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Based on observation, interview, and tour of the pharmacy it was determined that the facility failed to remove unusable drugs from the pharmacy stock and were available for patients use.


Findings were:


Facility Policy titled "Medication Use" stated in part, I. Storage and Security, A. Medications stored within the pharmacy and throughout the hospital are under the direct control of the pharmacy department. 3. Outdated or unusable drugs are removed from stock, marked, and stored in designated areas in the pharmacy until properly disposed.

Tour of the hospital pharmacy on 10/26/2015 revealed the following open, multi-use medication bottles stored on the pharmacy shelves that were unlabeled as to date opened and the staff member who opened them.

1. Pepto Bismal four ounce bottle
2. Sodium Polystyrene Solution (Suspension Kayexelate) sixteen ounce
3. Mineral Oil one ounce
4. Sodium Citrate and Citric Acid Oral Solution sixteen fluid ounces bottle.
5. Diabetic Tussin Expectorant six ounce bottle
6. Simple Syrup sixteen ounce bottle
7. Lidocaine Hydrochloride oral Topical three ounce bottle.

The above unusable medications missing opened dates were confirmed by the Facility Pharmacist on 10/26/15.

Based on observation, interview and review of documentation, it was determined that the Kitchen Manager failed to oversee staff to ensure their competency in operating all of its equipment.

Findings were:

Facility policy entitled "Infection Control Plan" stated its purpose as "To establish and provide oversight of the infection prevention and control standards necessary to reduce the risks of acquiring and transmitting healthcare-associated infections among patients, employees, independent licensed practitioners, and others through surveillance, prevention, and control activities within all St. Mark's Medical Center departments."
Tour of the kitchen on 10/27/15 revealed a dishwasher with a non-functioning thermostat. Per manufacturer recommendation, the dishwasher should have had a final rinse with water temperature at 180 degrees. Review of the dishwashing log revealed temperatures of the final rinse to be recorded at 160 degrees from 10/12/15 through 10/26/15. According to the Kitchen Manager, the temperature gauge was discovered to have been broken around the first of the month. The kitchen switched to a chemical disinfectant (bleach sanitization) from 10/1/15 through 10/24/15. At that point, they began using temperature strips which would indicate water temperature during the final rinse. Review of the "Water Log for a Heat Sanitized Dish Machine" revealed the 5 times the strips had been used; they indicated temperatures only going to 160 degrees. The Kitchen Manager discovered that the staff had been using the wrong strips. When he tried (twice) to use the correct strips, the water temperature of 180 degrees was not achieved.
In an interview with the Kitchen Manager on 10/27/15, it was confirmed that the temperature gauge on the dishwashing machine was not functional and had not been since the beginning of the month. It was also acknowledged that kitchen staff had been using the wrong strips to check the water temperature. It was agreed that the dishwashing machine would not be used further until it had been fixed by the manufacturer.

Based on observation and interview, it was determined that the facility failed to provide a safe and sanitary environment for its staff and patients.


Findings were:


" OSHA/Blood Borne Pathogen Regulations Policy #138-030-060 " stated in part " The facility provides sufficient housekeeping and maintenance personnel to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner. "

In an article published by Spectrum Health in July, 2014 it was stated "The heavier corrugated cardboard shipping boxes might harbor vermin or insects and spread the pests to areas where the boxes are stored after delivery. Corrugated cardboard boxes are not appropriate as storage units in medical or clean supply rooms. These boxes are not appropriate because they are an excellent harbor for insects and pests."

