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Based on observation, it was determined the facility failed to maintain the building physical structure in a state of good repair (rust, mildew and hole in a ceiling tile) in two [Medical-Surgical (Med-Surg) unit and the Gastro-intestinal (GI) Lab] of five areas observed. The failed practice had the potential to affect all patients, staff, and visitors due to the potential for infection control issues. Findings follow:

A. While on tour of the facility on 08/01/2017 at 1015, it was observed rust and mildew on the air conditioning vent and the surrounding ceiling tiles in the clean supply storage closet in the Med-Surg Unit.
B. While on tour of the facility on 08/01/2017 at 1037, it was observed a large hole in the corner of the ceiling above and behind the autoclave in the GI Lab.
C. While of tour of the facility, the Associate Administrator verified the failed practices.

Based on review of Pharmacy Policies 3.41.1.1-3.41.6.1, observation and interview, the facility failed to ensure Pharmacy policies reflected the current automated distribution system (Omnicell) utilized in three of three (Pharmacy, Medical Surgical Unit, Emergency Department) medication areas observed. The deficient practice had the potential to affect Pharmacy and Nursing staff by not having policies for the use of the Omnicell and affect all patients in receiving medications. Findings follow:

A. A tour of the facility was conducted on 08/01/17 between 10:00 A.M. and 11:15 A.M. Omnicell Automated Medication Dispensing Units were observed at the Medical/Surgical Unit and Emergency Department. A tour of the Pharmacy was conducted on 08/02/17 between 8:30 A.M. and 10:00 A.M. in which the Omnicell was observed in the Pharmacy.
B. Pharmacy Policies 3.41.1.1-3.41.6.1 were reviewed on 08/02/17 at 9:00 A.M. The policies reflected the use of Pyxis Automated Dispensing Units. No policies existed for the use of Omnicell Automated Dispensing Units for the facility.
C. During an interview on 08/02/17 at 9:30 A.M., the Director of Pharmacy verified the dispensing system in use was an Omnicell Automated Dispensing Units. In the same interview, the Director of Pharmacy verified Pharmacy policies reflected the use of Pyxis Automated Dispensing Units and not Omnicell Automated Dispensing Units.

Based on clinical record review and interview, it was determined that the facility failed to ensure there were accurate and complete History and Physicals on 7 of 7 (#10-#16) endoscopy records. The failed practice did not ensure the facility staff was knowledgeable and prepared for the care of the endoscopy patient. The failed practice affected Patients #10- #16. Findings follow:

Review of the clinical record of Patients #10-#16 from 1200-1315 on 08/02/17 revealed there was no accurate or complete and History and Physical in the patient's clinical record. The above findings were verified with the Emergency Room Outpatient Services Director on 08/02/17 at 1315.