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Based on observations, record reviews and interview, the facility administrative officials failed to ensure that medication administration errors, wastage, and drug discrepancies, were discussed by the Interdisciplinary Team (IDT) during monthly quality meetings.

Findings include:

Record review of the facility document entitled Medication Errors, for the time period of June 1, 2017 to June 18, 2018 revealed that nursing staff failed to accurately document the administration and/or waste of controlled substances for 23 of 23 controlled drug administrations.

Record review of the Facility Quality Assessment Performance Improvement (QAPI) for the time period of June 2017 to May 2018 revealed no evidence that the IDT had discussed nursing services failure to document the administration and/or waste of controlled substances.

Record review of the facility policy entitled Medication Management, origination date: June 6, 2007, revealed in part the following information:

Section A, Part 2:
- The disposition of all controlled substances must be documented. Administration to the patient will be documented in the patient medical record, wastage will be documented in pyxis with a witness.

In an interview conducted on June 20, 2018 at 10:30 am, the Director of Quality, Chief Nursing Officer and the Director of Pharmacy confirmed the above findings.

Based on record review, interview and review of Medical Staff Bylaws, the hospital failed to meet the requirement for 1 of 3 surgical patients (patient #2) because the history and physical was not authenticated by the person providing or evaluating the service provided.

Findings Include:

A. Review of the electronic medical record for patient #2 on 06/20/18 at 9:35 a.m. with S#1 and S#2 in classroom B revealed in part that the patient's date of service for surgery was on 02/08/2018 and included a history and physical dated 01/26/2018 that was not signed by the physician.

B. In an interview on 06/20/18 at 9:35 a.m. in classroom B, S#1 confirmed the above findings.

C. The Medical Staff Bylaws, last approved on June 14, 2018 were reviewed in part to include pages 10-11 on 06/20/18 at 12:00 p.m. in the conference room and stated in part:

The medical history and physical examination for each patient shall be done no more than 30 days before or twenty-four (24) hours after an admission or registration, but prior to surgery or other procedure requiring anesthesia services and placed in the patient's medical record within twenty-four (24) hours after admission.

Where the history and physical is completed within 30 days prior to admission (or procedure or service that requires a history and physical), the hospital will ensure that this history and physical is updated by a qualified individual to document any changes in the patient's condition. If there are no changes to the history and physical ...the physician can document an update note stating that the history and physical has been reviewed, that the patient has been examined, and that the physician concurs with the findings of the history and physical completed on the specified date or that "no change" has occurred ...This examination and update ...shall be completed and placed in the medical record within twenty-four (24) hours after admission or registration, but prior to surgery or other procedure ...

The practitioner completing the update is responsible for ensuring that the history and physical is documented in the medical record and is complete and accurate. The completed history and physical must be authenticated by the practitioner who conducted the history and physical ...Authentication includes dating and timing of this medical record entry.

Based on record review, interview and review of Medical Staff Bylaws, the hospital failed to meet the requirement for 1 of 3 surgical patients (patient #2) because the unauthenticated history and physical completed prior to the patient's admission was not updated as to whether there were any changes to the patient's physical condition prior to service.

Findings Include:

A. Review of the electronic medical record for patient #2 on 06/20/18 at 9:35 a.m. with S#1 and S#2 in classroom B revealed in part that the patient's date of service for surgery was on 02/08/2018 and included a history and physical dated 01/26/2018 that was not signed by the physician and the medical record was not updated by a physician as to whether there were any changes to the patient's physical condition.

B. In an interview on 06/20/18 at 9:35 a.m. in classroom B, S#1 confirmed the above findings.

C. The Medical Staff Bylaws, last approved on June 14, 2018 were reviewed in part to include pages 10-11 on 06/20/18 at 12:00 p.m. in the conference room and stated in part:

The medical history and physical examination for each patient shall be done no more than 30 days before or twenty-four (24) hours after an admission or registration, but prior to surgery or other procedure requiring anesthesia services and placed in the patient's medical record within twenty-four (24) hours after admission.

