HospitalInspections.org

Based on observation, interview and policy and procedure review the facility failed to ensure that outdated medication was not available for patient use. Findings include:
During a tour of the NICU on 12/3/12 at approximately 1515 it was found that the pediatric crash cart medication box had expired 12/1/12.
These findings were confirmed by staff I confirmed this finding. When staff I was asked who was responsible for the maintenance of the medication box she said it was pharmacy.
During policy and procedure review on 12/6/12 at approximately 0930 it was found in the policy titled, "Drug Control and Storage", it states, "Pharmaceuticals stored at patient care areas shall be monitored for appropriate "control" by personnel working in that area (e.g. nursing staff). "Control" includes the following: · Items are approved for floor stock
· Within expiration date (with the exception of medications sequestered in automatic dispensing cabinets (ADC) which are checked by Pharmacy staff), and "The integrity of the convenience box/tray and expiration date shall be under control of and checked by the designated unit/department staff at least every month for outdates and secure storage".

The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See A-709.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated December 7, 2012 for Life Safety Code.

Based on observation, interview and policy and procedure review the facility failed to, maintain a sanitary environment, resulting in the potential for the spread of infectious agents to patients. Findings include:

During the facility tour and inside the operating suite on the second floor of the facility; rusty casters for various equipment's as well as multiple on casters (wheels) stainless steel carts base and equipment exhibited rust all around vertical edges and to the bottom frame leading to unsanitary and unsafe environment. A potential for infectious diease's spread.


29313

Based on observation, interview and policy and procedure review the facility failed to ensure that supplies are maintained at an acceptable level of safety and quality. Findings include:
During observational tour of the neonatal intensive care unit (NICU) on 12/3/12 at approximately 1510 it was found that the following supplies from the NICU crash cart were expired:
1. Four 3.5 pediatric endotracheal tubes (ET) were expired. Three expired on 12/11 and one on 11/12
2. One 2.5 pediatric ET had expired on 6/09
3. One 3.0 pediatric ET had expired on 11/11
4. One pediatric Carbon dioxide detector had expired on 9/28/11
5. One pediatric umbilical catheter had expired on 10/12
6. One blood collection set had expired on 7/11
7. Eight 5 milliliter tubes of sterile 0.9 normal saline inhalation solution had expired on 3/11
These findings were observed and confirmed by staff I, when asked whom was responsible for checking for expired supplies she said the nursing staff.
During policy and procedure review on 12/6/12 at approximately 0900 it was found in the policy titled, "Stocked Supplies with Expiration Dates", states, "All expired products will be removed from inventory...".

In addition to the above items note and based on observation, interview and policy and procedure review the facility failed to, maintain a sanitary environment, resulting in the potential for the spread of infectious agents to patients. Findings include:

High dusting, dirt, lint's, and grime collections were noticeable during the tour of the facility on 12/3/2012;

1. On top of the sloped top at the nurses' station of the 6th floor east, top of the refrigerator serving the pantry room of the 6th floor, and at patient room A6524 on top of the blanket warmer;

2. In Cath Lab Room #4, on top shelves for supply cabinets, on the lead shield glass and hood, and on the typical slopped top in that room;

3. Wall between control room and Cath Lab #4 exhibited damage leading to un-smooth/un-cleanable surface;

4. Chipped base for portable surgical light in clean equipment room serving the Cath Labs. These portable surgical light are used in Cath Lab cases;

5. Tape is widely used on equipment and wall. When tap removed it leaves un-cleanable or very hard to clean surface which leads to dirt collection and unsanitary and infectious environment;

6. Dust, grime, and dirt collection are noticeable in fourth floor (4A) medication next to the refrigerator, on base cabinet, and other high surfaces;

7. On top of the blanket warmer in storage room on 3A east and on top of blanket warmer in PACU across from PACU Station #19 on the second floor, surgery suite;

8. Open and un-dated single serving milk in the refrigerator in pantry room serving B-2 ICU. Single serving milk must be used in whole and must not be left open and not dated. It is a potential health hazard; and

9. Cleaning/bathing skin prep for pre-operative patient items with warmer were located in-touch with the sharp collector bin across from room B 2209 serving B-2, ICU patients. This current condition will promote the spread of infectious diseases'.


29313

Based on observation, interview and policy and procedure review the facility failed to, maintain a sanitary environment, resulting in the potential for the spread of infectious agents to patients. Findings include:
During the observational tour on 12/3/12 at approximately 1300 the following was found in the Emergency Department:
1. Patient equipment was being stored next to the sink in a splash zone
2. The ice machine in the central area was dirty with white scale build up
3. The microwave oven in the central area was dirty with debris and dried on food particles
4. The ice machine in the ambulance area was dirty with white scale build up
The findings were confirmed at the time of observation by staff J
During the observational tour on 12/4/12 during the hours of 0830-1130 the following was found:
Rehabilitation:
1. The refrigerator was dirty with food particles, dried up liquid and other debris
2. The coffee maker had burnt coffee on the burner and build up of a black substance around the lip of the top burner
3. The drawers had debris and food particles in them
4. The front of the cupboards had dried on liquid substance and visible finger prints
These observations were confirmed by staff O at the time of the finding
Orthopedics:
1. The coffee maker had burnt coffee on the burner and build up of a black substance around the lip of the top burner
2. The drawers had debris and food particles in them
These observations were confirmed by staff R at the time of the finding
Oncology:
1. The coffee maker had burnt coffee on the burner and build up of a black substance around the lip of the top burner
2. The drawers had debris and food particles in them
These observations were confirmed by staff T at the time of the finding
During policy and procedure review on 12/6/12 at approximately 0930 the policy titled, "Unit Pantries", states, "The sanitation of the refrigerators is the responsibility of Environmental Services on a biannual rotation. Nursing units/departments are responsible for the day-to-day cleaning and monthly disinfecting according to the established schedule". The maintenance schedule for ice machine cleaning states that the dispensing tubes are to be cleaned monthly, filters changed monthly and complete cleaning semi-annually.