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Based on observations, staff interviews and policy review the facility failed to employ methods to maintain monitoring and evaluation of infection prevention (asepsis) practices as evidenced by:
1. Expired medications and opened/undated medication available for administration to patient;
2. Opened and expired supplies available for use during patient care and treatment;
3. The inability to clean keyboards utilized in patient care areas;
4. Operating room attire worn in the general community areas of the hospital.

The findings included:

1. Observations conducted during the initial tour of the facility's Emergency Medicine Department (EMD), on September 6, 2011 from 12:30 p.m. through 2:10 p.m. revealed:
? The following multi-dose medication vials had not been dated after being opened and accessed: Lidocaine 1% and Xylocaine 2% 20 ml (milliliter);
? One multi-dose vial of 0.9% Sodium Chloride with an expiration date of 1 Aug (August) 2011.

An interview was conducted on September 6, 2011 at 12:50 p.m. with Staff #1, the EMD Manager, Staff #2, the EMD Director and Staff #3, the EMD Medical Director. Staff # 1 verified the date on the 0.9% Sodium Chloride as expired and verified the multi-dose vials of Lidocaine 1% and Xylocaine 2% had been opened/accessed but not dated. Staff #1 reported the medication should not be available for administration to patients and removed the vials from the South side EMD suture cart.

2. Observations conducted on September 6, 2011 of the suture carts and suture restocking cart revealed opened sutures, expired sutures and sutures with various expiration dates placed in boxes together.
? Three suture packs had been opened and were found in the suture drawer of the South side EMD suture cart.
? The South side EMD suture cart contained expired sutures with the expiration date marked on the boxes Chromic Gut-July 2007 (contained one); Chromic Gut-Jan 10 (six); Plain Gut-Jan 10 (eleven); and Vicryl Rapide-June 2011 (three). The cart had the following expired sutures loose in the drawer: Chromic Gut-Jan 09 (one); Chromic Gut-July 09 (two); Silk-July 2010 (one) and Silk-Jan 2010 (one). The cart had seven boxes of various sutures which had suture packs within with different expiration dates (I.e. 0 Silk box with an expiration date of July 2015 had two suture packs inside with an expiration date of July 2011).

An interview was conducted on September 6, 2011 at 1:28 p.m. with Staff #1 and Staff #2. Staff #1 verified the findings. Staff #1 reported the suture cart was stocked by resource staff (Staff #14).

An interview was conducted on September 6, 2011 at 1:40 p.m. with Staff #14 in the presence of Staff #1. Staff #14 stated "I'm responsible for restocking the supplies used here (EMD)." When asked how the restocking of the suture cart occurred, Staff #14 stated "When I see something is low I put a new box in the cart." Staff #14 stated "If a few are left in the old box I put them in front in the new box." Staff #14 reported he had assumed the EMD staff would pull from the front of the suture box.

? An observation was conducted of the North side EMD suture cart with Staff #1 and Staff #14. Staff #14 stated "I'm in the process of restocking the cart." The observation revealed: a box of Vicryl Rapide-Jan 2012 with a July 2009 suture pack inside; a "Grab all box" with the expiration date torn off, that contained 22 suture packs of which twelve had expired in July 2009 and two had expired in July 2011. Staff #1 verified the findings.

? An observation was conducted in the South Clean Holding room of the suture restocking cart with Staff #1 and Staff #14. The observation revealed: A box labeled 4-0 Silk with an expiration date of July 2011 contained four Ethibond excel sutures that had expired July 2010 and three PDS II sutures that had expired July 2011 the box did not contain any 4-0 Silk sutures. A box labeled 0-Silk with the expiration date of Jan 2009 contained eight sutures packs which had expired in Jan 2009 and one pack had expired in July 2011. Staff #1 verified the findings.


3. Observations conducted during the initial tour of the facility's Emergency Medicine Department (EMD), on September 6, 2011 from 12:39 p.m. to 12:52 p.m. With Staff #2, Staff #3 and Staff #4, the Assistant Vice President of Quality. The observation revealed computer keyboards used by staff during direct patient care in the Triage, South and North EMD areas did not have protective covers. The computer keyboards were open to potential contaminants and could not be disinfected.

An interview was conducted on September 6, 2011 at 12:50 p.m. with Staff #2, Staff #3 and Staff #4. When asked how the computer keyboards were disinfected between patients, Staff #2 reported the keyboards were disinfected with Cavicide wipes. When asked how areas between the keys were disinfected; Staff #2 did not supply a response. When questioned related to computer keyboard covers, Staff #3 stated "None of our keyboards have covers." Staff #2 reported the idea of cover would ensure disinfection of the keyboards between patients.





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4. On 9/7/11 at approximately 2:15 P.M. while in a common area that had an escalator in the center, doors that led to the outside of the building, cafeteria, gift shop and at least 2 hallways that led to various other areas of the hospital a person (Staff #8) was observed on the first floor in a scrub shirt and pants and a head covering walking from the vicinity of the outer doors down one of the hallways. Staff #8 did not have a cover jacket over the scrub shirt and pants.

Staff #8 was followed to a hallway where a door opening device was on the right wall and he pushed it to enter another hallway. Prior to entering he was stopped and asked where he was going. He stated, "Surgery" and proceeded through the door. He was followed into the ante-hallway of surgery. He stopped and changed his head covering. He was asked who he was and he stated, "(Name, if you have any other questions ask those women standing over there" and he pointed to the left of the hallway.

He walked away and was followed down a short hallway to another doorway with an electric door opening device. He entered the area. When the surveyor attempted to follow Staff #8 they were stopped and told they could not enter the area. When asked why the surveyor was told by Staff #10, "Because that is the surgery area and you must be wearing scrubs to enter there." Staff #10 was asked if a person wearing scrubs could come from anywhere and enter surgery. Staff #10 stated, "Yes, so long as you are wearing scrubs you can enter the surgery area."

A copy of the facility's policy titled 200: Operating Room Attire effective date September 2008 was provided by the staff and a review of the policy revealed the following:
1. Purpose: To provide recommended guidelines for attire worn within the semi-restricted and restricted areas of the Operating Room suite.
2. Supporting Data: "People are the major source of environmental contamination of the surgical suite."
3. Equipment: Scrub attire, disposable masks, head coverings, shoe covers and protective eyewear.
4. Definitions:
A. Restricted area: Includes operation rooms, procedure rooms, and the clean core area. Personnel wear masks, scrub attire and surgical head coverings i.e., operating rooms, clean core, procedure rooms
B. Semi-restricted area: Peripheral support areas including storage areas in the suite, work areas for storage/processing of instruments and the corridors to restricted area of OR suite. Personnel war scrub attire, surgical head coverings i.e., dirty core.
C. Unrestricted area: Where street clothes are permitted and traffic is not limited. i.e., pre-op and PACU areas.
5. Number 5 of the policy states, "Whenever visibly soiled or wet, operating room attire will be changed."