HospitalInspections.org

Based on observation, interview and policy review, the facility does not ensure outdated, mislabeled or otherwise unusable drugs and biologicals are not available for use. This practice potentially places patients at risk of receiving ineffective treatment.

Findings include:

Observation on 12/05/16 at 10:15AM in the Acute Faith 5th unit medication room revealed one (1) bottle of Airlife Sterile water 500 ml that expired 07/2016, two (2) bottles of 0.9% sodium chloride 250 ml that expired 11/2016, four (4) bottles of sodium chloride 10 ml that expired 10/1/16 and one (1) opened bottle Hydrogen Peroxide 16oz with no date of opening or discard date. Interview with Staff #3 verified these findings at the time of observation.

Review on 12/05/16 of policy # VIII-19 " Pharmacy Services " last revised 08/2012 indicates medications whose shelf life has expired or are no longer in use shall be disposed of or destroyed. The facility shall label drugs in accordance with the appropriate accessory and cautionary instructions and the expiration date.

Based on observation and interview the facility does not ensure the hospital environment is maintained and free from hazards in all areas of the building.
Findings include:
Observation on 12/06/2016 at 10:00AM in boiler room (sterilizer equipment room) there was a cardboard box on the floor, with many smaller boxes in it. The boxes had evidence of water damage with green mold on them. Interview with Staff #11 indicates the boxes were Steris machine parts.
Observation on 12/05/2016 at 01:30PM outside of the hospital at the south entrance there was a large area of water pooling at the sidewalk leading to the entrance. Interview with Staff #12 indicated that the road was recently repaved causing the water to pool.
Interview on 12/06/16 at 10:00AM with Staff #12 verified these findings.

Based on observation, policy review and interview, the facility does not maintain supplies, the physical plant and components of the medical gas system to ensure an acceptable level of safety and quality.

Findings Include:

Observation on 12/05/16 at 10:45AM with Staff #3 on Acute Faith 5th unit revealed two (2) AED pad packets that expired 10/2016.

Review on 12/05/16 of the manufacturer manual " HeartStart FR3 Defibrillator Guide to Setup, Operation, and Maintenance " indicates to replace any expired supplies and accessories.

Interview on 12/06/16 at 03:40PM with Staff #1 verified this finding.


Observation on 12/05/2016 at 2:00PM in room FA5 CO3 revealed three ceiling tiles that were water stained. Two of those tiles had large areas of staining. Above the ceiling there was evidence of a non-active leak due to many paint chips on the back side of the ceiling tiles.
Observation on 12/06/2016 at 10:00AM in the boiler room (sterilizer equipment room) revealed the ceiling housed an electrical junction box with many wires that did not have a cover on it.
Interview on 12/06/16 at 01:30PM with Staff #12 verified these findings.

Observation on 12/06/2016 at 11:00AM revealed a zone valve shutoff box with two gas shutoffs, one labeled "air" and the other labeled "vacuum". The zone valve shutoff box was on the wall adjacent to the Ophthalmology room located in the dental suite. Interview with Staff #12 revealed the zone valve shutoff box was no longer in use, however, there was nothing to indicate it was not in service.

Based on observation, interview and policy review, the facility does not ensure temperature monitoring of the medication refrigerator. Failure to maintain temperatures could adversely effect the medications.

Findings:

Observation on 12/06/16 at 10:30AM of the Acute Faith 5th unit medication refrigerator revealed no temperature log for that refrigerator. The refrigerator contained Two (2)boxes of Acephen 325 mg, two (2) boxes of Acephen 650 mg, two (2) boxes of Biscolax 10 mg and one (1) Tubersol 1 ml vial. Interview with Staff #3 verified the findings at the time of observation.

Review on 12/06/16 of policy #1400 " Storage of Medication " last revised 05/07/14 indicates medication storage conditions are monitored on a monthly basis.

Based on medical record review, document review and interview, the facility does not provide organ procurement and donation, as evident in 3 of 3 patients deaths (Patient # 4, 7, 21). Failure to provide this service could prevent transplantation of viable organs/tissues to potential recipients.

Findings include:

Review on 12/07/16 of medical records for Patient # 4, 7 and 21 revealed no evidence that the Organ Procurement Organization (OPO) was notified of the patient's death.

Review on 12/07/016 of policy # VII-57 "Donation of Organs and Tissues" last revised 4/15 indicates that the facility would determine if organs were clinically unsuitable for transplant. In special circumstances, organs may be donated at the time of cardiopulmonary death if the OPO has been notified.

Review on 12/07/16 of the Finger Lakes Donor Recovery Network (OPO) contract revealed it has not been updated, reviewed or renewed since 2002.

Interview on 12/07/16 at 11:00AM with Staff #2 verified these findings.