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Based on observation and interview, it was determined the facility did not meet Life Safety Code requirements related to fire drills, inspection of the fire alarm system, inspection of the sprinkler system, and inspection of the kitchen hood fire suppression system. The failed practice had the potential to affect three of three patients (one inpatient, one observation patient and one outpatient) in the facility on the first day of the survey and all staff, visitors, and patients admitted to the facility. Failure to conduct fire drills had the potential to affect the safety of all building occupants because the effectiveness of the fire plan and staff training in the event of a fire event could not be evaluated. Failure to inspect the fire alarm system had the potential to affect the health and safety of all building occupants because the function and reliability of all fire alarm system devices could not be assured. Failure to inspect the sprinkler system had the potential to affect the health and safety of all building occupants because the function and reliability of the sprinkler system could not be assured. Failure to inspection the kitchen hood fire suppression system had the potential to affect the health and safety of staff, visitors and patients because the ability of the fire suppression system to extinguish a fire under the kitchen hood could not be assured. See CMS 2567 K50, K52, K62, and K69.

Based on observation and interview, the facility failed to ensure outdated medications were not available for patient use in three (Surgery, Medical/Surgical Unit, Emergency Department) of four (Surgery, Medical/Surgical Unit, Emergency Department, Post Anesthesia Care Unit) nursing areas. The potential existed for the average daily inpatient census of 4 patients, average monthly surgery census of 12 patients, and average daily census of 8.3 Emergency Department patients to receive outdated medications. Findings follow:

A. Tour of Surgery, Post Anesthesia Care Unit, and the Medical/Surgical Unit was conducted on 05/25/11 between 1400 and 1530. The following outdated medications were observed:
1) Surgery (Anesthesia Cart)
a) Two ampules of Dihydroergotamine Mesylate 1 Milligram (mg)/milliliter(ml) expired 03/11; and
b) Thirty-six vials of Dantrium expired 03/11.
2)Medical/Surgical Unit
a) One pint of Carafate 1 gram(gm)/10 ml expired 02/11;
b) One pint of Geri-Tonic expired 04/11;
c) One half pint Nystatin Oral Suspension expired 04/11;
d) One ampule Metoprolol Tartrate 5 mg/5 ml expired 01/11; and
e) One Byetta 5 micrograms (mcg) expired 04/11.
B. Tour of the Emergency Department was conducted on 05/26/11 at 0845. The following outdated medications were observed:
1) Two Aminophylline 500 mg/20 ml expired 05/01/11;
2) One 500 ml intravenous solution of Sodium Chloride 0.9% expired 12/10;
3) One 100 ml intravenous solution of Lactated Ringers expired 04/11.
C. The Chief Nursing Officer verified through interview on 05/25/11 at 1410 the outdated medications in Surgery were available for patient use. LPN (Licensed Practical Nurse) #1 verified through interview on 05/25/11 at 1500 the outdated medications on the Medical Surgical Unit were available for patient use. RN (Registered Nurse) #2 verified though interview on 05/26/11 at 0855 the outdated medications in the Emergency Department were available for patient use.

Based on review of Infection Control Policy and Procedure Manual and interview, it was determined the facility did not have a policy and procedure or a plan in place to monitor infections and communicable diseases in health care workers in a manner and time sufficient to limit the spread of infection. Failure to monitor infections and communicable diseases in health care workers had the potential to allow the spread and infection to other health care workers, patients and visitors. The failed practice had the potential to affect the one inpatient on census on 05/25/11 and all patients, visitors, and health care workers in the facility. Findings follow:

A. During review of the Infection Control policy and procedure manaul,it was determined the facility did not have policies, procedures or a plan in place to monitor infections and communicable diseases in health care workers.
B.During an interview with the Infection Control Nurse on 05/27/11 at 1100, she confirmed the Facility had not been monitoring employee illness for infections and communicable diseases.

Based on review of the Chief Nursing Officer (CNO)/Operating Room (OR) Director's Physician Binder and interview, it was determined a current roster of surgical privileges for each physician was not maintained in the CNO/OR Director's office. The Physician Binder contained licensure information for each physician but did not list approved surgical procedures for each physician. Failure to have each physician's approved surgical procedures available in the OR area did not afford the CNO/OR Director and or other OR staff the ability to ensure that physicians only performed procedures they were approved for. The failed practice had the potential to affect all patients admitted for surgical procedures. Findings follow:

A. The Physician Binder kept in the CNO/OR Director's office was reviewed on 05/26/11 at 0926 and found not to contain a roster of surgical procedures each physician was approved to perform.
B. The above findings were confirmed by the CNO/OR Director on 05/26/11 at 0926.

Based on interview and review of Nursing Service Quality Assurance/ Performance Improvement (QA/PI) documents, it was determined there was no identification of corrective actions, implementation of corrective actions, evaluation of corrective actions and measures to improve quality on a continuous basis. Failure to identify, implement and evaluate corrective actions did not facilitate an effective quality assurance program for the Nursing Service. The failed practice affected the one inpatient on census on 05/25/11 and all patients receiving care from Nursing Services. Findings follow:

A. Based on interview and review of the Nursing Service QA/PI revealed evaluation of program indicators. The evaluation documented "satisfactory" and "below satisfactory" of the program indicators. There was no identification of corrective actions, implementation of corrective actions and evaluation of corrective actions on a continuous basis.
B. The above findings were verified by the Director of Nursing at 1045 on 05/27/11.