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Based on wound clinic tour, interview and review of policies it was determined that the disinfectant solution (Silcraft Disinfectant) used to disinfect the whirlpool, was in a plastic container mislabeled " 3-M Glass Cleaner " . The label on the plastic container did not provide MDS (Material Data Safety) information for the substance in the plastic container (Silcraft Disinfectant) in the event of eye or skin contact with the substance. The mixture for and precautions for Silcraft Disinfectant to meet the Material Data Safety Sheet was compromised when mixed into the plastic container that previously held the 3M glass cleaner. No information on safety by the Silcraft Disinfectant Material Data Safety Sheet was available on the container used.

The findings include:

1. On March 2, 2011 a tour was conducted through the hospital based wound clinic. The wound clinic has whirlpool wound procedures conducted when physician ordered. The whirlpool system and devices are cleaned between patients with Silcraft Disinfectant.

2. On March 2, 2011 an interview was conducted with a Wound Care Technician in the wound clinic. The Wound Care Technician explained that the whirlpool device is cleaned between patient use with Silcraft Disinfectant. The Wound Care Technician showed the surveyor a plastic bottle used to mix the Silcraft Disinfectant into for cleaning use. The plastic bottle was labeled as 3M glass cleaner. The Wound Care Technician stated that no other delivery system was used for mixing the Silcraft Disinfectant.

On March 2, 2011 an interview was conducted with the Director of the Wound Clinic (RN) in the wound clinic. The Director of the Wound Clinic confirmed that that the Silcraft Disinfectant was mixed into a plastic container labeled with previous chemical known as 3M glass cleaner.

3. A review of the Material Data Safety Sheet for the 3M glass cleaner contained the following content: "Ingredients: Water, Isobutane and 2-Butoxyethanol. Section:Hazards Identification: Aerosol, foamy white, slight ammonia-like odor, liquid and Immediate health, physical and environmental hazards: Aerosol container contains gas under pressure. The Material Data Sheet contained precaution and how to handle exposure's to eyes/face, skin, respiratory and swallowing related to 3M glass cleaner.

A review of the Material Data Safety Sheet for the Silcraft Disinfectant contained the following content:Alkyl (C14-50%, C12-40%, C16-10%), Dimethyl Benzyl, Ammonia Chloride. First Aide Measures list the info for exposure to eyes/skin, Under section: Reactivity Data: Materials to avoid: Avoid mixing with an other cleaning product. The Material Data Sheet contained precaution and how to handle exposure's to eyes/face, skin, respiratory and swallowing for Silcraft Disinfectant.

The mixture for and precautions for Silcraft Disinfectant to meet the Material Data Safety Sheet was compromised when mixed into the plastic container that previously held the 3M glass cleaner. No information on safety by the Silcraft Disinfectant Material Data Safety Sheet was available on the container used.

The Medical Staff failed to ensure that practicing physicians complied with state laws and regulations. One physician placed two (2) dated and signed blank prescriptions on a patient's medical record (Patient #6). The prescriptions were not only signed, but were not in control of the physician and were available to persons who do not have authorized access. Both of which are violations of state law.

The Findings Include:

On 3/2/11 during the review of an open medical record two (2) physician signed and dated blank prescriptions were observed. The physician was interviewed regarding this practice and he stated, "I know that is wrong. That is not my usual practice. I usually date and sign the prescription and have my PA (Physician's Assistant) fill out the rest of the script." "I don't know why those are filled out."

The Director of Regulatory Compliance provided a copy of the facility's Medical Staff Bylaws which was reviewed on 3/2 and 3/11. The Director of Regulatory Compliance stated, "We do not have a policy related to physician writing prescriptions and there is nothing in the Medical Staff Bylaws related to prescription writing."

The Code of Virginia, Title 54.1 Professions and Occupations, Chapter 34 Drug Control Act documents the following.

