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Based on observation and interview the facility failed to provide a sanitary ice dispensing machine resulting in the potential for transmission of infectious agents among patients served and staff who work there. Findings include:

On 6/26/13 at approximately 1110, during the building tour found in the Emergency Department accumulation of soil and scale at the dispensing port of the ice machine. On 6/26/13 at approximately 1110 the above finding were confirmed by the maintenance supervisor.

Based on observation and interview the facility failed to provide a sanitary environment that was free from dust resulting in the potential for transmission of infectious agents among patients served. Findings include:

On 6/26/13 at approximately 1140 during a tour of the facility, observed accumulation of dust at various locations including but not limited to; the tops of all exam lights in every exam/treatment rooms of the Emergency Department, above the Pyxis (medication dispensing unit), in the medication room serving the Emergency Department, above the intravenous (IV) fluid and blanket warmer machine between the acute care and the Emergency Room, and on the slopped top of the wall mounted cabinet in the triage room. On 6/26/13 at approximately 1145 the above findings were confirmed by the maintenance supervisor.

Based on observation and interview the facility failed to ensure adequate ventilation and monitor appropriate temperature of the medication refrigerator resulting in the potential for patient discomfort and patient harm for patients served by the facility. Findings include:

On 6/26/13 at approximately 1030, it was noted that floor and table fans were in use in both the blood draw area, the general laboratory rooms and at the nurses' station serving the Emergency Room. On 6/26/13 at approximately 1035 the maintenance supervisor confirmed the widespread use of fans for patient and staff comfort.

On 6/26/13 at approximately 1040, the temperature log for the patient medication refrigerator serving the surgery Department was not available. When surgery staff was asked regarding the location of the temperature monitoring sheet, she indicated that they do not maintain any medication refrigerator temperature readings on site, rather the temperature is monitored off site. The patient medication refrigerator contained eye surgery medications. On 6/26/13 at approximately 1040 the maintenance supervisor confirmed that there is no "on-site" monitoring of the temperature of the eye medication refrigerator, surgery staff indicated that the temperature is monitored off-site.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on 6/27/13, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated 6/27/13 for Life Safety Code survey results.