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Based on a review of facility policy and procedures, observation of two medication administration passes and interview with facility staff (EMP), it was determined the facility failed to ensure that each dose of medication was recorded after the drug was administered for one of two medication administration passes observed.

Findings include:

Facility unable to provide policy as to when the the documentation of medication is to be recorded.

Observation of EMP 6 on January 27, 2020 at 11:00 AM revealed that EMP 6, removed a medication from the Pyxis in the medication room and took it to the patient room to administer, as the patient had dropped the medication on the floor. EMP 6 opened the Medication Administration Record (MAR) and it revealed that the medication had already been signed as given before the patient took the medication.

Interview with EMP1 confirmed that the documentation of the medication given was recorded prior to the patient receiving the medication.


Review of Medication Administration Policy last reviewed 1/20/2020: Medication is Defined AS: 2. Always observe the " Five Rights"; right patient, right time, right medication, right dosage, right route, of administration. Check medication 3 times while preparing.

Review of Medication Administration, Revised by ClinDoc Training: October 2, 2018:
Give a medication
1. Scan the patient's wristband. The MAR opens.
2. Scan the medication you're administering.


Observation of EMP 7 on January 28, 2020 at 1:30PM revealed that EMP 7, was administering medication in the patient's room which included Midodrine (a medication to help with low blood pressure) and Miralax (a medication to help with constipation). EMP 7 scanned the Midodrine and did not scan the Miralax prior to giving. When documenting that the medication was given EMP 7 documented nurse's discretion for the Midodrine. Further investigation revealed that Midodrine was to be given at 11:30AM.

Interview with EMP 1 and EMP 5 confirmed that all medications should be scanned prior to being given, and the nurse can use nurse's discretion when documenting in MAR.

Interview with EMP7 regarding giving the medication late stated, "I forgot "

Based on Life Safety Code Validation survey completed on January 09, 2020, the Condition for Physical Environment is not met. See the Life Safety Code 2567 for the deficiencies.

Based on observations of the post-surgical unit and the rehabilitation unit and interview with facility staff, it was determined that the facility failed to ensure the condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured.

Findings include:

Observation of the post-surgical unit and rehabilitation unit the hand sanitizers were above the night lights in all the rooms. It was noted in multiple rooms that the hand sanitizer drip tray had liquid in it and dripping onto the floor.

An interview conducted on January 27, 2020 with EMP 1 revealed that there should not be any liquid in the drip tray.


A review of facility policy on January 27, 2020 of Labeling and Dating:
"The following list illustrates the standards and parameters that FNS has adopted for the labeling of food receiving, food in storage and food in Production: ... Opened up shelf stable items without TCS ingredients; 4 weeks ... ."

A tour of the Post- Surgical Unit revealed that in both freezers units of the refrigerators had in a plastic container five small containers of fruit paste with ice crystals formed on top and there was no date on any container.

An interview with EMP 2 on January 27, 2020 at 11:10AM confirmed that there was no date on the fruit paste.

Based on a review of facility documentation, observations and interview with facility staff, it was determined that the facility failed to ensure the condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured.

Findings include:

Observation of the Post-Surgical Unit and Rehabilitation Unit the hand sanitizers were above the night lights in all the rooms. It was noted in multiple rooms that the hand sanitizer drip tray had liquid in it and dripping onto the floor.

An interview conducted on January 27, 2020 with EMP 1 revealed that there should not be any liquid in the drip tray.


A tour conducted on January 29, 2020, at 10:30 AM of the Dietary Department's Dry Storage area revealed the dry food items were stored on open shelving that did not protect the dry goods by contamination from mopping.

An interview conducted on December 29, 2020, at 11:00 AM with EMP2 confirmed that the dry goods were stored on open shelves.

Based on observations and interview with staff, it was determined that the facility failed to ensure the transmission of infection within the hospital.

Findings include:

Facility unable to provide policies related to the storage and collection of soiled linens on the nursing units.

Observation of Soiled Utility rooms on the Post-Surgical Unit revealed that one Soiled Utility room upon entering had ten bags of soiled linen laying on the floor with two bags having tears.

Interview with EMP 3 on January 27, 2020 at 11:00 AM revealed there should have been a gray bin there for the dirty laundry.