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Based on observation, interview, and review of the facility's policy and procedures, it was determined the facility failed to ensure patients received care in a safe setting. During tour of the facility, observations included; the floor technician's cart was unattended with two (2) bottles of chemicals hanging from the side of the cart, medications prepared and left unattended and unlabeled on the nurse's work station, two (2) pairs of scissors lying on the nurse's work station and one (1) pair on a cart sitting on the outside of a patient room, and a housekeeping cart unlocked with the hood open leaving chemicals accessible.

The findings include:

Review of the facility's policy entitled, "Training Guide-Patient Room-Safety First", undated, revealed chemicals must be stored in a locked storage area when associate is not at the work station. Further review revealed, the chemicals cannot be stored on top shelf of the cleaning cart when not in use.

Review of the facility's policy entitled, "Labeling Medications and Solutions on Procedure Fields, A14-050", dated 08/2011, revealed once transferred to another container, solutions or medications must be attended at all times. Further review of the policy revealed, label containers at the time a medication or solution is transferred from the original container to another container and to pour and label one medication or solution at a time.

Review of the facility's policy entitled, "Nursing Standards of Care, #NU01-33", dated 04/2011, revealed the nurse evaluates factors related to safety, effectiveness, availability and practice options that would result in the same expected outcome.

Observation of the facility during a tour, on 04/23/12 at 4:00 PM, revealed a floor technician's cart was left unattended in the Emergency Department (ED) with chemicals hanging from the side of the cart. Further observation of the cart, revealed the chemicals were Stride Citrus HC Neutral Cleaner, GP Forward SC Cleaner, and Emerel Multi-Surface Creme Cleanser.

Review of a Material Safety Data Sheet (MSDS) for Stride Citrus HC Neutral Cleaner, dated 10/06/2010, revealed the handling precautions to include: avoiding contact with skin, eyes and clothing; do not taste or swallow; remove and wash contaminated clothing and footwear before re-use; wash thoroughly after handling; produce resident may remain on/in empty containers; all precautions for handling the product must be used in handling the empty container and residue. Further review confirmed the storage for this chemical was to protect from freezing; keep tightly closed in a dry, cool and well-ventilated place; and keep out of reach of children.

Review of the MSDS for GP Forward SC Cleaner, dated 03/28/2011 validated the handling precautions to include handle in accordance with good industrial hygiene and safety practice. Further review confirmed the storage to include: protect from freezing; keep tightly closed in a dry, cool and well-ventilated place; and keep out of reach of children.

Review of the MSDS for Emerel Multi-Surface Creme Cleanser, dated 02/04/2010, validated the precautions to include: avoid contact with skin, eyes and clothing; and wash thoroughly after handling. Further review confirmed storage to include: protect from freezing; keep tightly closed in a dry, cool and well-ventilated place; and keep out of reach of children.

Interview with the Environmental Services Manager, on 04/24/12 at 2:00 PM, revealed the housekeeping cart should have been locked when the associates were away from them. Further interview revealed, if the associates were going to be away from the carts for a while, they were educated to put them in a locked room.

Interview with the Environmental Services Director, on 04/24/12 at 2:15 PM, revealed the staff was trained to place the carts in front of the doors of the room of which they were cleaning. Further interview validated, the carts should be locked when away from them. Continued interview revealed, the floor technician's cart should have not been left unattended and the housekeeping cart should have been locked.

Interview with Floor Technician (FT) #1, on 04/26/12 at 10:00 AM, revealed he was the FT assigned to the ED on 04/23/12 when the cart was observed unattended. Further interview revealed, FT #1 had left the ED for a few minutes and he felt the cart would be okay. Continued interview revealed, the carts were not to be left unattended and should have been stored when a staff member had to leave the area of assignment. Further interview revealed, he felt not being able to lock the cart was a safety issue but had not voiced the concerns to anyone.

Observation of the facility during a tour, on 04/25/12 at 10:00 AM, revealed two (2) pair of scissors lying on the nurse's work station between rooms 233-234. Further observation revealed, a styrofoam cup sitting on the nurse's work station with medications that had been prepared for administration but were unlabeled and unattended.

Interview with the Registered Nurse (RN)/Nurse Manger #3, on 04/25/12 at 10:00 AM, confirmed the cup had medications that had been prepared and were unlabeled and unattended. Further interview revealed, the medications should have not been left unattended. Continued interview revealed, the medications had not been prepared according to the facility's policy. Further interview, the scissors laying on the nurse's work station was a safety risk for patients, visitors, and staff.

Interview with RN #9, on 04/25/12 at 10:10 AM, revealed she had prepared the medications in the styrofoam cup. Further interview revealed, she placed the cup of medications on the nurse's work station while she went to another room to care for another patient. Continued interview revealed, she was aware leaving the prepared medication unlabeled and unattended was against policy.

Interview with Nursing Administration, on 04/25/12 at 3:00 PM, revealed all licensed nurses complete a general orientation program followed by a competency checklist verified by their preceptors. Further interview revealed, the medication issue was beyond the standards of practice and would not have met the guidelines for compliance.

Continued observation, on 04/23/12 at 4:00 PM, revealed a cart in the hallway with a gallon jug of Centrisol Acid Concentrate with Potassium added (dialysate-fluid used during dialysis) that was opened and uncapped. Also, observed on the cart was a used meal container.

