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Based on observation the hospital failed to assure that all supplies provided for emergency treatments were safe for use. More specifically, that the supplies were not kept beyond the expiration date established by the equipment manufacturer.

Failure on the part of the hospital to provide emergency supplies that are considered safe for use puts patients at risk of harm.

Finding:

On 3/18/2015 Surveyor #1 noted that an unopened pediatric ventilation kit onboard the Broselow cart located in the Emergency Department was beyond its expiration date of 8/2013. Certain items within the kit were not expired but the outer wrapper's expiration date indicated that other item(s) within the kit that could not be seen had expired.



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Based on observation the hospital failed to properly store drugs.

Failure on the part of the hospital to properly store drugs puts patients at risk from potentially compromised medicines.

Findings:

On 3/18/2015 at 3:15 PM Surveyor #1 noted that an open box containing Heparin infusion bags was being stored on the floor of the pharmacy. It was also noted that a plastic bag of pill containers and tops were also being stored on the floor of the pharmacy.



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Based on observation the hospital failed to assure that the premises, more specifically patient care areas and patient rooms were maintained in a clean and orderly fashion.

Failure to maintain clean and orderly patient care areas and rooms puts patients at risk of infection.

Findings:

1. On 3/18/2015 between the hours of 2:50 PM and 3:45 PM Surveyor #1 noted various levels of dust on high horizontal surfaces in the following locations: Emergency Department bays 1 - 3; and patient rooms 4, 5, 8, 9 and 11. It was further noted that air supply ducts in these and other areas of the hospital were also dusty.

2. On 3/18/2015 at 3:15 PM Surveyor #1 noted that the hospital pharmacy had a large accumulation of dust on the floor.

These findings were acknowledged by the Supervisor of Maintenance (Staff Member #2) when they were identified.



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Based on observation the hospital failed to maintain an appropriate air pressure relationship (ventilation) between the laboratory and adjacent spaces.

Failure on the part of the hospital to maintain appropriate air pressue relationships put patients, staff and visitors at risk from air-borne contaminates.

Finding:

On 3/18/2015 at 3:00 PM Surveyor #1 used a light weight strip of tissure (flutter strip) to determine if the direction of air flow was into or out of the laboratory. The flutter strip showed that the direction of air flow at the door of the laboratory was out to the corridor not into the laboratory as is required.



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Based on observation and interview, the facility did not have or follow a policy on removing expired or potentially degraded supplies from availability for use on patients.

This failure placed patients at risk for unintended outcomes of care.

Findings:

1. During tour of the emergency department on 3/17/2015 between 10:00 AM - 10:30 AM Surveyor #2 observed the following:
a. One package of EKG electrodes which had expired 9/2014; the package contained directions not to use them more than 30 days after opening. The Surveyor also observed a plastic bag containing the same type of electrodes; the bag was not marked with a date when the electrodes had been removed from their original packaging, so it was not possible to determine if the electrodes could be used effectively.
b. Surveyor #2 also observed a package of suture material which had expired 1/2015.
c. The above findings were confirmed by the Chief Nursing Officer (Staff Member #3) at the time of oservations.

2. During tour of the acute care unit at 1:30 PM Surveyor #3 found another opened and undated package of electrodes on the unit's crash cart. This was confirmed by the Chief Nursing Officer (Staff Member #3) at the time of the observation.



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Item #1: Outdated Medications

Based on observation and interview outdated, unusuable drugs were available in the hospital pharmacy for patient use.

Failure to remove outdated drugs from area of potential use placed patients at risk for receeiving ineffective or degraded products.

Findings:

1. On 3/17/2015 Surveyor #2 observed the following items in the hospital pharmacy:
a. One tube of Tobradex eye ointment on the shelf, expired 2/2015
b. Thirteen vials of Gastroview (iodine for gastrointestinal X-ray contrast) on the shelf, expired 2/2014
c. Seven bags of intravenous Dopamine (used for shock and other cardiac emergeencies) on the shelf, expired 11/2014

2. On 3/19/2015 at 11:00 AM the Pharmacist (Staff Member #1) observed and confirmed these findings and stated that the pharmacy technician would inspect all drugs in the pharmacy and remove from potential use any that were outdated.


Item #2: Medication Security

Based on interviews, the facility failed to secure medications from personnel not authorized to administer them.

Failure to do so places patients at risk of not having needed drugs available, or receiving drugs that haves potentially been mishandled or tampered with.

Findings:

1. On 3/18/2015 at 8:45 AM Surveyor #2 interviewed the Director of Plant Services (Staff Member #2). S/he stated that s/he had a key to the pharmacy, but was not licensed or approved to administer or handle drugs.

