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Based on record review, observation and interview, the facility failed to maintain the equipment in the laboratory by documenting the required safety tests of the refrigeration equipment necessary for the laboratory tests performed.

Findings:

During the laboratory tour on 7-26-11, it was discovered that the refrigerators in the laboratory had stickers on them that indicated that the last safety tests were due on 4-14-10. the Blood Bank Refrigerator did not have a inventory number on it and there was no documentation of the test for the temperature alarm for the Blood bank Refrigerator. An accumulation of dust and debris was observed behind the computers and testing equipment in the middle of the laboratory, stained ceiling tile observed in the Hematology area along with equipment sitting on stained wooden blocks and cloth towels. A cloth towel was observed in the cabinet below the sink in the corner of the laboratory and under the rubber stress mat in the Histology area.

In interview with the Housekeeping Director on 7-26-11 at 2:00 PM, it was stated that he did not know why the towels were on the floor or under the sink and he was unaware of the dust behind the computer counters.

Review of the test records with the maintenance department indicated that there were six pieces of equipment in the laboratory that were not listed in the maintenance log.

In interview with a maintenance staff member on 7-27-11 at 9:00 AM, it was stated that they did keep electronic records but he could not find any safety tests for the Blood Bank Refrigerator or the six pieces of equipment that was not listed.

Based on observations, document review and staff interviews the facility failed to ensure that Infection Control principals were followed and that the facility failed to follow their own policy for the Emergency room regarding retention of specimens.

FINDINGS:

1. Observation on 07/26/2011 at 9:45 AM of a patient receiving care on the 5th floor room 507 revealed that the patient had been placed in contact and droplet isolation precautions. The patient was noted to have a G-tube, Foley catheter and receiving oxygen by a nasal cannula. Observation of the Registered Nurse (RN) providing care revealed that the RN first touch the G-tube and the patient's abdomen and then touched the Foley catheter and catheter tubing and then without changing his gloves the RN removed the nasal catheter from the patient nose in the process of removing the nasal cannula the RN touch the patient's face. Following the removal of the nasal cannula the RN was observed placing a cream on a long Q-tip, (one for each nostrils) and then applying the cream to the patient's nostrils. The nasal cannula was replaced and throughout the process the RN never changed his gloves.
2. Observations of Emergency room over a 3 day time frame, and various times, revealed that there was blood in tubes sitting in a holder at the Nurses station, easily accessed by patients.
Observations made on 07/25/2011 at 12:05 PM (Counted approximately 12 or more tubes, some were from previous day) and again at 3:30 PM. (Counted 7 tubes in holder.) On 07/26/2011 at 9:09 AM and at 2:30 PM. (Various number of tubes in holder both observation times). On 07/27/2011 at 11:00 AM. (Noted there was only 1 tube in holder, and then 2nd tube put in holder by staff)
Review of Emergency Room policy on retention of specimens (Effective date 06/84, and revised on 05/11.) states that the Emergency Room is to save tissue or other specimens but to be sent to the laboratory (Lab). If specimen testing not needed the specimen will be discarded by appropriate methods, by Lab personnel.
Interview on 07/25/2011 at 12:05 PM with the Director of the Emergency Room, who states that they draw blood in green tube and hold in Emergency Room for further testing eventually discarded. The Director further stated does not need to hold tube since it is not tested again after initial I-Stat test done.
Interview on 07/26/2011 at 2:30 PM with Lab coordinator, who could not find any policies in lab regarding the holding of blood in Emergency Room, to do further Lab. Checked I-Stat policy and no policy regarding the holding of the blood by the emergency room. Did have Lab Coordinator check the emergency room policy regarding the retention of specimens, but the Coordinator had nothing further to add.
Second Interview with the Director of Emergency Room on 07/27/2011 at 2:40 PM, revealed that she did not know of the policy shown to her, but would check into this policy. She further stated she would remove the blood immediately from the counter in nurses station.