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Based on observation, interview, and record review, the facility failed to keep the area below a sprinkler head unobstructed, and failed to secure three oxygen tanks. The practice had the potential to affect all patients in the facility. Findings include:

During an observation of the kitchen freezer with staff member G, dietary manager, on 7/28/15 at 7:55 a.m., boxes of food items were stacked to a level that was 3-4 inches below the sprinkler head and would have obstructed output from the sprinkler head if it were activated. Staff member G observed the box and said he would move the box in order to eliminate the problem.

During an observation of the oxygen storage area with staff member H, cardiopulmonary services manager, on 7/29/15 at 1:35 p.m., one size H and two size G oxygen tanks were not restrained in the storage area. Staff member G said the tanks should be restrained, and restrained them.

A review of the Portable Oxygen policy showed, "Portable oxygen cylinders must not be stored unrestrained."

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Based on observation and interview, the facility failed to date a multi-dose vial when it was opened, failed to dispose of a multi-dose vial that had been opened and was expired, failed to dispose of an expired test tube, and failed to dispose of a closed IV catheter system that was expired, in two of five medication and supply storage areas observed. The facility failed to dispose of four expired supplies in the emergency room. Findings include:

1. During an observation of the medication storage room, with staff member B, DON, on 7/27/15 at 3:10 p.m., a multi-dose vial of Tuberculin PPD had not been dated when it was opened, and was available for use in the facility. A test-tube for chlamydia had expired on 12/30/13, and was available for use in the facility.

Staff member B, viewed the items, said the items would be disposed of because of the missing open date and the expiration date, and removed the items.

2. During an observation of the medication cupboard in the respiratory therapy room, with staff member F, RRT and cardiopulmonary services manager, on 7/29/15 at 1:35 p.m., a multi-dose vial of Esmolol had expired in May of 2015, and was available for use in the facility. A Saf-T-Intima closed IV catheter system had expired in March of 2012, and was available for use in the facility.

Staff member F, viewed the multi-dose vial and the Saf-T-Intima-closed IV catheter system, said they were expired, and removed them from the cupboard.


3. During an observation of the emergency room department on 7/27/15 at 11:15 a.m. with staff member B, director of nursing, four Bio-culture swabs had expired 6/2015. The swabs were available for use on patients.

Based on observation and interview, the facility failed to protect the integrity of the labor and delivery registry book. This practice had the potential to compromise any medical documentation that was hand written by staff in the medical records department. Findings include:

During a review of the labor and delivery registry, White Out had been used to cover errors in writing on more than three entries. Examples of the practice included:

- September 2014, patient #30's registry entry had been whited out under the category "Complications."

- December 2014, patient #34's registry entry had been whited out under the categories "Anesthesia" and "Anesthetist."

- July 2015, patient #29's registry entry had all categories whited out other than name, date, and delivery number.

During a interview on 7/28/15 at 2:00 p.m., staff member E, health information manager, said she had used White Out on the labor and delivery registry when she first started working at the facility, because a prior employee had used White Out. She said she understood this was not an acceptable practice and no longer used White Out on the registry.

Based on observation, record review and staff interview, the facility staff failed to ensure the donor inquiry form for 3 (#s 1, 2, and 3) of 3 death records reviewed was complete.
Findings include:


Review of the electronic health record for patient #1 reflected the required donor inquiry form was incomplete. The facility staff failed to complete the sections clarifying if the patient was a candidate for organ or tissue donation, if the corner had to be contacted, who was the physician, and the disposition of the body.

Review of the electronic health record for patient #2 reflected the required donor inquiry form was incomplete. The facility staff failed to complete who was contacted for the donor determination.

Review of the electronic health record for patient #3 reflected the required donor inquiry form was incomplete. The referral number was not documented on the form.

In an interview on 7/29/15 at 10:30 a.m., staff member B, director of nursing, stated the donor inquiry forms were to be filled out completely by staff members.