Where the history and physical is completed within 30 days prior to admission (or procedure or service that requires a history and physical), the hospital will ensure that this history and physical is updated by a qualified individual to document any changes in the patient's condition. If there are no changes to the history and physical ...the physician can document an update note stating that the history and physical has been reviewed, that the patient has been examined, and that the physician concurs with the findings of the history and physical completed on the specified date or that "no change" has occurred ...This examination and update ...shall be completed and placed in the medical record within twenty-four (24) hours after admission or registration, but prior to surgery or other procedure ...

The practitioner completing the update is responsible for ensuring that the history and physical is documented in the medical record and is complete and accurate. The completed history and physical must be authenticated by the practitioner who conducted the history and physical ...Authentication includes dating and timing of this medical record entry.

Based on medical record review, interview and hospital policy review, the hospital failed to meet the requirement for 1 of 3 surgical patients (patient #1) because the informed consent was incomplete.

Findings Include:

A. Review of the electronic medical record for patient #1 on 06/19/18 at 2:15 p.m. with S#1
in classroom B revealed that informed consent signed by the patient on 05/23/18 at 8:25 a.m. was signed by the physician but the date and time were left blank.

B. In an interview on 06/19/18 at 2:15 p.m. in classroom B, S#1 confirmed the above findings.

C. The hospital policy number RI.022 entitled, "Consent for Treatment," with a "final approval date of 5/1/2018," was reviewed on 06/20/18 at 12:30 in a conference room and stated the following in part:

Physician Responsibilities

It is the responsibility of the physician to inform the patient of all procedures that require informed consent and to ensure that all parts of the consent form are complete.

Based on record reviews and interviews, the facility failed to ensure that nursing staff accurately documented administration and wastes of controlled drugs listed in schedules II, III, IV and V of the Comprehensive Drug Abuse Prevention and Control Act.

This deficient practice placed the facility at increased risk of experiencing serious drug diversions and/or adverse patient outcomes.

Findings include:

Record review of the facility document entitled Medication Errors, for the time period of June 1, 2017 to June 18, 2018 revealed that nursing staff failed to accurately document the administration and/or waste of controlled substances for 23 of 23 controlled drug administrations.

Record review of the facility policy entitled Medication Management, origination date: June 6, 2007, revealed in part the following information:

Section A, Part 2:
- The disposition of all controlled substances must be documented. Administration to the patient will be documented in the patient medical record, wastage will be documented in pyxis with a witness.

In an interview conducted on June 20, 2018 at 10:30 am, the Director of Quality and the Chief Nursing Officer confirmed the above findings.

Based on observation, interview, and review of hospital policy, the hospital failed to meet the requirement to ensure the facility and supplies were maintained to ensure an acceptable level of safety and quality because of inappropriately packaged Magill forceps on crash carts, dirty tape on a keyboard tray, dusty debris and corrosion in a cabinet, expired supplies, unpackaged oral airways available for patient use, chipped laminate with exposed wood on a cabinet, separation of caulk around backsplashes, a hole in the drywall of a soiled utility room, rust colored dried drippage under a sink, chipped and missing pieces of floor tiles, deteriorated and chipped baseboards, and a doorway with chipped paint.

Findings Include:

A. During a tour of the surgical services department on 06/18/18 beginning at 11:15 a.m. accompanied by S#1 and S#2, observations revealed the following:

1. The crash cart in the pre-operative area contained a Magill Forceps in a peel pouch that did not contain an internal indicator such that sterility could not be ascertained. In addition, the pouch was not labeled with a load number, date, description and identification of the staff member that packaged it.

2. A piece of dirty coverall tape about 4 x 6 inches in size was adhered to the right side of a tray holding a keyboard such that it could not be properly cleaned.

