HospitalInspections.org

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Based on observation and interview, the facility failed to ensure a safe environment for the provision of pharmaceutical services.

Findings include:

Observations during a tour of the Pharmaceutical Department on 2/17/22 at approximately 11:00 AM identified the following:

a) The air vent was blocked with multiple pieces of white paper stuffed inside of it preventing proper air exchange.

b) The emergency light was blocked by supplies stored above the recommended 18 inches from the ceiling. Specifically, these items included boxes of hypodermic needles, and sterile gauze pads.

c) The fire extinguisher was blocked by several boxes of intravenous (IV) fluids stored on the floor from the ground up that could prevent easy access to the fire extinguisher in a fire emergency.

These findings were confirmed by Staff A, Vice President and Chief Nursing Officer on 2/17/22 during the tour and with other facility leadership staff on 2/18/22 during the morning conference.
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Based on observation, and interview, the facility failed to maintain a clean and sanitary environment for the provision of pharmaceutical services.

These lapses in infection control practices may place patients at risk for harm.

Findings include:

1. During tour on 2/17/22 at approximately 10:45 AM the following was observed:

a) The clean storage room had personal belongings of staff. Specifically, three (3) coats, two (2) handbags, a coffee maker, and several disposable cups.

b) The shelves of a rolling storage cabinet in the clean storage room used for storing medications was laden with dust bunnies and grime. Some of the packaged medication stored on the dirty shelves were identified as being stored too close to the ground which can expose the items to dust and splash during cleaning.

c) The exterior of four (4) garbage bins were found to be dirty.

d) The exterior of the narcotics storage had multiple stains and discolorations.

e) clean supplies were stored on the counter directly beside the handwashing sink which could cause cross contamination of the clean supplies.

f) Multiple medication bins stored on the floor which could expose the items to dust and splashes from cleaning the floor.

g) The air conditioning system was blocked with boxes of computer paper, boxes of Personal Protective Equipment, and empty cardboard boxes. Some of these supplies were leaning directly on the air conditioning system.

h) Medication storage refrigerator (brand name-Victory) and its glass door had white and brown splash stains and there was thrash in the bottom of the refrigerator.

i) Multiple supplies stored directly under the sink. Specifically, N95 masks, gloves, gowns, two (2) bottles of cleaning agents, empty cardboard boxes which can cause contamination of the clean supplies.

At interview during tour of the Pharmacy on 2/17/22 at approximately 11:00 AM, Staff D, Supervising Pharmacist and covering Director, confirmed that nothing should be stored under the handwashing sink and stated: "The expectation is that staff use the break room for eating and store clothing in the lockers." Staff D was unaware of the requirement for storing articles beyond the 18 inches from the ceiling.

2. During tour in the IV medication preparation room on 2/18/22 at approximately 10:45 AM, the following was observed:

The counter adjacent to the hand washing sink was being used for medication preparation. Staff C, Pharmacy Tech, performed hand hygiene with the prepared IV medications laying on the side of the handwashing sink. She then reached across the prepared IV medication to access the hand towels for drying her hands, thereby exposing the medication to water splashes and contamination.

During interview a concurrent interview with Staff C at the time of observation, the Pharmacy Tech stated: "That is how I always do it."

During interview on 2/18/22 at 11:42 AM, Staff B, Director of Infection Prevention and Control stated: "I tour the pharmacy once every two (2) to three (3) weeks. I had no findings"

These findings were shared with Staff A, VP and Chief Nursing Officer on 2/18/22 and with facility staff during exit conference on 2/22/22.