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Based on surveyor observation on 9/14/11, the facility failed to maintain the fire alarm system in accordance with Section 9.6.1.4 and NFPA 72 , the National Fire Alarm Code.

A test of the facility's fire alarm system was conducted at approximately 9:10 AM. After the fire alarm system was reset the fire alarm system annunciator panel indicated a "trouble condition". The facility's staff were unable to clear the "trouble condition" from the annunciator panel. Another test of the fire alarm system was conducted. The facility's fire alarm system was fully functioning and operational with the annunciator panel indicating a "trouble condition".

Based on observation, policy and procedure review and staff interview, the facility did not ensure that policies included rules for the storage, handling, dispensation, and administration of drugs and biologicals, and the rules must provide that there is a drug storage area that is secured in accordance with accepted professional principles.

Findings included:

1. There were no written policies and procedures for the handling, dispensing, and replacement of drugs and/or biologicals in the kits kept in the Emergency department and the "In-Patient Night Closet" (IPNC).
- Interview with the ER head nurse on 9/14/2011 revealed a drug was removed from the "anaphylaxis kit" during provision of care for a patient the previous day. A note on the patient's record noted the medication need to be replaced by the pharmacist.
- Review of the IPNC revealed MOM, lisinopril, go-lightly, antibiotics and other drugs stored in the night closet.. The pharmacist stated no narcotics were stored in the night closet.
- The pharmacist confirmed that there was no written policy/procedure for the night closet, but showed a clipboard where staff were to sign out of any medication taken.

2. The facility did not ensure that all drugs and biologicals were kept in a locked room or container. If the container was mobile or readily portable, when not in use, it must be stored in a locked room, monitored location, or secured location that will ensure the security of the drugs or biologicals. - Observation on 9/14/2011 at 1110 revealed the door to the treatment room which contained a medication cart, treatment cart and clean supplies was not locked. The medication cart was locked as drawers did not open, however, a container of skin protectant and box of antibiotic ointments were observed on the top of the treatment cart.
- On 9/15/2011 at 1511, during a tour of the nursing unit with the pharmacist, the door to the treatment room was locked, however, the medication cart was open as the drawers to hold medication could be pulled out from the cart. Skin protectant and antibiotic ointment were located on the treatment cart.

Based on review of facility policies and procedures, the facility did not ensure that patient care policies were reviewed at least annually by a group of professional personnel (one or more doctors of medicine or osteopathy, nurse, and one member that is not a member of the CAH staff), and reviewed a necessary by the CAH.

Findings included:

Review of pharmacy and radiology manuals revealed there were no attestation of current policy and procedure review. This was confirmed by pharmacy and radiology staff.

Based on record review and staff interview, the facility did not ensure that a registered nurse provided the nursing care of each patient. Two of twenty-eight patients (#1 & 4) did not have nursing assessments in the medical record.

Findings included:

Patient #1 was admitted to the facility on 4/28/2011 and Patient #4 was admitted to the facility on 5/16/2011. During record review, nursing assessments were not found. This was confirmed by the Head Nurse upon review of the medical record.