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Based on observation and interview the facility failed to monitor emergency equipment in the crash cart, resulting in the potential for patient harm. Findings include:

On 11-15-2011 at approximately 1100 during a tour of the critical care unit (CCU) it was revealed that seven days out of a two month period the crash cart did not have "daily checks" performed.

On 11-15-2011 at approximately 1100 this finding was confirmed with staff A.

The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See C-231

Based on observation and interview the facility failed to provide physical facilities large enough for the number of patients served in the Infusion Center.

Findings include:

On 11-15-2011 at approximately 1315 during a tour of the Infusion Center the room was observed to be set up with five chair stations and a nurse station/office cubicle. The total room size is approximately 400 square feet. Two of the five patient chair station areas were less than 40 square feet each and the chairs between these two stations were less than 3 feet apart. The patient care for these two cubicles is compromised due to lack of adequate space.

Based on observation and interview the facility failed to insure proper ventilation of the ER airborne isolation room (Room 3). This could expose other patients and staff to airborne infectious diseases. Findings include:

On 11-15-2011 at approximately 12:40 PM during a tour of the ER it was observed that ER 3 was under a net positive pressure by means of visual observation of air flowing out of the room at the door undercut.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated November 17, 2011 for Life Safety Code.

Based on observation and interview the facility failed to insure medications were maintained and disposed of properly, resulting in the potential for patient harm. Findings include:

On 11-15-2011 at approximately 1115 during a tour of the CCU it was observed that the following medications were outdated in the Pediatric Code 100 Box:

1 Vial Phenytoin expired 3-2011
2 Vials Atropine Sulfate expired 7-2011
3 Boxes 4.2% Sodium Bicarbonate (Infant) expired 5-2011
1 box Lidocaine 2% expired 10-2011

On 11-15-2011 at approximately 1115 the above findings were confirmed.

On 11-16-2011 at approximately 1100 during a tour of the surgical area, it was observed that the anesthesia cart (which contained scheduled drugs) was unlocked and unsupervised. Also, a syringe with propofol and xylocaine was drawn up on top of the anesthesia cart from the previous case. The room had been cleaned and was ready for the next case.

On 11-16-2011 at approximately 1105 it was stated by staff B "That should have been discarded after the case." Staff B was referring to the syringe that contained the propofol and xylocaine.

Based on policy, observation and interview the facility failed to ensure products were not outdated, resulting in the potential for patient harm. Findings include:

On 11-15-2011 at approximately 1400 during policy review it was revealed in the policy titled Expired Patient Care Product Monitoring "#1bi. Product that is expired, or will expire in less than 30 days, will be removed from the Clean Supply cart, discarded appropriately, and replaced with fresh product."

On 11-15-2011 at approximately 1115 during a tour of the CCU it was revealed that the following supplies were expired:

Crash Cart:
Arrow-Howes Multilumen CVC Kit expired 6-2011
2 Silvertrace ECG Electrodes expired 5-2011
10 lab tubes expired 8-2009
4 Portex Pro-Vent expired 9-2011
2 packages AED expired 11-2008 and 1-2010

Pediatric Code 100 Box
4 insyte autogaurds expired 3-2010
1 CO2 Detector expired 6-2010

Special Procedures Cart
2 Temporary pacemakers expired 4-2008
11 Universal Caps Male/Female Non Vented expired 9-2011
1 Surgical blade expired 9-2011
1 Winged Infusion Set expired 10-2007

Clean Supply Room
7 Universal IV Sets with 15 Micron Filter expired 11-2010

On 11-15-2011 at approximately 1115 the above findings were confirmed with staff A.