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Based on observation, staff interview and policy/procedure review, it was determined the facility failed to maintain the security of patient medications. This deficient practice had the potential to negatively affect patients # 37 and 38, visitors, and unauthorized staff who had access to these unattended medications. The hospital census at the time of the survey was 94 patients.

Findings include:

Tour of the out-patient infusion unit on 06/19/12 at 2:15 PM revealed a 50 ml bag of pre mixed medication (Zoledronic) found unattended at the bedside in treatment room # 3. The patient was receiving an infusion, alone in the room. When the nurse returned to the room she stated "I should not have left the medication in the room." When asked when she would be giving the IV Zoledronic, she said "In about 20 minutes." Leaving the medication unattended in the room was confirmed by employee T at the time of the tour.


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Observation of medication administration on 06/19/12 at 9:02 AM revealed Registered Nurse (RN) # I enter Patient # 37's room. The nurse carried a white plastic carton which contained patients' medications which had previously been placed in zippered plastic bags in preparation of medication administration. The nurse placed this carton on a shelf located adjacent to the patient's in-room computer substation.
A physician was observed to walk up and down the hallway until he located Nurse # I in Patient # 37's room. The physician knocked on the door and asked if he could speak with the nurse. The nurse exited the patient's room and partially closed Patient # 37's door. The carton containing the medications remained in the patient's room. The nurse stepped into the hall to speak with the physician. The nurse stood with her back to the room and door while discussing a patient with the physician. The white carton containing patient medications was left unattended inside Patent # 37's room during the time she spoke with the physician. The conversation ended at approximately 9:06 AM when the nurse then re-entered the patient's room. The elapsed time that medications were left unattended was approximately 3 minutes.
Review of the facility's policy and procedure entitled Medication Administration revised 02/02/2012 failed to address medications left unattended.
Interview of nurse # I on 06/18/12 at 9:10 AM revealed medications were removed from the medication room's Pyxis machine (locked medication storage) and placed in individual zippered plastic bags for each patient at the beginning of the shift. The nurse verified that she had other patients' medications in her carton and that medications were left unattended while she spoke with the physician.
Interview of Staff # A on 06/20/12 at 2:30 PM revealed nurses are not to leave medications unattended.

Based on observation made during tour of the preoperative/postoperative areas on 06/19/12 and staff interview it was determined the hospital failed to ensure four 10 ml bottles of .9% normal saline had not expired. This has the potential to affect all patient's receiving care in the pre/post operative area of the hospital. The hospital census at the time of the survey was 94 patients.

Findings include:

During a tour on 06/19/12 at 9:50 AM of the preoperative and postoperative rooms, three surveyors observed expired 10 ml bottles of 0.9% normal saline in three of five rooms. (#6, 8 and 13) Room #6 had one bottle with an expiration date of May 01, 2012. Room #8 had one bottle with an expiration date of April 01, 2012. Room #13 had one bottle with an expiration date of May 01, 2012 and one bottle with an expiration date of April 01, 2012. On 06/19/12 at 09:50 AM the findings were shared and verified with Staff C.

Based on observation, interview, and policy review, the dietary manager failed to ensure organization of the dry food storage area as to prevent stocking of dented cans of food and cans without labels and storage of packaged food and drinks directly on the floor and failed to check patient dietary items for expiration dates and dispose of the expired and damaged items. This affects all patients receiving nutritional supplements. The hospital census at the time of the survey was 94 patients.
Findings include:


During tour of the kitchenette on the second floor of the Critical Care Unit on 06/18/12 at approximately 1:10 PM, observation was made of expired items located in the upper cupboards. This included ten cartons of a nutritional supplement (Ensure Enlive) with an expiration date of May 1, 2012 and a two quart bottle of cranberry juice with an expiration date of May 26, 2012. This was verified with Staff F at approximately 1:25 PM.
The tour of the dietary kitchen conducted on 06/19/12 at approximately 11:00 AM revealed one 8 ounce container of Palmocare with an expiration date of June, 01 2012. The can was on a cart with other nutritional supplements. This cart was getting ready to be brought to the patient care floors. This was confirmed by Staff G on 06/19/12 at approximately 11:00 AM.
The tour of the Emergency Department conducted on 06/19/12 at approximately 3:25 PM revealed five Similac Ready to Feed Infant Formula 2 ounce size containers with an expiration date of April, 01 2012. These were found in top cabinet drawer of the Clean Utility Room. This was verified by Staff H on 06/19/12 at approximately 3:30 PM.




