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Based on observation, the facility failed to assure all medications available for patient use in the Pyxis System on the Medical Unit were not expired. This had the potential to affect all patients.

Findings include:

A tour of the Medical Unit was conducted on 7/14/10 at 12:40 PM. During this tour the surveyor and Employee Identifier (E.I.) # 1, RN Manager 3 West, observed the following medications in the Pyxis System with expired dates:

Dextrose 5% 100cc times (x) 4 expired 4/1/08
Dextrose 5% with 1/4 Normal Saline 1000cc x 3 expired 3/1/08
Dextrose 5% with 1/4 Normal Saline 1000cc x 3 expired 4/1/09
Dextrose 5% with 1/2 Normal Saline 1000cc x 3 expired 7/1/10

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.

Findings include:

Refer to Life Safety Code violations.

On 7/14/10 at 9:00 AM, the surveyor observed medication pass on 6 West. During this observation, Employee Identifier (EI) # 5, the Registered Nurse obtained Intravenous (IV) Venofer from a medication refrigerator. The surveyor observed an excessive amount of ice accumulation on the freezer portion of the refrigerator.

On 7/14/10 at 9:30 AM, the surveyor showed the ice accumulation on the freezer portion of this refrigerator to EI # 7, the Nurse Manager, who verified it was excessive and would call maintenance to replace the refrigerator.




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Based on observation and policy review, the facility failed to assure all medications requiring refrigeration were stored properly in the Pharmacy, 3 West and 6 West.

This had the potential to affect all patients.

Findings Include:

Policy:

Medication Storage
...
Medications requiring refrigeration will be stored in a refrigerator which will be used exclusively for this purpose and refrigerator temperatures will be set at 2-8 degrees Celsius (C) and monitored daily on medication refrigeration log...

If temperature falls outside this range, the refrigerator temperature control will be adjusted and the temperature rechecked. If the temperature still is out of range, Plant Operations will be called.

Refrigerator/Freezer Temperature Log
Appropriate Refrigerator Range = 32 degrees Fahrenheit (F) to 41 degrees F. Appropriate Freezer = less than (<) 32 degrees F.

A tour of the Pharmacy conducted on 7/13/10 at 2:00 P.M. by the surveyor, Employee Identifier (E.I.) # 3, Case Management Manager, and E.I. # 6, Assistant Director of Pharmacy, revealed the following:

a. medications stored in the Break Room freezer with no temperature log found.
b. medications stored in the main room freezer with no temperature log completed since May 25, 2010.

A tour of 3 West conducted on 7/14/10 at 12:40 P.M. by the surveyor and E.I. # 1, the RN manager 3 West, revealed medications stored in the Pyxis refrigerator. The freezer compartment of the refrigerator was found to have an excessive ice buildup. A review of the temperature log revealed the following temperatures logged:

a. 7/13/10 = 60
b. 7/14/10 = 59

There was no documentation that the temperature had been adjusted or that Plant Operations had been notified.

Based on observation and review of facility's policies, it was determined the facility failed to ensure blood products were handled according to the facility policy by the laboratory staff. This had the potential to effect all laboratory staff.

Findings include:

Facility Policy

Dept. Laboratory
Title: Glove usage - Removal and Disposal

Gloves are required when obtaining, handling or distributing all specimens...

Gloves in the clinical areas should be replaced when they become torn, soiled or contaminated.

Facility Policy

Exposure Control Plan

Policy: Exposure Control Plan
Statement of Purpose:

The purpose of the plan is to:
Establish individual responsibilities to minimize the risk for healthcare workers of acquiring bloodborne disease to occupational exposure.

Definitions:
Standard Precautions and Respiratory Hygiene/Cough Etiquette: ... All human blood and certain human fluids are treated as if known blood and can cause disease in humans.

Contaminated: The presence or the reasonable anticipated presence of blood or other potentially infectious materials on an item or surface.

Exposure Determination:
This exposure determination shall be made without regard to the use of personal protective equipment:
Category I: Jobs with tasks that routinely involve exposure or potential exposure to blood, body fluids or tissues...

(Laboratory/Pathology Department is included in the Category I list)

Methods of compliance:
General: Standard Precautions and Respiratory Hygiene/Cough Etiquette are observed to prevent contact with blood or other potentially infectious materials. Under circumstances in which differentiation between body fluid type is difficult or impossible, all body fluids shall be considered potentially infectious materials.

Engineering and Work Practice Controls - used to eliminate or minimize staff member exposure... The following engineering/work practice controls are used throughout the facility:

Hand cleansing facilities - (or alcohol-based hand), which are readily accessible to all staff members who have potential for exposure...

Following any contact of body areas with blood or any other infectious materials, staff members wash their hands or any other exposed skin with soap and water as soon as possible: they also flush exposed mucous membranes with water...

Personal Protective Equipment:
Personal protective equipment is the "last line of defense" against bloodborne pathogens... This equipment includes, but is not limited to:
... gloves (latex or vinyl), in all sizes and hypoallergenic ...

Gloves are worn in the following circumstances:
Whenever staff members anticipate contact with potentially infectious materials
When performing vascular access procedures
When handling or touching contaminated items or surfaces

Facility Policy

Hand Hygiene in Healthcare setting

Manual: Infection Control

Purpose
To provide procedure for correctly performing hand antisepsis.

Policy

Appropriate hand hygiene is performed to reduce the potential risks of transmission of microorganisms to patients and to reduce the potential risks of health-care worker colonization or infection caused by organisms acquired from the patient.

The following are indications for performing appropriate hand hygiene procedure (either handwashing with hospital approved agent or using the hospital approved alcohol-based product - as indicated).

... After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings
If moving from a contaminated- body site to a clean body site during patient care
After removing gloves...

An initial tour of the facility laboratory was conducted on 7/13/10 at 2:10 PM. During this tour at 2:30 PM, the surveyor observed Employee Identifier (EI) # 8, the laboratory staff member reach into the "Blood Bank" refrigerator and removed a unit of blood that had been typed and cross matched with her bare hand. After explaining to the surveyor the procedure for blood that had been assigned to a patient, she placed this bag back into the refrigerator. The surveyor did not observe the staff member wash her hands.