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Based on observation, a review of documentation, interviews with staff and a tour of the facility, the facility failed to ensure that the provision of services requirements were met as evidenced by failing to remove expired medications from the patient care areas, failing to maintain a comprehensive and effective infection control program and failing to ensure that all facility policies and procedures were reviewed (and updated as needed) on an annual basis.

Findings were:

Cross refer to:
C0276
C0278
C0280

Based on observation, a tour of the facility and an interview with staff, the facility failed to ensure that outdated, mislabeled or otherwise unusable drugs were not available for patient use.

Findings were:

During a tour of the emergency department on 8-20-14:
? 4 of 4 40 mg vials of Furosemide had expired 8-1-14 but were still available for patient use.

During a tour of the emergency department medication room on 8-20-14:
? 2 of 6 1000 ml intravenous bags of lactated ringers had expired 5-14 but were still available for patient use.
? 2 of 2 1000 ml intravenous bags of 5% dextrose solution had expired 7-14 but were still available for patient use.

During a tour of the patient care unit medication room on 8-20-14:
? 1 of 4 1000 ml intravenous bags of 5% dextrose solution had expired 7-14 but were still available for patient use.
? 4 of 4 250 ml intravenous bags of 5% dextrose solution had expired 7-14 but were still avaible for patient use.

Facility policy titled "Expired Medications" states, in part, "Expired medications will be stored separately from active inventory in such a manner that will insure that they cannot be dispensed."

The above was confirmed in an interview with staff #17 on the afternoon of 8-20-14.

Based on a review of documentation and interviews, the facility failed to ensure that there was a system for identifying, reporting, investigating, and controlling health care associated infections and communicable diseases between patients and personnel.

Findings were:

Review of facility based Infection Control documentation revealed the policy and procedures for Infection Control were last reviewed on 9/22/13 with only the signature of the Infection Control Officer present. The policy and procedure for the "Management of Puncture Wounds" in the Infection Control Book referenced Centers for Disease Control guidelines from 1987-1996. No current professional standards were cited in the infection control policy and procedure manual.

No meeting minutes for an Infection Control committee were present. Review of the Board of Director (governing body) meeting minutes revealed no documentation of reports from Infection Control.

In an interview on 9/30/14 at 11:00 AM, staff member # 9 was asked how long they had been in the position of the Infection Control Officer. The staff member stated, "In 2002 I was hired on as the lab director, I inherited infection control and QA." The staff member was asked what training or background they had in infection control. The staff member replied, "I've never had training for infection control. I bought a book about it, but that's about it."

Staff member # 9 was asked what current acceptable professional guidelines for infection control are utilized at the facility. Staff member # 9 was only able to provide one manual for healthcare infection control. The staff member stated they had not read this manual or utilized the information in the facility based infection control program. The staff member stated, "I just took it out of the box to bring in here to you."

The staff member # 9 was asked if there was documentation of Infection Control Committee meeting minutes. Staff member # 9 responded, "All we do is meet during QA. I don't know what to do, other than call out how many community acquired infections and nosocomial ones there were." The staff member stated that Quality meetings were held quarterly.

Staff member # 9 was asked if Infection Control makes reports to the Board of Directors. He stated that Infection Control was included in the Quality Assurance reports. The staff member replied, "All we have for infection control is what the nurses bring to us (referring to the surveillance sheets)."

Staff member # 9 was asked if the data obtained through the infection surveillance forms was compiled and used to identify and/or address possible trends. The staff member replied, "Sometimes we discuss if they need cultures for staph aureus." The staff member was asked what happens to the infection surveillance sheets after they are completed by nursing staff. The staff member replied, "Those forms are submitted to me." The staff member was asked how the infection surveillance forms were utilized to improve infection control. They replied, "Honestly my role is to collect those sheets and make sure they're in order. That's all I've done. I don't know what else to do."

The above findings were confirmed in an interview on 8/20/14 with staff member #16.

Based on observation and an interview with staff, the facility policies were not reviewed at least annually.

Findings were:

During a review of facility policy and procedure manuals, the following policies and procedures had not been reviewed on an annual basis.
? Laboratory - last reviewed on 9-22-13, but only by the Laboratory Director
? Emergency Room - last reviewed 11-20-12
? Patient Safety Policy - last reviewed 10-26-04
? Quality Assessment - last reviewed 4-20-11
? Infection Control - last reviewed 9-22-13, but only by the Infection Control Officer
? Medical Staff Bylaws - last reviewed 1-15-13, but only by the Board Chairman

The above was confirmed in an interview with staff #16 on the afternoon of 8-20-14.