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Based on review of facility documents, observation, and staff interview (EMP), it was determined the facility failed to ensure medications considered ready for patient administration were not outdated on the Intensive Care Unit (ICU) and the 4 West patient care unit.

Findings include:

Review on November 4, 2024, of the facility's "Pharmacy Scope of Care & Services Policy #46," last reviewed November 2023, revealed "Policy: It is the policy of Wayne Memorial hospital that the pharmacy provides care to our patients utilizing the following guidelines: Responsibility The Pharmacy manager is responsible for ensuring that all pharmacy services provided by the pharmacy department are of the highest possible quality ..."

Review on November 4, 2024, of the facility's "Inventory Control and Drug Accountability Policy #32," last reviewed November 2023, revealed "Policy: It is the policy of Wayne Memorial Hospital Pharmacy to maintain a supply of drugs and devices adequate to meet the needs of the health professionals and the patients it is intended to serve. Purpose: The purpose of this policy is to establish a format for inventory control and drug accountability in order to maintain a supply of drugs and devices adequate to meet the needs of the health professionals and the patients it is intended to serve ..."

Review on November 4, 2024, of the facility's "Medication Area Inspection Policy #36," last reviewed November 2023, revealed "Policy: 1. A pharmacist and a technician will conduct monthly inspections. The following medication preparation and storage areas will be inspected: ... ICU ...4 West ... 2. The Pharmacist will record the results of the inspection on the medication inspection record. A copy will be given to the unit supervisor when necessary and retain the original in the pharmacy. The Pharmacy team and unit supervisor will evaluate the findings and take action to correct the deficiencies and improve the system as soon as possible. Purpose: Periodic inspections of drug storage, administration and dispensing areas can identify most unusable medications. Inspections should focus on storage conditions ... security ...removal of outdated and other unusable medications and devices ..."

Review on November 4, 2024, of the facility's "Rotating Stock for Inventory Control Policy #58," last reviewed November 2023, revealed "Policy: It is the policy of Wayne Memorial Hospital Pharmacy to rotate stock for better inventory control. Purpose: To maintain a format for rotating inventory. Procedure: 1. When an item is received from a supplier, the item will be placed on the shelf or on the bin with the shortest dated item in front of the unopened items ..."

Observation on November 4, 2024, of the secured medication storage units in the Intensive Care Unit (ICU) revealed three intravenous (IV) bags of Clindamycin (an antibiotic) 300 milligrams (mg) in 50 milliliters (ml) of 5 % Dextrose. These three bags of IV Clindamycin expired on March 16, 2024.

Interview with EMP6 and EMP10 on November 4, 2024, confirmed the above findings at the time of the observation.

Observation on November 4, 2024, of the secured medication storage units on 4 West revealed five IV bags of Clindamycin 300 milligrams (mg) in 50 milliliters (ml) of 5 % Dextrose. These five bags of IV Clindamycin expired on March 16, 2024.

Interview with EMP6 and EMP10 on November 4, 2024, confirmed the above findings at the time of the observation.

Interview with EMP9 on November 4, 2024, revealed these secured medication storage units in the ICU and 4 West were reviewed monthly by EMP17, EMP18 and EMP19 from April through November 2024. Further interview revealed these employees did not identify the above medications as expired. EMP9 confirmed there was a potential for patients to receive a dose of the expired IV Clindamycin 300 mg in 50 ml of 5 % Dextrose.

Based on review of facility documents, observation, and staff interview (EMP), it was determined the facility failed to ensure rooms considered ready for patient occupancy were clean in the Intensive Care Unit (ICU) and on 4 West; the facility failed to ensure durable medical equipment was cleaned prior to placing it in a plastic bag and storing in the clean storage room on the ICU unit and on 4 West; the facility failed to ensure the facility followed its policy regarding storage of commodes in the clean storage room on the ICU unit and 4 West; the facility failed to ensure cracks in a wall above a window was identified and repaired in a timely manner in the ICU unit, and the facility failed to ensure vegetation (plant growth) was not present on a roof outside the ICU unit.

Findings include:

Review on November 4, 2024, of the facility's "Infection Prevention and Control Overview For Environmental Services (EVS) Reference #5010" policy, last revised August 2022, revealed "Purpose: To control the spread of infection, Wayne Memorial Hospital shall use evidence-based national guidelines, or in the absence of such guidelines, expert consensus to guide infection prevention and control practices throughout the organization. Policy: Environmental Service workers will consult the policy and procedure manual of Infection Control as well as the Environmental Services Manual that is maintained by the Director of Environmental Services for unit specific cleaning and disinfection policy and procedures as well as schedules for department cleaning procedures ... "

1. Observation on November 4, 2024, of the facility's Intensive Care Unit (ICU) revealed patient room 204 had a thermostat cover missing.

Observation on November 4, 2024, of the facility's 4 West patient care unit revealed the following:
Room 427 - the cleaning card indicated this patient room was cleaned on November 3, 2024. Observation of this patient room revealed multiple areas of white debris and dust on the mattress, dried toilet paper on the commode bowl and dried urine stains on the floor in front of the commode.

