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Based on observation, staff interview, and policy review, the facility failed to ensure all drugs and biological are kept in a secure area.

Findings Include:

Observation of the second floor nursing station on 8/15/18 at 11:50 a.m. revealed the medication room across the hall from the nursing station, where the floor stock vials of medication are kept,,,,,,, was open and unattended from 11:50 a.m. to 12:05 p.m. When the Registered Nurse (RN) arrived back at the nursing station at 12:05 p.m. she was asked what the hospital's policy was regarding the security of medications. She stated, "The door is suppose to be kept locked, I don't know what happen."

During an interview with the Director of Nursing (DON) at 12:45 p.m. on 8/15/18, she confirmed the door to the medication room is always to be kept locked.

Review of the Hospital's Policy, "Medication Security" (revised on 7/25/18) revealed, "Policy - All drugs and biological stored in this hospital shall be kept in a secure area, locked when appropriate and accessible only to authorized personnel... Procedure - All medications at nursing stations shall be in lockable storage at all times ...When unattended, the medications carts and medications rooms are to be locked."

Based on observation, staff interview, and policy review, the facility failed to ensure only authorized personnel may have access to locked areas.

Findings Include:

Cross Refer to A502 for the facility's failure to ensure that only authorized personnel have access to the medication room, which is to be locked at all times.

Based on observation, interview, and document review, the facility failed to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases in five (5) of 11 rooms, Room 201, 206, 207, 208, and 209.

Findings Include:

On 8/13/18 at 1:00 p.m. observation revealed that Room 201, 206, 207, 208, and 209's oxygen receptacles had an attached a nipple nut adapter or Christmas tree.

During an interview on 8/13/18 at 1:10 p.m. the Respiratory therapist stated "I was unaware of the Oxygen Nipple Adapters (Christmas Trees) was for single patient use I thought they were for multi patient use." A package insert was requested at this time.

Review of the package insert for the Oxygen Nipple Adapters / Christmas Tree confirmed they are to be for single patient use.

On 8/14/18 the Respiratory Therapist presented an In-service to which all nursing staff and respiratory staff acknowledged with their signature revealing that all staff have been educated on the Christmas Tree Adaptors and how to properly use them one time.