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Based on observation and interview on the afternoon of 6/22/15, it was determined that the facility failed to remove expired supplies in the Emergency Room #1 and in the emergency cart.

Findings were:

Hospital policy "Supply Rotation" states in part, "All items maintained in inventory will be rotated by materials management on a first-in-first-out (filo) basis to prevent stock from deterioration or expiration."

Tour of the Emergency Department on 6/22/15 revealed the following expired supplies:

· X 3 Aquacel Sterile Dressings expired on 05/2014.
· Foley Catheterization Tray expired on 11/2014
· 3.0 Trach Tube cuffed expired on 04/2015

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In an interview with staff member # 2 on 6/22/15, the above expired emergency supplies were confirmed. These expired supplies potentially were compromised or deteriorated, presenting a safety risk to patients.

Based on observation and interview, it was determined that the physical plant was not maintained to ensure the safety of its staff and patients.

Findings were:

Facility based policy entitled, "Cleaning Emergency Department" stated in part, "Damp dust counters, furniture, telephone and receivers, etc., with the hospital-approved germicidal solution."
Facility based policy entitled, "Cleaning Light Fixtures" stated in part, "Remove all dirt from the outside of the light fixture with the damp cleaning cloth ...Wipe the inside of the cover or shade and then dry carefully."

During tours of the facility on 06/22/15 and 06/23/15 the following infection control issues were noted:

* In the Pharmacy the medication storage refrigerator had 8 missing temperature checks this month. Failure to monitor temperatures correctly could compromise the integrity of medications.
* In the Emergency Room #1 dust was observed on high horizontal surfaces and at the foot of the hospital bed, indicating ineffective cleaning.
* In the Emergency Room #2 the air vent in the bathroom was dirty, with visible dust present, indicating ineffective cleaning. The bottom of shower door was visibly dirty with soap film visible.
* In the Emergency Room #3 the air vent in the bathroom was dirty, with visible dust present, indicating ineffective cleaning
* In the supply closet of the Emergency Department, a hole was observed in the wall tiling approximately half an inch in circumference and a crack in the tile around a non-functioning faucet handle. The hole in the tile could provide an entry point for pests and contaminates.
* In the radiology area there were 2 foam pillow wrapped in pillowcases, secured with tape. These pillows cannot be effectively cleaned between patients. Several floor tiles in x-ray room had a dark stick substance on the edges, preventing effective cleaning of the floors.
* Dead insects were observed in the light fixtures in the computed tomography (CT) room.
* In the medication room of the inpatient hall, two pieces of yellow tape were observed on the counter. Tape cannot be cleaned effectively increasing the risk for contamination.
* In the kitchen an open, non-functioning duct was observed in the ceiling near a food storage area. This open ductwork could provide an entry point for pests and contaminates.
* In the dry storage area for the kitchen, external shipping boxes were noted storing cup lids. External shipping boxes present a risk of introducing outside contaminates such as dirt, debris, and pests.
* Dead insects were observed in the light fixtures in the physical therapy area.

The above findings were confirmed with staff member # 1 and 2 on 06/22/15 and 06/23/15.


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Based on observation and interview of staff on the afternoon of 06/22/2015, the facility failed to maintain a safe environment for patients in the Radiology Department.

Findings were:

The hospital's "Patient Rights Policy" states in part, "#13 Reasonable personal and environmental safety".

Tour of the Radiology Department revealed the following.

· The patient bathroom in X-RAY room did not have an emergency call system.
· The patient bathroom in the Magnetic Resonance Imaging area did not have an emergency call system.

In an interview the staff member #2 on 6/22/15, they acknowledged the lack of safety equipment in the bathrooms. It is of concern that the missing emergency call equipment posed a safety risk to patients.