§ 54.1-3408.01. Requirements for prescriptions.
A. The written prescription referred to in § 54.1-3408 shall be written with ink or individually typed or printed. The prescription shall contain the name, address, and telephone number of the prescriber. A prescription for a controlled substance other than one controlled in Schedule VI shall also contain the federal controlled substances registration number assigned to the prescriber. The prescriber's information shall be either preprinted upon the prescription blank, electronically printed, typewritten, rubber stamped, or printed by hand.
The written prescription shall contain the first and last name of the patient for whom the drug is prescribed. The address of the patient shall either be placed upon the written prescription by the prescriber or his agent, or by the dispenser of the prescription. If not otherwise prohibited by law, the dispenser may record the address of the patient in an electronic prescription dispensing record for that patient in lieu of recording it on the prescription. Each written prescription shall be dated as of, and signed by the prescriber on, the day when issued. The prescription may be prepared by an agent for the prescriber's signature.
This section shall not prohibit a prescriber from using preprinted prescriptions for drugs classified in Schedule VI if all requirements concerning dates, signatures, and other information specified above are otherwise fulfilled.
No written prescription order form shall include more than one prescription.

Based on observation and staff interviews the facility failed to ensure that medications available for administration to patients were not expired.
The findings include:
An observation was conducted on 03/02/2011 at 12:43 p.m. with Staff #2; Operation Room (OR) Manager and Staff # 3, Anesthesiology Technician. An observation and review of the mediations within t OR #9 ' s anesthesiology cart. The observation revealed:
· One box labeled " Furosemide 100 mg [milligrams] 10 mg/ml [milliliter] 10 ml vial single dose for IM [intramuscular] IV [intravenous] use. " The box had a handwritten notation which read " 2/1/11 " . The manufacturer ' s expiration date was " 1Feb 2011 " . [Furosemide is a medication that can be used to manage hypertension and edema.]
· An opened bottle labeled " Ultane (Sevoflurane) " had not been dated when opened. The opened medication did not have a sticker as to how long the medication was good after it had been opened. [Sevoflurane is a volatile liquid used for inhalation anesthesia, administered by vaporization.]
An interview was conducted on 03/02/2011 at 12:43 p.m. with Staff #2 and Staff #3. Staff #2 read the date on the Furosemide and stated, " That ' s expired. " Staff #3 stated, " I ' m responsible for stocking the anesthesia carts. I missed it. That ' s my notation on the box. " A request was made for the hospital ' s policy related to expired medications and safeguards to prevent administration to patients.
An interview was conducted on 03/02/2011 with Staff #1, the Director of Regulatory . Staff #1 reported the hospital did not have a specific policy related to expired medications. Staff # 1reported the incident of the expired medication and the opened undated medication had been discussed with pharmacy and anesthesiology. Staff #1 stated, " The expired medication should have been removed from service by the expiration date. The anesthesia gas (Sevoflurane) was reviewed by Pharmacy. The package insert indicated it has no additives. We will have to determine how long it will be kept after it has been opened. It (Sevoflurane) should have been dated. "

Based on a Life Safety Code Validation survey, completed 3/3/11, the Condition of Physical Environment is not met. Those deficient practices and the associated regulations can be found in the respective Life Safety Code survey (C05W21).

The facility staff failed to ensure an air gap was maintained in the ice machine in the Emergency Department and in the kitchen.

The Findings Include:

On 3/1/11 during the initial tour of the Emergency Department (ED) with the Vice President of Emergency Services and the Chief Operations Officer (COO) the ice machine was observed. The COO stated, "The ice machine is about a year old. The old was one was pretty bad."

The ice machine sat on top of a cabinet with a plastic type drain hose going through the top of the cabinet to the inside of the cabinet. The bottom part of the cabinet was divided into 2 sections with each section having 2 doors covering each section. The plastic drain hose entered the first section of the cabinet covered by 2 doors. Approximately 6 inches of the plastic drain hose was inside a PVC pipe . The PVC pipe went through the side of the first section of the cabinet and entered the second section of the cabinet. The PVC pipe then exited through the back of the cabinet into the facility's sewage pipes.

The facility's Director of Engineering was asked if the drain had an air gap. He stated, "I don't know I will have to have one of my staff that is familiar with plumbing see this and let me know." A member of the Engineering staff arrived and pulled the plastic drain from the ice machine out of the PVC pipe and a blackish slime dropped off the end of the drain. The member of the Engineering staff stated,"Yes, the drain has an air gap because the PVC pipe the drain goes into is not closed."

The second cabinet appeared to have what was mold inside the cabinet.

The facility's ice machine in the kitchen was observed on 3/1/11 with the COO present. The drain from the ice machine entered the floor drain. The COO stated, "I know it doesn't have an air gap. The Dietary Manager stated, "I the pipes don't touch the floor drain. I don't think they have to be above the floor because the water would pour over onto the floor."