Tour of the facility on 10/26/15 revealed the following infection control issues in the Emergency Room (ER).
ER room five:
· The stretcher mattress was dirty, it had a piece of moist tape labeled "replaced 3/19/10" and the frame had chipped paint.
· The linen cart was dirty.
· A layer of dust was found in both ceiling vents, on top of the Maxant Techline X-Ray viewer, on top of the exam light, on the Welch Allen otoscope/ophthalmoscope wall unit and on the computer.
ER room six:
· There was a layer of dust on the Maxant Techline X-Ray viewer.
· The bed frame paint was chipped.
· The wheels on the cart were dirty.
· The floors were dirty.
Employee # 1 confirmed the above, stated they are "going from room to room to re-polish".
ER Patient Bathroom:
· Wall gouges in the sheet rock.
· Ceiling vent covered in dust.
· Bugs in overhead light.
Soiled Utility room:
· Several vents were covered in dust.
Employee #7 stated he was "looking to creating new policies to clean (the vents) regularly".
Clean utility room:
· Dust was found on top and in the vent of the ice maker.
· The vinyl underside of the cabinets were peeling away and kept in place with tape.
· The refrigerator log parameters for acceptable ranges were in degrees Celsius, but staff recorded temperature checks in degrees Fahrenheit. When asked how someone knows when refrigerator is not in parameters, employee #1 stated, "I don't know".
· Corrugated boxes were found. Employee #7 stated, "They're not supposed to have those in here".
Trauma room:
· Dirty bed.
· Supplies stored under the sink.
· Dead bugs in corner.
· Equipment stored on floor, long slide board and papoose.
· Live spider on wall.
· A layer of dust on top of warmer.
Crash Cart #3 (three):
· All seven drawers were dusty inside.
· Dirty tape.
· Dirt/dust on outside of cart.
· Two Magill Forceps #8R7542 dated 5/6/16 were closed.
ER Hallway:
· Bugs were observed in nine overhead light covers.
· Supplies found under the sink across from ER bed eight.

Tour of the facility on 10/26/15 revealed the following infection control issues in the Surgery Department.
· Chipping ceiling tiles by the sterilizer.
· Stretcher in the main hall broken.
· Tape holding up railing.
· Corrugated boxes found in storage areas.

Tour of the facility on 10/26/15 revealed the following infection control issues in the Pharmacy Department.
· Grime/soap build-up behind sink.
· In narcotic control room, two ceiling tiles with water stains.
· Corrugated boxes found in storage area.

Tour of the facility on 10/26/15 revealed the following infection control issues in the Birthing Center.
· Room 503 had dust on top of over-bed light and a dirty vent.
· The nursery had dust on the paper towel holder by the sink and a crack the whole length of the floor.
· In the nurse's station, the ice maker had a dirty tray and dust in the vent.
· Corrugated boxes found in equipment storage area. Employee #4 stated, "We are trying to put all supplies in clear boxes."

Tour of the facility on 10/26/15 revealed the following infection control issues in the Medical-Surgical Department.
Room 108:
· Dust on both over bed lights.
· Over bed light by the window dirty.
· Overhead vents dusty.
· Chip in bedside table.
· Bed frame with a lot of rust.
· Sink not draining water.
Room 203:
· Wall chipped in entry of room on both sides.
· Wall chipped in walls by bed.
· Water stains on ceiling tiles.
· Dusty vent.
General Areas:
· Hand rails across from room 108 and 104 held up with tape.
· The ice/water dispenser was dirty.
· Cleaning products were being stored under the sink by the nurse's station.


Tour of the facility on 10/27/15 revealed the following infection control issues in the Laboratory Services Department.
· Two sinks with build-up/dirt.
· Dirty floors.
· A dirty overhead light.
· The "dirty" sink not designated.
· In the microbiology room, there was a stain on the floor and a dye stained sink.

Tour of the facility on 10/27/15 revealed the following infection control issues in the Kitchen.
· Dirt and dust behind the refrigerator.
· Dirty floors.
· Bottom shelf with water stains/grime.
· In the janitorial service closet, a very rust/dirty vent.
· Employee #23 wiped a dish with shirt sleeve.
· Between dock doors with a little bit of visible light noted.
· Two water stained ceiling tiles in the dry storage room.
· Food labeled with date, not with contents. When asked "how do you know what this is?" employee #23 stated, "I do not know".

Tour of the facility on 10/27/15 revealed the following infection control issues in the Radiology Department.
· In room five: water stains in ceiling tiles. Tear in vinyl mattress and rust on bedframe.
· The computed tomography (CT) machine had Velcro straps up the arm holding the cable in place. When removed, dust was noted.
· In room eight, water stains in the ceiling tiles.
· Soiled utility sink dirty and clogged.
· In room two, nuclear medicine, wedge foam pillow torn and old. Three holes in floor.

Tour of the facility on 10/27/15 revealed the following infection control issues in the Obstetric/Gynecology Clinic.
· Cracked wall socket.
· Floors dirty.
· Water damage in ceiling tiles.
· Washer and dryer used without monitoring temperatures or sanitizing between loads.

In a tour of the facility, observations, and interviews with staff members #1, #6 and #8 on 10/26/15 and 10/27/15, the above infection control issues were confirmed. These infection control issues presented a safety risk to patients.