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Based on observation, document review and interview, it was determined that for 1 of 1 Accu-check machine (blood sugar machine) in the ED (emergency department), the Hospital failed to ensure that a Registered Nurse supervised and evaluated patient care, by failing to ensure that the quality control testing requirement for the Accu-check machine, was performed. This could potentially affect the care for an average ED patient census of eight (8).

Findings include:

1. On 5/17/2022 between 9:30 through 10:30 AM, an observational tour of the ED was conducted. During the tour, the quality control log for the Accu-check machine was reviewed. The log lacked documentation that the quality control was performed on 5/6/2022, 5/7/2022, and 5/13/2022. The log also lacked information when a new test strip was opened.

2. On 5/17/2022, the Hospital's policy titled, "Accu-check Inform II Glucose Quality Control Testing" (revised on 5/11/2021) was reviewed and required, "... Quality control testing is performed as a primary means of ensuring on-going proper performance of the Accu- Check... Low and high quality control testing is performed on the following occasions: 1. 1 (One) time per 24-hour period of patient testing...When a new test strip vial is opened..."

3. On 5/17/2022, the Hospital's job description for registered nurse (undated) was reviewed and required, "... Essential Functions... 25. Monitors and coordinates maintenance of equipment..."

4. On 5/17/2022 at approximately 10:30 AM and 1:00 PM, findings were respectively discussed with E #10 (Nursing Supervisor) and E #4 (Chief Nursing Officer). E #4 and E #10 stated that the Accu-check machine should be checked daily. E #10 added that the quality control log lacked documentation of when a new test strip was opened. E #4 stated that nurses are responsible for performing daily quality control check for the Accu-check machine.

Based on observation, document review and interview, it was determined that for 2 of 3 multi-dose vials of insulin (medication for diabetes) observed on the Medical Detox Unit and the OR (operating room), the Hospital failed to follow acceptable standards of practice regarding handling of drugs or biologicals.

Findings include:

1. On 05/17/2022, between 10:00 AM - 11:00 AM, an observational tour of the Medical Detoxification Unit was conducted. During the tour, one (1) 3 ml (milliliters) opened mutli-dose vial of Insulin Lispro labeled with a discard date of 12/20/2021 (28 days after opening). The vial of insulin was available for patient use.

2. On 05/18/2022, between 9:00 AM - 11:30 AM, an observational tour of the Operating Room was conducted. During the tour, the anesthesia room refrigerator had one (1) 3 ml opened multi-dose vial of Insulin R labeled with a discard date of 6/8/2021 (28 days after opening). The vial of insulin was available for patient use.

3. The Hospital's policy titled, "Multi-dose Vial" revised date 05/22, was reviewed and included, "...all multi-dose vials must be dated and initiated ...if 28 days is exceeded, vial must be discarded ..."

4. On 05/17/2022 at 10:30 AM, the Registered Nurse (E #1) was interviewed. E #1 stated that she is not sure why the insulin multi-dose vial was still left in the refrigerator.

5. On 05/17/2022 at 10:45 AM, the Nursing Supervisor/Manager of Medical Detox Unit (E #2) was interviewed. E #2 stated that they should have discarded the expired multi-dose vial. E #2 stated that if it is used past the 28 days the medication may not be effective and could have been contaminated.

6. On 05/18/2022 at 11:00 AM, the Operating Room (OR) Head Nurse (E #11) was interviewed. E #11 stated that it is not okay to have expired medication left in the refrigerator.

A. Based on observation, document review and interview, it was determined that for 1 of 1 dry food storage area, the Hospital failed to manage the dietary services by ensuring that the temperature of the dry storage food area was monitored. This could potentially affect an average daily census of 41 patients receiving meals from the dietary department.

Findings include:

1. On 5/17/2022 between 11:15 AM through 12:15 PM, observational tour of the dietary service area was conducted. During the tour, the temperature monitoring log for the dry food storage area was reviewed. The monitoring log instructions included, "... Hang a temperature thermometer in the dry storage area to check storeroom temperatures daily..." The log lacked documentation of temperature monitoring in May 2022 on the following dates: 5/1/2022; 5/3/2022; 5/4/2022; 5/6/2022; 5/7/2022; 5/8/2022; 5/10/2022; 5/11/2022; 5/13/2022; 5/14/2022; and 5/15/2022. The storage area contained food items such as, but not limited to cartons of cereal, cream of wheat, Japanese Toasted Panko bread crumbs, chocolate chip cookies, cereal corn flakes, etc.

2. On 5/17/2022, the Hospital's policy titled, "Physical Environment" (effective 2/2022) was reviewed and included, "... Dry Storage. Store foods not requiring refrigeration or freezing in a dry, clean and well-ventilated room at temperature between 60 and 70 degree Fahrenheit... 5. Locate thermometer in the storeroom and monitor temperatures..."

3. On 5/17/2022 at approximately 12:15 PM, findings were discussed with E #3 (Director of Food Services). E #3 stated that the dry food storage area temperatures should be monitored daily. E #3 said that bacteria can grow if desired temperature is not maintained.

B. Based on observation, document review and interview, it was determined that for 1 of 1 cold food storage area, the Hospital failed to manage the dietary services by ensuring that perishable food items were labeled with used by date. This could potentially affect an average daily patient census of 41 patients receiving meals from the dietary department.

Findings include:

1. On 5/17/2022 between 11:15 AM through 12:15 PM, observational tour of the dietary service area was conducted. The following were observed inside the cold food storage area:

- A bowl with approximately a quarter full of sliced cantaloupe with no used by date. The bowl of cantaloupe was prepared on 5/12/2022.
- A bowl with approximately quarter full of cherry tomatoes with no used by date. The bowl of tomatoes was prepared on 5/12/2022.
- A gallon with approximately half full of 2% milk with no used by date. The milk had no date opened while in storage.

2. On 5/17/2022, the Hospital's policy titled, "Physical Environment" (effective 2/2022) was reviewed and included, "... Storage of Perishable Foods. Store all perishable foods in an appropriate fashion... 2. Cover all refrigerated food and dated while in storage..."

3. On 5/17/2022, findings were discussed with E #3. E #3 stated that opened and prepared food items should be labeled with a used by date. E #3 stated that the said food items can only be used within three days from the preparation or open dates to prevent food spoilage.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Full Survey Due to a Complaint conducted on May 17 - 18, 2022, the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of the Full Survey Due to a Complaint conducted on May 17 - 18, 2022, the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.