3. The safety storage cabinet in a storage room in hallway #1 contained the following:
A 4 ounce spray bottle of Tincture of Benzoin with an expiration date of "04/18" on the second shelf which had an area of white corrosion.
Four (4) expired medical gas tanks on the bottom shelf. Three of these tanks had 25 std liters each of 5% Carbon Dioxide, 4% Halocarbon - 23, 40% Nitrous Oxide, Bal Oxygen. Two (2) of the tanks had an expiration date of "04 08" and one (1) tank with dusty debris on top of it had an expiration date of 03/10. The fourth tank contained 20 liters of CO2 5.0%, O2 54.5%, N2) 36% Bal N2 and Desflurane 2% and had an expiration date of "04/14.". Dusty debris was around the tanks.

4. An anesthesia cart in a hallway outside the heart prep room contained 8 unpackaged oral airways in assorted sizes.

5. The crash cart for the operating rooms contained a Magill Forceps in a peel pouch that was not labeled with a load number and identification of the staff member that packaged it.

In an interview on 06/18/18 at 1:20 p.m. in hallway #1 of the operative suite, S#1 and S#2 confirmed the above findings.

B. During a tour of the emergency department on 06/19/18 beginning at 10:32 a.m. accompanied by S#1, S#5 and S#6, observation revealed the following:

1. A cabinet door in Room #12 with chipped laminate exposing the wood underneath about the size of a nickel and separation of the caulk around the backsplash such that these areas could not be properly cleaned.

2. A hole about 1 ½ inch x 3 inches in the drywall behind a door in the soiled utility room.

3. An area of the beige counter top on the left side of a sink in the medication room was worn such that a reddish brown color was visible with separation of the caulk around the backsplash and rust colored dried drippage under the sink.

4. Separation of the caulk around the backsplash in Room #11.

5. Two chipped and missing pieces of floor tile outside the door of Room 2B.

6. Chipped and deteriorated baseboards in the hallway outside the EMS Lounge.

7. Chipped paint around the doorway frame to the soiled utility room.

8. The Broselow's Cart contained 6 unpackaged oral airways in assorted sizes, a 500 ml bag of Lactated Ringers Injection USP solution "exp Apr 18," and a Broselow/Hinkle Pedi Emergency System with the following expired modules:

a. Blue Oxygen Delivery Module "exp 2018/04."
b. Orange Intubation Module "exp 2018/02."
c. White Intubation Module "exp 2017/09."
d. Yellow Intraosseus Module "exp 2018/05."
e. Purple IV Delivery Module "Exp. Date 2018/02."
f. Purple Intraosseus Module "exp 2018/01."
g. Pink Red Intubation Module "Exp. Date 2018/03."

In an interview on 06/19/18 at 12:00 p.m. at the nurses station, S#1, S#5 and S#6 confirmed the above findings.

C. The hospital policy number PC.CSS.018 entitled, "Sterilization Principles in Central Sterile," with a "final approval date 5/1/18," was reviewed on 06/20/18 at 1:00 p.m. in the conference room and stated the following in part:

4. Chemical indicators, also known as sterilization process indicators, are used to indicate that items have been exposed to a sterilization process.

8. Every package is imprinted or labeled with a load control number that indicates the sterilizer used, the cycle or load number, and the date of sterilization to include staff member initials.

Based on observation, interview, and review of hospital policy, the hospital failed to meet the requirement to maintain a sanitary environment to avoid sources of transmission of infections because of inappropriately packaged Magill forceps on crash carts, dirty tape on a keyboard tray, dusty debris and corrosion in a cabinet, unpackaged oral airways available for patient use, chipped laminate with exposed wood on a cabinet, separation of caulk around backsplashes, a hole in the drywall of a soiled utility room, rust colored dried drippage under a sink, chipped and missing pieces of floor tiles, deteriorated and chipped baseboards, and a doorway with chipped paint.

Findings Include:

A. During a tour of the surgical services department on 06/18/18 beginning at 11:15 a.m. accompanied by S#1 and S#2, observations revealed the following:

1. The crash cart in the pre-operative area contained a Magill Forceps in a peel pouch that did not contain an internal indicator such that sterility could not be ascertained. In addition, the pouch was not labeled with a load number, date, description and identification of the staff member that packaged it.