31159

On 06/19/12 during an environmental tour of the kitchen from 10:30 AM to 11:30 AM, an observation was made of seven different six pound nine ounce dented cans containing sauerkraut, spaghetti sauce, green beans, creamed corn, mandarin oranges, pizza sauce, and vanilla pudding on the wire storage shelves in the dry food storage area. These cans were visibly dented. Additionally, one can was observed with no label which had " mandarin oranges " written on the end with a marker. On 06/19/12 at 10:45 AM, Staff G confirmed that they did receive a shipment of canned goods on Monday 06/18/12 and that the staff members who stock these cans should have removed the dented cans immediately. Staff G confirmed there was a can with no label. Observation was also made of food items in the dry food storage area directly on the floor and up against the wall including two bags of flour, one box of individually packaged servings of cereal (Total), one box of marshmallows, one box of sweet and sour sauce, one box of bag-in-box ketchup, and one box of individually wrapped cookies. In the soda storage room it was also observed that there were two six packs of Dr. Pepper soda that were on their tops directly on the floor and five loose cans of Sprite soda that had fallen between a pallet and were on their tops directly on the floor. On 06/19/12 at 10:45 a.m. Staff G confirmed that the food and the soda pop should not be directly on the floor.

On 06/21/12 at 10:50 AM the policy manual entitled ServSafe updated 2009 was reviewed. In an interview with Staff G on 06/21/12 at 10:30 AM, Staff G stated that they follow the ServSafe manual as their policy for food storage. Section 6-4 of the manual stated, " Train employees to inspect deliveries properly. " Section 6-18 of the manual stated, " Do not accept cans with dents along side or top seams. Reject cans with dents large enough to make it difficult to open them with a can opener because the seams may be broken. Any cans received without labels should be rejected. " Section 7-7 of the manual stated, " Store dry food away from walls and at least six inches (fifteen centimeters) off the floor. "

Based on observations made during the Life Safety Code tours on 06/18/12 thru 06/22/12 as well as staff interviews, it was determined the facility failed to maintain a safe environment to protect the health and safety of patients. The facility failed to maintain smoke barriers, functional evacuation signage and perform required testing, failed to have fire extinguishers accessible and mounted properly, failed to have laundry and trash chutes close without gaps, failed to maintain proper humidity levels in the operating rooms, failed to have safe access from an exit to a public way, and failed to maintain sprinkler heads free of dust and debris. The facility also had smoke detectors located near air flow devices and had portable space heating devices in a patient care area. The facility failed to meet the provisions of the Life Safety Code of the National Fire Protection Association. The hospital census at the time of the survey was 94 patients.

Findings include:

Please refer to A0709 : Life Safety from Fire

Based on observations made during the Life Safety Code tour of hospital and three offsite locations on 06/18/12 thru 06/22/12, and staff interview, it was determined that the facility failed to maintain a safe environment to protect the health and safety of patients, staff, and visitors. The hospital census at the time of the survey was 94 patients.

Findings include:

Please refer to K18- Corridor doors not constructed to resist the passage of smoke

Please refer to K20- Stairwell doors not closing

Please refer to K22- Lacking exit directional signs

Please refer to K25- Penetrations in smoke barriers

Please refer to K27- Smoke barrier door leafs swing in same direction, smoke barrier doors not closing properly

Please refer to K29- Hazardous areas not enclosed with at least a one hour fire rated construction

Please refer to K38- No safe access to termination at a public way

Please refer to K42- Suite of sleeping rooms greater than 5,000 square feet

Please refer to K46- Battery operated lights not tested monthly and annually

Please refer to K47- Exit signs not illuminated

Please refer to K62- Sprinkler pendants coated with dust and debris

Please refer to K64- Fire extinguishers not mounted properly and access to fire extinguishers blocked

Please refer to K70- Portable space heating devices in patient care areas

Please refer to K71- Laundry and trash chute doors have gap when closed

Please refer to K78- Humidity levels less than 35% in operating rooms

Please refer to K130- Smoke detectors located by air flow devices


Business Occupancies:

Please refer to K130- Battery operated lights not tested for 30 seconds monthly and not tested annually,
Please refer to K130-Sprinkler system not tested quarterly,
Please refer to K130-Sensitivity testing of smoke detectors

Based on tour of the sixth floor, on the afternoon of 06/18/12 with Staff E and two surveyors, it was determined the hospital failed to ensure for timely trash pick-up as noted in two soiled utility rooms. The hospital census at the time of the survey was 94 patients.

Findings include:

Tour of the 6 South in-patient unit and the sixth floor Anticoagulation Clinic soiled utility rooms on the afternoon of 06/18/12 revealed large tied trash bags overflowing the trash containers. Lids could not contain the bags because of overfill. This was confirmed by Staff E during the tour.

