:

An initial tour of the surgical services area was conducted on 3/6/12 at 10:45 AM. During the tour, the surveyor requested a copy of the surgery log for 2/29/12. At 11:00 AM on 3/6/12, Employee Identifier (EI) # 1, Director of the Operating Room, presented the surveyor with the requested surgery log.

A review of the surgery log revealed no documentation of the names of the scrub tech, the circulating nurse or the name of the person who administered the anesthesia.

During an interview on 3/6/12 at 11:05 AM, EI # 1 confirmed their current system was not set up to list the scrub tech, circulating nurse or who administered the anesthesia.