2. On 3/19/2015 at 11:00 AM Surveyor #2 informed the Pharmacist (Staff Member #1) of the above, and asked him/her if this was approved as part of the facility's medication security policy. Staff Member #1 stated s/he was unaware that Staff Member #2 had a key to the pharmacy, that it was not approved, and would be retrieved immediately.



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Item #1: Lack of Infection Control Officer

Based on interview the hospital failed to have a designated Infection Control Officer. Failure on the part of the hospital to have an Infection Control Officer who can address needed infection control program activities on an on-going basis puts patients, staff and visitors of the facility at risk of infection.

Findings:

On 3/17/2015 at 9:30 AM Surveyor #1 was informed by the Chief Nursing Officer (Staff Member #LA2) that the hospital had been without the services of infection control officer for approximately one month. And, it was pointed out that the individual who is currently serving as the acting infection control officer lacked the required education, background and training needed to perform the duties of an infection control officer.


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Iten #2: Cross Contamination

Based on observation and interview, the facility failed to prevent cross contamination of patient care items in specific circumstances.

Failure to do so placed patients at risk of infection.

Findings:

1. During tour of the lab on 3/17/2015 at 1:20 PM Surveyor #2 observed a plastic "tote basket" which contained supplies for drawing blood specimens. The lab tech (Staff Member #4) stated that s/he brought the basket into patient rooms and placed it on the patient's bed or bedside table while drawing specimens. S/he stated s/he did not place a barrier beneath the basket to prevent potential contamination, or sanitize the basket or bedside table, even if the patient was in isolation precautions. This practice was acknowledged by the Chief Nursing Officer (Staff Member #3) at the time of the observation and interview.

2. During inspection of the hospital-operated ambulance on 3/18/2015 at 11:00 AM Surveyor #2 observed the EMT (Staff Member #5) remove a "code bag" from a shelf approximately one-inch tall, located directly next to the floor and a door, and place it on the patient stretcher which had been made up for use, thus potentially spreading contaminants onto the stretcher linen. This potential cross contamination was acknowledged by the EMT (Staff Member #5) at the time of the observation.



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Based on interview and document review the hospital failed to provide clear and precise policies and procedures that would ensure that the nutritional needs of patients would be met.

Failure on the part of the hospital to have clear and precise policies and procedures puts patients at risk of receiving inappropriate nutrition.

1. On 3/17/2015 Surveyor #1 interviewed a dietary aide (Staff Member #7). Various food service topics were discussed which included: Cleaning and sanitizing food service equipment and utensils, food handlers cards, operational temperatures of the dishwashing machine, patient meals, and proper meal heating temperature.

During the discussions with the dietary aide the surveyor was made aware that the hospital food kitchen was not actively being used for the preparation and service of food. It was further pointed out that patients would be served frozen entree's which had been selected by the dietitian for use within the facility.

2. On 3/19/2015 at 12:45 PM Surveyor #1 held a telephone conversation with the hospital dietitian who also serves as the Director of Food and Dietetic Services (Staff Member #8). During the course of the discussion the surveyor was informed that current policies and procedures relevant to food service could be found in the kitchen in a three ring binder (titled: "Food Service Policies").

3. On 3/19/2015 Surveyor #1 reviewed the policies and procedures identified by the dietitian as those being most current (found in kitchen three ring binder titled "Food Service Policies"). The policies located in the three ring binder lacked any mention of the use of retail frozen entrees for meeting the nutritional needs of patients. Therefore, no information or direction was provided on such basic topics as to what frozen entrees were approved for use, how substitutions should be made if the approved items are not available, what diet(s) they were suitable for (i.e. general, low sodium, diabetic, gluten free, etc.), how and where they were to be purchased, method of transport, heating methods, temperature checks, etc.

4. Policies and procedures found in the above mentioned Food Service Policies located in the three ring binder were last reviewed on 9/5/2014 by the dietitian (Staff Member #LA4) and on 9/30/2014 by the facility's Chief Nursing Officer (Staff Member #LA2). However, numerous cross-outs and notations had been made for several of the policies contained therein and it was not possible to determine if the cross-outs and notations were made before or after the policies were approved as a whole.



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Based on observation the hospital failed to maintain confidentiality of patient records, more specifically, protecting said records from unauthorized use.

Failure on the part of the hospital to maintain patient records in a manner that would prevent unauthorized use puts the patient(s) at risk of harm.

Findings:

1. On 3/18/2015 at 10:25 AM Surveyor #1 entered the Radiology Department for the purpose of seeking out the person in charge. Upon entering the unit (x-ray) it was determined that the unit was not occupied. And, it was further noted that the office door was not secured which would allow unauthorized person(s) to access patient information (films) being kept in the office.

2. On 3/18/2015 at 10:25 AM Surveyor #1 noted that patient records (films and index cards) were not secured from unauthorized person(s) in closets located in the Radiology Department changing station area. These items were removed from the closets and secured prior to the survey exit.



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