Based on observation during tour of the emergency department and staff interview it was determined the hospital failed to ensure the supplies available for patient use in the emergency department were not expired. Tour of fifth floor surgical in-patient unit revealed clean patient equipment stored on the floor. This has the potential to affect all patient's provided care in the two units observed. The hospital census at the time of the survey was 94 patients.

Findings include:

Tour of the emergency department was conducted on 06/19/12 at 3:10 PM with Staff H, the emergency department nurse manager. During tour of Pod 2 in the clean utility area, a 10 French nasogastric tube was noted with an expiration date of 06/13/12. During tour of the phlebotomy storage room, 17 safety glide injection needles were noted with an expiration date of 02/12.
These findings were confirmed with Staff H on 06/19/12 at 3:10 PM during the tour.

Tour of the fifth floor surgical in-patient unit was conducted on 06/18/12 at 1:10 PM with Staff E and two surveyors. During the tour of the Pyxis storage room, a clean continuous passive motion (CPM) machine was found stored on the floor. This equipment would be used on a patient after knee joint surgery.
This was confirmed with Staff E on 06/18/12 during the tour.

Based on observation and staff interview, it was determined the hospital failed to ensure staff cleaned respiratory equipment after use for four of four sampled patients. There were 33 patients receiving respiratory therapy services on 06/20/12. This potentially affects all patients receiving respiratory therapy services. The hospital census at the time of the survey was 94 patients.

Findings include:

Staff K was observed checking the oxygen saturation of four patients. Staff K removed a pulse oximeter from his/her uniform pocket and placed the equipment on four patients' fingers. Staff K returned the oximeter into pocket after obtaining the saturation readings. Staff K did not clean the equipment after each patient 's reading was obtained, between patient use or prior to placing oximeter into pocket.

On 06/20/12 at 2:25 PM, Staff K was interviewed. Staff K stated that he/she did not know the hospital policy or manufacturer instructions for cleaning the oximeter.

On 06/20/12 at 3:40 PM, Staff J was interviewed. Staff J stated that the therapist should have wiped the oximeter with a disposable wipe (Sanicloth) after each use.

The manufacturer's instructions for cleaning and disinfecting the oximeter states "To surface-clean the monitor, use a soft cloth dampened with either a commercial, nonabrasive cleaner, or a solution of 70% alcohol in water, lightly wipe the surfaces of the monitor. To disinfect the monitor, use a soft cloth saturated with a solution of 10% chlorine bleach in tap water. "
Staff K was observed administering nebulizer treatments with the medication (Duoneb) to four patients on 06/20/12. Staff K did not clean the disposable nebulizer after the completion of the 4 treatments. Staff K placed each nebulizer in a plastic bag for storage after each treatment.

On 06/20/12 at 2:25 PM, Staff K was interviewed. Staff k stated that he/she did not know the policy or manufacturer instructions for cleaning the nebulizer.

On 06/20/12 at 3:40 PM, Staff J was interviewed. Staff J, the Director, stated there was no need to clean the mouthpiece and nebulizer.

On 6/21/12 at 8:55 AM, Staff J was interviewed. Staff J stated the hospital did not have specific policies regarding the use and maintenance of all respiratory equipment.

Staff J presented the manufacturer's instructions for the nebulizer from the package that states "Between treatments, remove the supply tubing from the bottom of the nebulizer, unscrew and remove top of nebulizer parts in warm water/liquid dish detergent solution. Rinse in clean warm water and allow parts to dry thoroughly before reassembling."

Based on observation, staff interview and policy/procedure review, it was determined the facility failed to maintain the security of patient medications. This deficient practice had the potential to negatively affect patients # 37 and 38, visitors, and unauthorized staff who had access to these unattended medications. The hospital census at the time of the survey was 94 patients.

Findings include:

Tour of the out-patient infusion unit on 06/19/12 at 2:15 PM revealed a 50 ml bag of pre mixed medication (Zoledronic) found unattended at the bedside in treatment room # 3. The patient was receiving an infusion, alone in the room. When the nurse returned to the room she stated "I should not have left the medication in the room." When asked when she would be giving the IV Zoledronic, she said "In about 20 minutes." Leaving the medication unattended in the room was confirmed by employee T at the time of the tour.


