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Based on observation and staff interview, the facility failed to ensure detection and quarantine of outdated medications for 1 of 1 (Maternal Health Unit) areas toured.

Findings:

1. While on tour of the Maternal Health Unit on 8/29/13 at approximately 1130, accompanied by P2, the following was observed in Room 2221, the infant warmer locked drawer had an emergency medication kit for newborns with expired medications:
A. Naloxone HCI 0.4mg/ml, lot 02-186-EV, expired 2/1/13.
B. two 4.2% Sodium Bicarbonate, lot 96-030-DK, expired 12/1/12
C. two Epinephrine 0.1mg/ml, lot SI088K1, expired 4/13.

2. Personnel P2 was interviewed on 8/29/13 at approximately 1140 and confirmed the above-mentioned medications were expired and unusable.

Based on observation and staff interview, the facility failed to ensure no condition was created or maintained that may result in a hazard to patients and public due to unsecured needles in 1 of 1 (Maternal Health Unit) areas toured.

Findings:

1. While on tour of the Maternal Health Unit on 8/29/13 at approximately 1130, accompanied by P2, the following was observed in Room:
A. 2268 (triage room), unsecured 18 gauge (g), 20g, 22g needles, and a syringe with needle in a drawer, as well as glass microscope slides in an unopened box, and all are accessible to patients and visitors.
B. 2218, the drawer on the infant warmer containing needles was not locked.

2. Personnel P2 was interviewed on 8/29/13 at approximately 1140 and confirmed the above-mentioned needles and glass microscopes should be locked in a secure manner for patient or visitor safety.

Based on observation, policy and procedure review and personnel interview, the infection control officer failed to ensure policies were followed for cleaning of 3 of 4 rooms toured (patient rooms 2218, 2219 and triage room 2268) related to privacy curtains and furniture.

Findings:

1. a. While on tour of the Maternal Health Unit on 8/29/13 at approximately 1130, accompanied by P2, the following was observed in Room:
A. 2218, possible black marker spots on the privacy curtain.
B. 2219, possible dark grease marks and what appears to be faint reddish/orange droplet stains on the edge of the privacy curtain.
C. 2268 (triage room), faint reddish droplet mark on the privacy curtain and a bedside cabinet drawer that was unorganized and dusty with an empty straw wrapper.

2. Policy No.: ES-007, titled, "Cleaning of Discharged Rooms" revised/reapproved 10/7/11, was reviewed on 8/29/13 at approximately 1:00 PM, and indicated on pg. 2, points B., C., and E., "Visual Inspections: As you are cleaning the room, make visual inspections. In the event you find anything wrong, write a work order and turn into the administrative assistant...Work Order Visual Inspections: Wallpaper, shower curtain, floor/carpets, curtains soiled...Clean the Room: Check for soil on the drapes. Replace drapes if soiled."

3. Policy No.: ADM-IC-023, titled, "Exposure Control Plan/Standard (Universal) Precautions" revised/reapproved 3/31/10, was reviewed on 8/29/13 at approximately 1:00 PM, and indicated on pg. 6, under Housekeeping section, point A. 7., "Extraordinary attempts to disinfect or sterilize walls, floors, and other surfaces are not necessary. However, cleaning and removal of soil should be done routinely. Cleaning of walls, blinds, and curtains is recommended only if they are visibly soiled."

4. Personnel P2 was interviewed on 8/29/13 at approximately 1140 and confirmed children and visitors are given red juice when with patients and the privacy curtains in the above-mentioned rooms appeared to be soiled with either black marker or faint reddish/orange droplet marks. The bedside cabinet drawer also appeared dusty and unorganized.