Interview with RN #8, on 04/26/12 at 9:40 AM, revealed the dialysate should have not been sitting on the cart uncapped and/or opened. Further interview revealed, after mixing the appropriate concentration of dialysate, the mixture should be immediately hooked up to the dialyzer. Continued interview revealed, the container should have not been sitting on the cart out in the hallway. RN #8 validated the dialysate should have been considered contaminated and should have not been used.

Interview with RN#12, on 04/26/12 at 3:47 PM, revealed nurses working in the dialysis department were required to go through an annual competency checklist that included infection control protocols. Further interview revealed, the appropriate procedure for mixing the dialysate was to prepare the supplies, mix the concentration, and then immediately hook the solution to the dialyzer.

Based on observation, interview, and review of the facility's policy and procedures, it was determined the facility failed to prepare and administer medication in accordance and accepted standards of practice. During tour of the facility, observations included medications prepared and left unattended and unlabeled on the nurse's work station and gallon jug of Centrisol Acid Concentrate with Potassium added (dialysate-liquid used during dialysis) was opened and uncapped.

The findings include:

Review of the facility's policy entitled, "Medication Administration: Nasogastric Tube or Enteral Tube," dated 01/2012, revealed tablets are crushed using a pill crushing device to grind pill into a fine powder. The pills are to dissolve in at least thirty (30) milliliters (mL) of warm water and if there is more than one (1) tablet, crush and dilute each one individually. Further review of the policy revealed, all medications need to be labeled. . Continued review of the policy revealed, if administering more than one medication, give each separately, and flush between medications with fifteen (15) to thirty (30) mL of warm water.

Review of the facility's policy entitled, "Labeling Medications and Solutions on Procedure Fields, A14-050," dated 08/2011, revealed once transferred to another container, solutions or medications must be attended at all times. Further review of the policy revealed, label containers at the time a medication or solution is transferred from the original container to another container and to pour and label one medication or solution at a time.

Review of the facility's policy entitled, "Nursing Standards of Care, #NU01-33," dated 04/2011, revealed the nurse evaluates factors related to safety, effectiveness, availability and practice options that would result in the same expected outcome.

Observation of the facility during a tour, on 04/23/12 at 4:15 PM, revealed a cart with a gallon jug of Centrisol Acid Concentrate with Potassium added (dialysate-liquid used during dialysis) was sitting on a cart in the hallway of the Intensive Care Unit of two hundred (200) Tower sixth (6th) floor opened and uncapped.

Interview with Registered Nurse (RN) #2, on 04/23/12 at 4:15 PM, revealed the cart sitting in the hallway was a dialysis supply cart. Further interview revealed the dialysis nurse was in a room and the cart was out of her direct visual path.

Interview with RN #8, on 04/26/12 at 9:40 AM, revealed the dialysate should have not been sitting the cart uncapped and/or opened. Further interview revealed, after mixing the appropriate concentration of dialysate, the mixture should be immediately hooked up to the dialyzer. Continued interview revealed, the container should not have been sitting on the cart out in the hallway. RN #8 validated the dialysate should have been considered contaminated and should have not been used.

Interview with RN #12, on 04/26/12 at 3:47 PM, revealed nurses working in the dialysis department were required to go through an annual competency checklist that included infection control protocols. Further interview revealed, the appropriate procedure for mixing the dialysate was to prepare the supplies, mix the concentration, and then immediately hook the solution to the dialyzer.

Observation of the facility during a tour, on 04/25/12, at 10:00 AM revealed, a cup of medications that were prepared for administration for Unsampled Patient A, but were left on the nurse's work station unattended and unlabeled. Further observation of the cup revealed, two (2) empty syringes, one (1) pouch of several medications, Protonix Intravenous solution, and Micophenilate.

Interview with RN #3, on 04/25/12 at 10:00, revealed the medication should not be sitting on the nurse's work station. Further interview revealed, the medications sitting out posed a risk for patients, visitors, and/or staff. Continued interview validated, this was in violation of the facility's policy for medication administration.

Interview with RN #9, on 04/25/12 at 10:10 AM, revealed she had prepared the medications in the styrofoam cup. Further interview revealed, she placed the cup of medications on the nurse's work station and left then unattended and did not label them. Continued interview revealed, she was aware leaving the prepared medication unlabeled and unattended was not standard practice according to the facility's policy.

Review of the Medication Administration Record for Unsampled Patient A, on 04/25/12 at 10:20 AM, revealed the following medications had been crushed together; Acyclovir (anti-viral for infection), Aspirin (salicylates for thinning the blood), Atropine (anticholinergic), Diflucan (antifungal for infection), Folic Acid (B-complex vitamin for hemoglobin), Iron (essential mineral for normal body function), Keppra (anticonvulsant in prevention of seizures), Synthroid (thyroid hormone to stabilize thyroid levels), Zyvox (antibacterial for infection), Lopressor (beta blocker for high blood pressure or heart rate), Multivitamin (vitamin), Prednisone (corticosteroid), and Zoloft (antidepressant for depression).
Interview with RN #9, on 04/25/12 at 10:30 AM, revealed the medications listed on the Medication Administration Record (MAR) were the medications that were crushed in the pouch together. Further interview revealed, RN #9 was aware of the policy of crushing medications one (1) pill at a time, but had failed to follow policy.

Interview with Nursing Administration, on 04/25/12 at 3:00 PM, revealed all licensed nurses complete a general orientation program followed by a competency checklist verified by their preceptors. Further interview revealed, the medication issue was beyond the standards of practice and would not have met the guidelines for compliance.