22432

Observation of medication administration on 06/19/12 at 9:02 AM revealed Registered Nurse (RN) # I enter Patient # 37's room. The nurse carried a white plastic carton which contained patients' medications which had previously been placed in zippered plastic bags in preparation of medication administration. The nurse placed this carton on a shelf located adjacent to the patient's in-room computer substation.
A physician was observed to walk up and down the hallway until he located Nurse # I in Patient # 37's room. The physician knocked on the door and asked if he could speak with the nurse. The nurse exited the patient's room and partially closed Patient # 37's door. The carton containing the medications remained in the patient's room. The nurse stepped into the hall to speak with the physician. The nurse stood with her back to the room and door while discussing a patient with the physician. The white carton containing patient medications was left unattended inside Patent # 37's room during the time she spoke with the physician. The conversation ended at approximately 9:06 AM when the nurse then re-entered the patient's room. The elapsed time that medications were left unattended was approximately 3 minutes.
Review of the facility's policy and procedure entitled Medication Administration revised 02/02/2012 failed to address medications left unattended.
Interview of nurse # I on 06/18/12 at 9:10 AM revealed medications were removed from the medication room's Pyxis machine (locked medication storage) and placed in individual zippered plastic bags for each patient at the beginning of the shift. The nurse verified that she had other patients' medications in her carton and that medications were left unattended while she spoke with the physician.
Interview of Staff # A on 06/20/12 at 2:30 PM revealed nurses are not to leave medications unattended.

Based on observation, interview, and policy review, the dietary manager failed to ensure organization of the dry food storage area as to prevent stocking of dented cans of food and cans without labels and storage of packaged food and drinks directly on the floor and failed to check patient dietary items for expiration dates and dispose of the expired and damaged items. This affects all patients receiving nutritional supplements. The hospital census at the time of the survey was 94 patients.
Findings include:


During tour of the kitchenette on the second floor of the Critical Care Unit on 06/18/12 at approximately 1:10 PM, observation was made of expired items located in the upper cupboards. This included ten cartons of a nutritional supplement (Ensure Enlive) with an expiration date of May 1, 2012 and a two quart bottle of cranberry juice with an expiration date of May 26, 2012. This was verified with Staff F at approximately 1:25 PM.
The tour of the dietary kitchen conducted on 06/19/12 at approximately 11:00 AM revealed one 8 ounce container of Palmocare with an expiration date of June, 01 2012. The can was on a cart with other nutritional supplements. This cart was getting ready to be brought to the patient care floors. This was confirmed by Staff G on 06/19/12 at approximately 11:00 AM.
The tour of the Emergency Department conducted on 06/19/12 at approximately 3:25 PM revealed five Similac Ready to Feed Infant Formula 2 ounce size containers with an expiration date of April, 01 2012. These were found in top cabinet drawer of the Clean Utility Room. This was verified by Staff H on 06/19/12 at approximately 3:30 PM.




31159

On 06/19/12 during an environmental tour of the kitchen from 10:30 AM to 11:30 AM, an observation was made of seven different six pound nine ounce dented cans containing sauerkraut, spaghetti sauce, green beans, creamed corn, mandarin oranges, pizza sauce, and vanilla pudding on the wire storage shelves in the dry food storage area. These cans were visibly dented. Additionally, one can was observed with no label which had " mandarin oranges " written on the end with a marker. On 06/19/12 at 10:45 AM, Staff G confirmed that they did receive a shipment of canned goods on Monday 06/18/12 and that the staff members who stock these cans should have removed the dented cans immediately. Staff G confirmed there was a can with no label. Observation was also made of food items in the dry food storage area directly on the floor and up against the wall including two bags of flour, one box of individually packaged servings of cereal (Total), one box of marshmallows, one box of sweet and sour sauce, one box of bag-in-box ketchup, and one box of individually wrapped cookies. In the soda storage room it was also observed that there were two six packs of Dr. Pepper soda that were on their tops directly on the floor and five loose cans of Sprite soda that had fallen between a pallet and were on their tops directly on the floor. On 06/19/12 at 10:45 a.m. Staff G confirmed that the food and the soda pop should not be directly on the floor.

On 06/21/12 at 10:50 AM the policy manual entitled ServSafe updated 2009 was reviewed. In an interview with Staff G on 06/21/12 at 10:30 AM, Staff G stated that they follow the ServSafe manual as their policy for food storage. Section 6-4 of the manual stated, " Train employees to inspect deliveries properly. " Section 6-18 of the manual stated, " Do not accept cans with dents along side or top seams. Reject cans with dents large enough to make it difficult to open them with a can opener because the seams may be broken. Any cans received without labels should be rejected. " Section 7-7 of the manual stated, " Store dry food away from walls and at least six inches (fifteen centimeters) off the floor. "