Room 429 - the cleaning card indicated this patient room was cleaned on October 17, 2024, and re-checked on October 22, 2024. Observation of this patient room revealed multiple areas of white debris and dust on the mattress.

Room 430 - the cleaning card indicated this patient room was cleaned on November 2, 2024. Observation of this patient room revealed multiple areas of white debris and dust on the mattress.

Room 431 - the cleaning card indicated no date this patient room was cleaned but the card indicated this room was rechecked on October 22, 2024. Observation of this patient room revealed multiple areas of white debris and dust on the mattress and an area of nasal discharge on the wall leading to the bathroom.

Interview with EMP6 and EMP8 on November 4, 2024, confirmed the above findings at the time of the observation.

2. Observation on November 4, 2024, of the facility's ICU clean storage room revealed a tube feeding pump in a clear plastic bag. This tube feeding pump had tape on the pump along with drops of dried tube feeding.

Interview with EMP6 on November 4, 2024, confirmed the above findings at the time of the observation. EMP6 confirmed this tube feed pump was not appropriately cleaned and that it was identified as ready for patient use.

Observation on November 4, 2024, of the facility's 4 West clean storage room revealed a tube feeding pump in a clear plastic bag. This tube feed pump had dried tube feeding in the area where the tubing is secured to the pump, on the sides and bottom of the pump and on the back of the pump.

Interview with EMP6 and EMP8 on November 4, 2024, confirmed the above findings at the time of the observation. EMP8 confirmed this tube feed pump was not appropriately cleaned and that it was identified as ready for patient use.

3. Observation on November 4, 2024, of the facility's ICU clean storage room revealed three bedside commodes that did not have clear liners on the seat.

Interview with EMP6 on November 4, 2024, confirmed the above findings at the time of the observation. EMP6 confirmed the commodes were not correctly identified as clean.

Observation on November 4, 2024, of the facility's 4 West clean storage room revealed three bedside commodes that did not have clear liners on the seat.

Interview with EMP8 on November 4, 2024, confirmed the above findings at the time of the observation. EMP6 confirmed the commodes were not correctly identified as clean.

4. Observation on November 4, 2024, of the ICU revealed a window located in the area where the door opens into the stair way. The area had a vertical crack in the wall measuring approximately 12" long and one-eight inch wide above the window where the exterior wall and the interior wall meet. There was also a horizontal crack in the exterior wall directly above the window measuring approximately 8" long and one-eight inch wide.

Interview with EMP7 on November 4, 2024, confirmed the above finding at the time of the observation.

5. Observation on November 4, 2024, of the roof area located outside the ICU revealed an area of vegetation (plant growth) on this roof. This vegetation measured approximately 8" by 6" and included a thick dense clumps and a mat of moss growth and several dried brown plants measuring approximately 15 inches high.

Interview with EMP7 on November 4, 2024, confirmed the above finding at the time of the observation. EMP7 confirmed the vegetation and plant growth inhibits the structure of the roof and potentially can cause roof damage.

Based on review of facility documents, observation, and staff interview (EMP), it was determined the facility failed to ensure operating room staff and Central Service Sterile Processing staff appropriately wore surgical scrub caps that covered all hair; the facility failed to ensure all facial hair was covered in the Central Service Sterile Processing area and the facility failed to ensure operating room staff did not wear jewelry while assisting in the operating room.

Findings include:

Review on November 5, 2024, of the facility's "Dress Code Policy: D-4," last revised April 2022, revealed "Purpose: All staff are expected to be professionally attired at all times. Policy ... Operating Room/PACU/Cardiac Cath Lab: ... Caps will be worn to cover the hair. Jewelry should not be worn, except a plain wedding band or other plain band with no stone ...Central Services: Hair ... Hair covers will also be worn ..."

1. Observation on November 5, 2024, of the operating room (OR) revealed EMP13 in the OR preparing for a surgical case. Further observation revealed EMP13's hair on the top of the head and near the ears was not fully contained in the surgical scrub cap.

Observation on November 5, 2024, of OTH1 revealed this surgeon was wearing a surgical cap with approximately 1" of hair showing below the surgical cap on each side of the head above the ears and approximately 2" of hair showing below the surgical scrub cap at the posterior neck area.

Interview with EMP14 on November 5, 2024, at the time of the observation confirmed the above findings.

2. Observation on November 5, 2024, of the Central Service Sterile Processing area revealed EMP15 examining surgical equipment and preparing surgical instruments for sterilization. EMP15's hair was not fully contained in the surgical cap.

Observation on November 5, 2024, of the Central Service Sterile Processing area revealed EMP16 examining surgical equipment and preparing surgical instruments for sterilization. EMP16 had facial hair. Further observation of EMP16 revealed this employee's facial hair was not fully contained in the facial covering.

Interview with EMP14 on November 5, 2024, at the time of the observation confirmed the above findings.

3. Observation on November 5, 2024, of the OR revealed EMP13 in the OR preparing for a surgical case. Further observation revealed EMP11 and EMP12 were wearing necklaces with dangling pendants.

Interview with EMP14 on November 5, 2024, at the time of the observation confirmed the above findings. EMP14 revealed necklaces are not to be worn by OR staff.