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Based on observations, staff interviews, and manufacturer's specifications for smoke detectors, the facility failed to meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association in regards to locations of smoke detectors. This affected 13 smoke detectors on three floors of the facility. The facility had a census of 10 patients at the time of this survey.

Findings include:

The facility was observed with total of 13 smoke detectors on the ground floor, first floor, and second floor that were located within 36 inches of air supply diffusers and air returns. These smoke detector locations were not installed in accordance with manufacturer's specifications. Refer to K52.

Based on observation, staff interview and review of the policy and procedure for infection control (Policy IC 3.06), hospital staff nurses failed to follow policy and procedure for control of infections while administrating medications to patients. This affected 2 patients (#2, #21) from the total of 20 patients reviewed. The patient census was 10.

Findings include:

During the administration of medications on the nursing unit on 07/27/11 at 9:15 AM, the following observation was made: Staff C (Registered Nurse) was observed administering medications to patient #21. Staff C prepared to administer injectable Lovenox (anticoagulant) to the patient. Staff C cleansed the area for injection with un -gloved hands using an alcohol wipe on the patient's abdomen. The hospital policy IC 3.06, for infection control, with the title of tasks and procedures requiring personal protective equipment, was reviewed. The task for "giving medications direct or into hub" requires the use of gloves.

During the administration of medication on the nursing unit on 07/27/11 at 2:30 PM, the following observation was made: Staff D (Registered Nurse) was observed to administer medications to patient
#2. The patient had a central line ( a catheter that is passed through a vein ending up in the chest portion of the large vein returning blood to the heart). Staff D, without the use of any personal protective equipment, cleansed off the connector of the central line. The hospital's policy IC 3.06 regarding tasks and procedure requiring personal protective equipment stated "invasive lines (central lines) requires the use of gloves, gowns, masks and eye protection.

The above findings were verified with Staff A and Staff E on 07/27/11 at 4:00 PM.