Virginia State regulation 12 VAC 5-421-2200 states:
"An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall at least be twice the diameter of the water supply inlet and may not be less than 1 inch (25 mm)"

Virginia State Regulation 12 VAC 5-421-2260 states: "A plumbing system shall be installed to preclude back flow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the food establishment, including on a hose bib (threaded faucet) if a hose is attached or on a hose bib if a hose is not attached and back flow prevention is required by law " .

The facility staff failed to maintain a sanitary environment in the Emergency Department (ED), the kitchen and the clean linen storage area. The ED was observed on 3/1/11 to have dirt and debris in the corridor and the patient care rooms and doorways. The facility also failed to keep clean linen free form dirt and debris.

The kitchen area was observed on 3/1/11 to have opened and accessed bags and boxes of items used in the preparation of meals for patients and staff that were left open and unlabeled as to when opened. The bins used to store opened bags of flour, sugar and other perishable items was observed to have water inside the bins. The flour bin had a bag of flour with a scoop with the handle inside the bag. There were pans stored upside down wet. There were pipes draining from the sink held in place with zip ties and draining on the floor rather than the drain. There was standing water under the sink. A trash can with dirty mop heads was observed next to the clean dishes on the racks for drying.

The clean linen holding area was observed to have torn and or no cover over the clean linen. The linen was observed being moved by and employee who was holding the clean linen next to his body.

The Findings Include:

The ED was observed on 3/1/11 with the Vice President of Emergency Services (VPES) and the Chief Operating Officer (COO) present. The floors of the corridors and rooms (where patients were receiving care) and the door ways were observed to have dirt and debris along the walls. The VPES stated, "We have had cut backs and no longer have a designated housekeeping staff member in the ED on all shifts." "We have a person designated during the day shift but on the other 2 shifts someone is assigned they are not designated." "We saw approximately 45,000 people in this ED last year. With that much traffic it is hard to keep up."

The kitchen was observed on 3/1/11 with the Dietary Manager and the COO present. The dry storage area contained a 50 pound bag of opened bread crumbs that was also not dated as to when it was opened. A opened box of spaghetti that also did not have a date as to when it was opened. While observing the dry storage area a staff member came into the area and picked up a container of olive oil. The lid dropped off onto the shelf. The dietary manager stated, "The bag should be in a clear container with a lid and the spaghetti should have been re-wrapped and dated." "The olive oil should have had the lid securely on the top of the bottle."

Under one of the preparation tables 3 closed bins were observed. The bin nearest to the dry storage room contained a open 50 pound bag of sugar which was sitting in water on the bottom of the bin and water droplets on inside of the lid. The second bin contained an opened 50 pound bag of flour sitting in water on the bottom of the bin and water droplets on the inside of the lid. Also inside the bag was a long handled scoop with the handle of the scoop inside the bag. The third bin also had water in the bottom of the bin. The third bin contained several different items such as biscuit mix, pancake mix, bread crumbs and several other items. The pancake mix and biscuit mix were open. The Dietary Manager stated, "They just washed out the inside of the bins and forgot to dry them."

The sink area was observed to have 3-4 pipes running under the sink for 4-6 feet that ended up zip tied together and draining onto the floor. There was a drain near where the pipes ended. The pipes were not over the drain. Also under the sink area an old unused grease trap was observed to have a hole in the floor next to it where the Dietary Manager stated, "the floor eroded away." Another grease trap was observed to have standing grease over the top. The Dietary Manager stated, "We don't use those traps anymore."

In the area where the serving pans were stored ready for use 4-5 pans were observed to stored upside down and wet inside. The Dietary Manager stated, "They should have been left out to air dry."

The clean linen area was observed on 3/1/11 with the Director of Nursing (DON). The clean linen was stored on shelves with vinyl covers which were torn and hanging off in several areas. One shelf had a plastic bag such as seen in covering dry cleaning covering the shelf. The bag had several large tears. One shelf had a blanket lying across the top of the clean linen but the sides were exposed. During this observation one employee was observed moving linen from the bin where the clean linen had been delivered to another bin used to transport the linen to the patient care areas. The employee picked the linen out of the bin held it next to his person and carried it to the bin for transport.

The laundry employee was asked if the clothes he had on were the clothes he wore to and from work and he stated, "Yes."

The DON stated, "I was taught in nursing school to not let the linen touch our uniforms."