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Based on observation, document review, and interview, the outpatient clinics did not ensure patient environmental safety was maintained and did not conform to facility policy and procedure that requires sharps to be secured. This was evidenced by the unsecured storage of intravenous (IV) needles with syringes, sutures, needles, and lancets, which was observed in 5 of 15 cabinets located in patient exam rooms.

These lapses in environmental safety places patients and visitors at increased safety risks.


Findings:

During a tour of the facility's Family Clinic between 10:15am and 12:15pm on 5/18/17, the following observations were made:

1. In procedure room # 3, a cabinet containing needles and syringes was unlocked.

2. In exam room # 15, a cabinet containing suture needles and syringes with needles was unlocked.

3. In exam room # 17, a cabinet containing lancets was unlocked.

4. Similar findings were observed for unsecured sharps during the tour of the outpatient Physical Therapy Clinic on 5/19/17.

During interview with Staff D on 5/18/17 at the time of the observations. Staff D acknowledged the cabinets should have been locked.

The Facility's Policy and Procedures titled "Sharps" last reviewed 1/2013, contained the following statement: "To insure the safety of patients and staff, all unused needles and syringes will be maintained in a locked cabinet at all times."

Based on document review and interview, Nursing Services did not ensure: a) nursing staff had an annual performance evaluation, and b) nursing staff received annual education and training.

Findings include:

a) Personnel files for Staff C, Director of Nursing - Ambulatory, lacked an Annual Performance Evaluation.

The same lack of an Annual Performance evaluation was found in the personnel files of Staff J, K, and M.

b) Personnel files for Staff M, Nurse Manager, lacked annual "Mandatory Re-Orientation" education.

The same lack of an Annual Performance evaluation was found in the personnel files of Staff E, J, L and N.

These findings for a) and b) were confirmed with Staff O, Nurse Educator, and Staff P, Administrator, on 5/19/17 between 12:00 and 1:00PM.

Based on observation, document review, and interview, the facility did not ensure expired medications and otherwise unusable drugs and biologicals were not available for patient use.

These lapses place patients at increased risk for receiving expired medications.

Findings:

The Facility's Policy and Procedures titled "Use/Dating of Multi-dose vials" last reviewed 8/2016, contained the following statement: "The manufacturer bases the expiration date on the fact that the agent has not been opened ...Once a multi-dose vial is opened or punctured it must be re-labeled with a "beyond-use-date" of no more than 28 days, unless the manufacturer specifies otherwise."


During observations in the facility's Family Clinic on 5/18/17 at 11:30AM, 1 vial of Humulin Insulin labeled with an open date of 3/27/17 but no discard date, was observed in the medication refrigerator.

During observations in the facility's Ambulatory Care center on 5/19/17 at 10:25 am, a box of Albuterol solution with a manufacturer's expiration date of 4/2017 was observed in the medication cabinet of the triage room.

Similar findings of unusable biologicals were also found during the same observation on 5/18/17.

During interview of Staff C, Staff D, and Staff H at the time of these observations, they acknowledged the medications should have been discarded.

During interview of Staff I on 5/19/17 at 11:45am, he stated "multi-dose vials should be discarded after 28 days of opening."