2. A piece of dirty coverall tape about 4 x 6 inches in size was adhered to the right side of a tray holding a keyboard such that it could not be properly cleaned.

3. The safety storage cabinet in a storage room in hallway #1 contained the following:

A 4 ounce spray bottle of Tincture of Benzoin with an expiration date of "04/18" on the second shelf which had an area of white corrosion. Four (4) expired medical gas tanks on the bottom shelf. Three of these tanks had 25 std liters each of 5% Carbon Dioxide, 4% Halocarbon - 23, 40% Nitrous Oxide, Bal Oxygen. Two (2) of the tanks had an expiration date of "04 08" and one (1) tank with dusty debris on top of it had an expiration date of 03/10. The fourth tank contained 20 liters of CO2 5.0%, O2 54.5%, N2) 36% Bal N2 and Desflurane 2% and had an expiration date of "04/14." Dusty debris was around the tanks.

4. An anesthesia cart in a hallway outside the heart prep room contained 8 unpackaged oral airways in assorted sizes.

5. The crash cart for the operating rooms contained a Magill Forceps in a peel pouch that was not labeled with a load number and identification of the staff member that packaged it.

In an interview on 06/18/18 at 1:20 p.m. in hallway #1 of the operative suite, S#1 and S#2 confirmed the above findings.

B. During a tour of the emergency department on 06/19/18 beginning at 10:32 a.m. accompanied by S#1, S#5 and S#6, observation revealed the following:

1. A cabinet door in Room #12 with chipped laminate exposing the wood underneath about the size of a nickel and separation of the caulk around the backsplash such that these areas could not be properly cleaned.

2. A hole about 1 ½ inch x 3 inches in the drywall behind a door in the soiled utility room.

3. An area of the beige counter top on the left side of a sink in the medication room was worn such that a reddish brown color was visible with separation of the caulk around the backsplash and rust colored dried drippage under the sink.

4. Separation of the caulk around the backsplash in Room #11.

5. Two chipped and missing pieces of floor tile outside the door of Room 2B.

6. Chipped and deteriorated baseboards in the hallway outside the EMS Lounge.

7. Chipped paint around the doorway frame to the soiled utility room.

8. The Broselow's Cart contained 6 unpackaged oral airways in assorted sizes, a 500 ml bag of Lactated Ringers Injection USP solution "exp Apr 18," and a Broselow/Hinkle Pedi Emergency System with the following expired modules:

a. Blue Oxygen Delivery Module "exp 2018/04."
b. Orange Intubation Module "exp 2018/02."
c. White Intubation Module "exp 2017/09."
d. Yellow Intraosseus Module "exp 2018/05."
e. Purple IV Delivery Module "Exp. Date 2018/02."
f. Purple Intraosseus Module "exp 2018/01."
g. Pink Red Intubation Module "Exp. Date 2018/03."

In an interview on 06/19/18 at 12:00 p.m. at the nurses station, S#1, S#5 and S#6 confirmed the above findings.

C. The hospital policy number IP.001 entitled, "Infection Prevention & Control Program Plan" with a "final approval date of 5/2/2018," was reviewed on 06/20/18 at 12:15 p.m. in a conference room and stated the following in part:

Routine scheduled "walking rounds" are integrated with safety, and environmental services or done independently. Problems identified are referred to the appropriate department, division, or committee for discussion and correction.

The hospital policy number PC.CSS.018 entitled, "Sterilization Principles in Central Sterile," with a "final approval date 5/1/18," was reviewed on 06/20/18 at 1:00 p.m. in the conference room and stated the following in part:

4. Chemical indicators, also known as sterilization process indicators, are used to indicate that items have been exposed to a sterilization process.

8. Every package is imprinted or labeled with a load control number that indicates the sterilizer used, the cycle or load number, and the date of sterilization to include staff member initials.