HospitalInspections.org

Based on observation, interview and review of the facility's policy, it was determined the facility failed to ensure expired medications were not available for patient use.

The findings include:

Review of the facility's policy, titled "Beyond-use Dates" (dated 09/03), revealed expired drugs and devices should not be made available for patient use.

Observation, on 08/23/12 at 9:55 AM, of the Respiratory Stock Room revealed three (3) one (1) liter bags of Sterile Water, used for inhalation purposes, were on the stockroom shelf. These bags had an expiration date of June 2012.

Interview, on 08/23/12 at 10:00 AM, with the Respiratory Department Manager, revealed the three (3) bags of Sterile Water should not have been on the shelf for patient use.

Observation, on 08/23/12 at 10:20 AM, of the Pediatric Respiratory Code Box on the Medical and Surgical floor revealed one (1) tube of Xylocaine with an expiration date of June 2012.

Interview, on 08/24/12 at 10:20 AM, with the Director of the Medical and Surgical Unit, revealed the medication should not have been available for patient use. Further interview revealed the Respiratory Department was responsible for ensuring the respiratory boxes contain no expired medications.

Interview, on 08/24/12 at 1:45 PM, with the Director of Infection Control, revealed the three (3) bags of Sterile Water and the Xylocaine should not have been available for patient use. Interview further revealed the facility utilized the "first in, first out" theory and the date of expiration should have been highlighted and removed from stock prior to the date of expiration.

Based on observation, interview and review of the facility's policy, it was determined the facility failed to maintain a clean and sanitary environment to prevent and control infections.

The findings include:

Review of the facility's policy titled, "Cleaning patient Room after Discharge", dated 01/00, revealed all patient rooms would be cleaned when a patient had been discharged or transferred.

Observation of patient room #225 (patient ready room), on 08/23/12 at 10:45 AM, revealed a straw was on the floor behind a chair, the floor appeared unswept with white paper-like debris, a piece of dry cereal and a penny were on the floor under the bed, the toilet in the bathroom was unflushed and contained toilet paper, there was a brown ring on the floor around the toilet, and hair was observed in the sink.

Interview, on 08/23/12 at 10:45 AM, with the Director of the Obstetrics Unit revealed room #225 had been cleaned and ready for patient use.

Interview, on 08/23/12 at 10:50 AM, with the Administrator revealed he was unsure if the room had been swept. Interview further revealed the Administrator stated that the patient room and bathroom appeared it had not been cleaned appropriately per the facility's policy.

Observation, on 08/23/12 at 10:40 AM, revealed an industrial fan was on the floor of an occupied semi-private patient room (room 232). The industrial fan was in patient area #1, blowing across the patient in bed #1 and on the patient in bed #2.

Interview, on 08/23/12 at 10:40 AM, with the Chief Nursing Officer revealed the industrial fan blowing across one patient area into another patient area would be a potential infection control issue.

Interview, on 08/24/12 at 1:45 PM, with the Director of Infection Control revealed the industrial fans forcefully blowing air across patient areas would be a potential source of cross contamination and a potential infection control issue. Interview further revealed the fans were used to dry the floors of the patient rooms and were not decontaminated between patient rooms.