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Based on observation, review of documentation and an interview with staff # 3 the facility failed to maintain the facility generator in safe operating condition; the facility failed to perform weekly and monthly generator checks according to the facility policy.
Findings were.
Review of documentation Life Safety, Policy Loss of Power stated, " The generator is run once a week for 10 minutes and once a month for 30 minutes under load for testing purposes. "
Review of the Emergency Generator Operation Log form 12/19 through 4/19 revealed 10 minute generator checks were performed 3 times in December 2012, (12/14, 12/21, 12/27), 1 generator check in January 2013, (1/28), and 2 times in April (4/5, 4/19) and the 30 minute generator checks were only performed 1 time (3/19) in 2012.
In an interview with staff # 3 the findings were confirmed. The facility failed to perform weekly 10 minute generator and 30 minute monthly checks according to facility policy.

Based on observation and interview with staff, the facility failed to ensure that drugs and supplies were appropriately stored, as outdated medications and supplies were found in 3 areas of the hospital available for patient use.

Findings were:

A tour was conducted of the facility the afternoon of 5/6/2013. Found in the ER trauma room were the following expired supplies which were available for patient use: One lab vacutainer tube which expired 10/2012 and 3 which expired 4/2013; one package of oxygen supplies in the pediatric crash cart which expired 11/2012 and 6 which expired 4/2013. Four suture packets were expired, 1 in 1/2013 and 3 in 7/2012. In the Surgery Department, the crash cart contained a bag of IV fluid which expired 1/5/2013 and 5 vials of saline which expired 4/2013. One vial of Atropine expired 4/13 and 3 expired 3/2013.
A tour of the medical unit was conducted the morning of 5/7/13. In the medical unit nursing station, 4 lab vacutainers were found which had expired in March 2013. These supplies were available for patient use.

An in-person interview was conducted with the Chief Nursing Officer the afternoon of 5/9/2013. The CNO acknowledged the above findings of the expired medications and supplies which were available for patient use.

Based on observation and an in-person interview with staff #4 on the morning of 5/7/13 at the facility in the pharmacy; the facility failed to ensure that policies were provided to ensure that current accurate records were kept and disposition of schedule drugs. The count for lorazapam (ativan) a schedule drug was incorrect.
Findings were.
During a tour of the pharmacy on the morning of 5/7/13 with staff # 4, the schedule medication lorazapam 0.05 mg documented balance was 79. A manual count performed by staff # 4 revealed the balance on hand was 63. A random schedule count was performed by staff # 4 on ativan 2mg/ml per vial and the balance was 49. The documented balance was 48.
Review of the pharmacy policy manual did not reveal a policy to ensure the correct, accurate, and disposition of schedule drugs.
In an in-person interview with staff # 4 on the morning of 5/7/2013 in the pharmacy, the findings were confirmed.