HospitalInspections.org

Based on observation and interview, the facility failed to ensure patient rooms were maintained in a good state of repair as evidence by damaged walls and floors. The failed practice had the potential to affect the health and safety of all patients, staff and visitors. The findings follow:

Tour of the Senior Care Unit was conducted on 08/28/12 at 0900 with the Program Director and Nurse Manager. The following was observed and confirmed at the time of observation by the Nurse Manager:
1) Patient Room #30 unoccupied and identified by the Nurse Manager as clean and ready for patient occupancy revealed the floor contained a buildup of dirt, the wall air unit contained stains of a dark brown unknown substance with peeling paint and rust.
2) Patient Room #37 occupied revealed broken floor tiles and the flooring underneath the toilet contained a buildup of dirt and grime.
3) Patient Room #40 occupied revealed broken floor tiles and the flooring underneath the toilet contained a buildup of dirt and grime. The wall air unit contained peeling paint, stains of an unknown dark brown substance and rust.
4) Patient Room #41 unoccupied revealed broken floor tiles; the flooring underneath the toilet contained a buildup of dirt and grime. The wall air unit contained peeling paint, stains of an unknown dark brown substance and rust. A section of wall was damaged with peeling paint. The sink in the bathroom was stained with rust.

Based on observation and interview, it was determined the facility failed to follow their "Oral Medication" policy in that three of three Mortar Pestles (manual pill crusher) contained a white chalky residue. The failure to clean the manual pill crusher between the crushing of patient's medications created the potential for adverse drug reactions between patients who required medications to be crushed. The failed practice had the potential to affect any patient who required medications to be crushed. The findings follow:

A. Review of the "Oral Medications" policy on 08/28/12 at 1030 revealed "...The pill crusher is to be cleansed after each use with soap and water."

B. Tour of the medication room on 08/28/12 at 0900 revealed three of three Mortar Pestles contained a white chalky residue. Licensed Practical Nurse #1 confirmed at the time of observation through interview the residue was from previous crushed medications.



Based on observation, review of the policy and procedure "Proper Use of Multi-Dose Vials" and interview, it was determined the facility failed to follow the policy in that opened multi-dosed vials (MDV) did not contain a date or initials when the vials were opened. Without a date of discard of MDVs, it could not be assured the vials were within the time frame allotted to ensure the efficacy of the medication and created the potential for patients to receive outdated medication. The failed practice had the potential to affect any patient who was administered medications from a MDV. The findings follow:

A. Tour of the Senior Care Unit was conducted on 08/28/12 at 0900 with the Program Director and Nurse Manager. The following was observed and confirmed at the time of observation by the Nurse Manager:
1) Lovenox 300 milligram (mg)/milliliter (ml) 3 ml vial revealed opened and no evidence of a date and initials by staff as per facility policy; and
2) Three of three Lidocaine HCL 1% injection 10 ml MDV opened and no evidence of a date and initials by staff as per facility policy.

B. Review of the "Proper Use of Multi-Dose Vials" policy on 08/28/12 at 1000 revealed "When a multi-dose vial of medication is opened, you are to date and initial the vial. The vial will be good after opening until the date the Manufacturer has on the bottle or for 30 days."

C. The Nurse Manager confirmed the findings in an interview on 08/28/12 at 0930.



Based on policy and procedure review, review of the United States Pharmacopeia (USP) documents and interview, it was determined the facility failed to ensure medications from Multiple Dose Vials (MDV) were not made available for patient use beyond 28 days once opened. The failure to dispose of MDVs within the current allotted time frame did not ensure the efficacy of the medication and created the potential for patients to receive expired medications. The failed practice had the potential to affect any patient who was administered Lovenox 300 milligram (mg)/milliliter (ml) 3 ml vial and Lidocaine HCL 1% injection 10 ml vial. The findings follow:

Review of the "Proper Use of Multi-Dose Vials" policy on 08/28/12 at 1000 revealed "When a multi-dose vial of medication is opened, you are to date and initial the vial. The vial will be good after opening until the date the Manufacturer has on the bottle or for 30 days." The facility policy did not reflect current acceptable practice of a 28 day expiration date as per the United States Pharmacopeia documents. Finding confirmed by the Director of Nursing.