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Based on observations and interviews, it was determined the facility staff failed to ensure medication administration according to facility policy for five (5) patient care areas observed.

The findings include:

During the tour of the facility on 3/20/18 with Staff Member #3, #6 and #28, the following items were noted:

Radiology:
In treatment area the following expired items were available for use: a bottle of normal saline, expired 11/16, a 1000 cc (cubic centimeters) bag of 10% Dextrose, expired 2/18.


Surgical Suite: ENT (Ear, Nose and Throat) Cart had 7-8 expired (from 2016 to 2/2018) Endotracheal tubes and 4 expired (2016 and 2017) ambu bags. Staff Member #28 stated, "We have just hired a new nurse who will be in charge of maintaining this cart."

Two (2) operating rooms were toured.
OR #1, the anesthesiologist was observed with three (3) syringes in their pocket all of which did not have the initials of the person who drew up the medication, or date and time it was drawn up.

One of the medications was Propofol (Per GlobalRPH.com Administration should commence promptly and must be completed within 12 hours after the vial has been spiked. The tubing and any unused portions of Propofol Injectable Emulsion must be discarded after 12 hours.) There were also three (3) vials of opened and accessed dexamethasone that were not initialed, dated or timed as to when they were accessed. Staff Member #29 stated, "All the vials should be treated as single use vials and thrown away."

In the second operating room (OR), the surveyor requested to inspect the anesthesia cart. There were:
5 syringes of medications that were not initialed by the person who drew up the medication and they were not dated and timed as to when they were drawn up,
2 vials of medications that were opened and accessed and not initialed, dated and timed as to when they were accessed,
2 containers of anesthetic opened and accessed and not initialed, dated and timed as to when they were accessed.

While reaching into the pocket of their jacket to remove a vial of narcotics, the Certified Registered Nurse Anesthetist (CRNA) stated; "I carry my narcotics in my pocket with me." Another anesthesiologist entered the OR and stated; "The syringes have the name of the drug on them. I have never heard of putting initials, date and times on syringes."

NICU (Neonatal Intensive Care Unit): In Pod F and G, the medication carts were not locked and in the medication drawers for each infant was a vial of vitamins. None of the vials that had been opened and accessed had initials, dates or times of when they had been accessed.

On 3/21/18 at approximately 1:00 P.M. Staff Member #37 was interviewed regarding the anesthesiologist and CRNA's handling and non-labeling of medications. Staff Member #37 stated, "I am ok with them not labeling the medications if they are giving the immediately but, if not, they should be labeled. Propofol has specific needs and should be definitely labeled."

Staff Member #8 provided the following:
1. Policy #350.113 with an effective date of 12/99 with the subject of Sterile Supplies documents in #8 "Check expiration dates prior to use. Expired items will be discarded."

2. Policy #350.112.05/2130-100/105-04-ME.41 with an effective date of 7/11/11 with the subject Single Use and Multidose Mediation Vials documents in Procedure #2: "Single dose vials (Parenteral medication vials without preservatives) should be used once and discarded. In some situations where a multiple doses for a single patient are anticipated soon after the first, additional doses maybe withdrawn aseptically and administered within one hour of the vial being opened. The vial and any contents must be discarded if not used within one hour or if contamination is suspected." Sub-section b. "If two or more syringes are drawn at the same time from a single dose vial both syringes will expire in one hour label all syringes with the patient's name and expiration date/time, which is one hour after the vial was opened."

3. Policy #H209 with an effective date of February 2, 2018 with the subject Principal Pharmacy Policy, Procedure section X, documents, "All medications that are transferred, withdrawn, poured or placed into another container (syringe, medicine cup, basin) from the original container must be labeled unless it is immediately administered to the patient."
Sub-section:
a. "Immediately" is defined as no break or interruption from the time the medication is transferred from the original container to another container. Interruption includes prep of a patient, phone calls etc.
b. The label must include the following information: medication name, strength, amount, expiration date and expiration time..."

Based on findings identified during the Life Safety Code survey that ended on March 29, 2018, the facility was found to be out of compliance for the Condition of Physical Environment. See CMS 2567 - Statement of Deficiencies for the Life Safety Code survey.

Based on observations and interviews, it was determined the facility failed to ensure the equipment and facilities were maintained in a manner that would prevent the spread of infection in seven (7) patient care areas observed.

The findings include:

During the tour of the facility on 3/20/18 with Staff Member #3, #6 and #28 the following items were noted:

Nuclear Med: Approximately 8 chairs had the finish worn off the arms leaving exposed wood.

CT Waiting Area: Several chairs had the finish worn off the arms leaving exposed wood.

Infusion Area (CCBDC): The area was built to resemble a ship or boat. Each support beam is surrounded by wood. Patients sit in chairs around the support beams to receive infusions of blood, chemotherapy, etc. The wood had gouges and scratches in it leaving exposed porous wood.

OR #2: Observations were made of the OR staff cleaning and disinfecting OR #2 following surgery and preparing for next surgery. The disinfecting wipes required a one (1) minute wet time (Items being disinfected must be kept wet for one (1) full minute to be disinfected). The items (a cart and two (2) gel positioning supports were wiped down but not kept wet. The cart was wiped down then the positioning supports were wiped and placed immediately on top of the cart now allowing the items time to dry.

PACU (Post-Anesthesia Care Unit): Staff Member #34 was observed cleaning and disinfecting a stretcher in PACU. The top and siderails of the stretcher were cleaned and disinfected with three (3) regular sized disinfecting wipes. The stretcher did not stay wet the required one (1) minute. Staff Member #28 stated, "We will have to work on that."

Day Surgery Area Pre-Op: Four to Five (4-5) chairs were observed in the bays and along the wall that had cloth backs and seats. The Staff Member #35 stated, "We were supposed to get rid of those chairs but I don't know what happened." When asked how they are disinfected should some type of body fluid get on the chairs, Staff Member #35 stated: "I don't know, (Name of Environment of Care Staff) takes care of that."

Unit 8C: Staff Member #32 was twice observed carrying lines held snuggly to their body while walking from the nurses station to the area of patients' room. Staff Member #32 was asked who they were assigned to care for and stated, "I have 28 A & B and 26 (rooms 828 and 826)." Patient #31 was in room 826 and was on contact precautions for suspected Escherichia coli (E. coli) meningitis.


A telephone interview was conducted with the Staff Member #36 and the Infection Control Team on 3/21/18 at approximately 1:30 P.M. Staff Member #36 was made aware of the above findings and concurred that they were all areas that needed improvement.