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Based on policy and procedure review, personnel educational file review and staff interviews, the facility's nursing personnel failed to maintain compliance with required Basic Life Support (BLS)certification in 2 of 6 nursing files reviewed (RN #1, RN #3).

The findings include:

Review of hospital policy, "Licensed and Unlicensed Nursing Staff Competency Requirements", effective June 2011, revealed "I. Description Describes educational requirements of Division of Nursing staff in order to stay current with practices in Nursing and to assist the employee in providing safe and effective care to the patient... Certification in Emergency Resuscitation American Heart Association (BLS, ACLS, PALS) or NRP certification is required every 2 years per unit requirements. BLS is required prior to hire and maintained as required by unit/service standards..."

1. Review of personnel file of Registered Nurse #1 working in the behavioral health unit revealed that the BLS certification was last attended in 05/2013.

Interview with Administrative Staff #1 on 09/24/2015 at 1715 confirmed there was no current certification on file.

2. Review of personnel file of Registered Nurse #3 working in the behavioral health unit revealed that the BLS ( Basic Life Support) certification was last attended in 05/2013.

Interview with Administrative Staff #1 on 09/24/2015 at 1715 confirmed there was no current certification on file.

Based on observation during unit tour and staff interview, the hospital failed to appropriately remove expired supplies from stock.
Findings include:
Observation during tour of the Adolescent Unit medication room on 09/22/2015 at 1515 revealed eight out of eight vials of 0.9% Bacteriostatic Sodium Chloride (sterile salt water solution) with an expiration date of 3/1/2015 (over 6 months ago), one Protect IV (intravenous catheter) Plus Safety brand IV catheter 20 gauge x 1 inch with an expiration date of 12/2014 (9 months ago), one Protect IV Plus Safety brand IV catheter 18 gauge x 1¼ inch with an expiration date of 12/2014 (9 months ago) , three Protect IV Plus Safety brand IV catheter 20 gauge x 1 inch with an expiration date of 08/2015 (1 month ago) and 39 out of 39 insulin syringes 1 ml x ½ inch with an expiration date of 04/2015 (5 months ago). Further observation of the Child and Adolescent shared supply room on 09/22/2015 at 1515 revealed 25 out of 25 vials of 0.9% Bacteriostatic Sodium Chloride with an expiration date of 08/2015 (1 month ago). Observation revealed NM (Nurse Manager) #1 physically removed expired supplies that were identified during the unit tour.
Interview with Nurse Manager #1 revealed that, "Expired supplies should be removed from the unit and replaced."

Based on policy and procedure review, observation during unit tour and staff interviews, the hospital failed to appropriately clean and store a soiled tube feeding pump and dispose of used tube feeding tubing for 1:1 tube feeding sets observed.
Findings include:
Review of the infection Control Manual (effective date April, 2015) on 09/24/2015 revealed "... III Policy.... C.... 3. Cleaning of Equipment and Shared Patient Items: a. Medical equipment and instrument/devices must be cleaned and maintained according to manufacturer's instructions to prevent patient to patient transmission of infectious agents.... b. An EPA-registered hospital disinfectant (Metriguard or Sani-Cloth) should be used for cleaning surfaces and patient care equipment with a minimum one minute contact time.... c. All patient care equipment should be disinfected when visibly soiled and on a regular basis (e.g., daily, weekly, etc). ..."
Observation of the Adolescent Unit clean treatment room on 09/22/2015 at 1515 revealed used feeding pump and visibly soiled tubing hanging on the pump stand. Observation revealed clear liquid in both tubings, one tubing in a biohazardous bag hanging from the stand and another tubing looped across the top of the pump stand dangling over the clean crash cart.
Interview during tour with Registered Nurse #2 (RN #2) on 09/22/2015 revealed, "There is a patient on the unit who receives tube feeding at night and this is the pump that we use." RN #2 also stated that, "The equipment was dirty and should not be in the clean treatment room." Interview revealed the facility's policy was not followed.

Interview with Nurse Manager #1 on 09/24/2015 at 1200 revealed, "We have an opportunity to improve our practice in this situation (regarding the recently used feeding pump with visibly soiled tubing observed in the clean treatment room)." Interview revealed policy was not followed.

NC00110008, NC00109798, NC00108927