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Based on review of facility policy, review of medical records (MR), and interviews with staff (EMP), it was determined that the facility failed to identify and provide adequate justification for the use of medications as a chemical restraint for two of 19 restraint records reviewed (MR1 and MR2).
Findings include:
Review of facility policy "Restraint Policy," dated June 2014, revealed "MHS is committed to preventing, reducing, and striving to eliminate the use of restraint(s); preserving the individual's safety and dignity when restraint is used; using alternative measures as preferred interventions; ... limiting the use of restraint to emergencies in which there is imminent risk of an individual physically harming himself or herself or others, and/or interference with healing. ... II. Policy A. ... Alternatives will be used as a first line intervention prior to the use of restraints. B. When alternatives measures are assessed as ineffective or no longer feasible, and the safety and well-being of patients and/or staff is threatened, restraint may be utilized following established policies and procedures. The decision to restrain a patient is driven not by diagnosis, but by comprehensive individual assessment which concludes that for this patient, at this time, the use of less intrusive measures poses greater risk than the risk of using restraint or seclusion. Focused behavior assessments shall address history and clinical symptoms of abuse, or violence and medical/psychiatric issues that may be pertinent to restraint practices. The comprehensive assessment should include a physical assessment to identify medical problems that may be causing behavior changes in the patient. C. The least restrictive method of restraint that meets the patient's need will be utilized. Patient rights and dignity will be preserved ... E. Patients have the right to be treated with respect and dignity in a safe, humane, culturally sensitive, and developmentally appropriate manner that respects patient choice and maximizes self-determination. H. The patient and family are recognized as integral members of the care team. Staff will attempt to contact the family or medical decision maker to inform them of the restraint episode either when authorized by the patient or when the patient lacks capacity to make his/her own medical decisions. ... IV. Definition: B. A chemical restraint is defined as a drug or medication when it is used as a restriction to manage a patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition. ... 1. Chemical restraints are utilized in the following manner: Behavior Management: Protect the aggressive or violent patient at risk to harm himself or at risk to harm others when alternatives have failed. ... 2. Medical Management: A mechanism to promote medical or surgical healing in a non-violent and/or non-aggressive patient to ensure necessary procedure(s) or treatment(s) when other alternatives have proven ineffective. ... 4. When choosing the type of restraint, the least restrictive type of restraint will be chosen to optimize individual mobility. VI. Procedures A. Alternative Measures Alternative measures are to be considered prior to application of restraint device. ... If alternative methods cannot be used prior to restraint use, or have failed, clear detailed documentation of rationale for restraint use will be noted on the Restraint Flow sheet in the medical record. Examples of Alternative Measures 1. Staff will evaluate and implement appropriate alternatives. Suggestion for alternatives include: Companionship: family or friend, Modify Environment, Decrease Stimuli/Noise Reduction, Assessment for underlying physiological problems ... E. Documentation of the use of medical surgical restraints 1. Each episode of use of medical surgical restraints shall be documented on the Restraint Flow Record and in the Interdisciplinary Plan of Care. ... 2. Documentation in the patient's medical record will include: a. Evaluation for restraint b. Specific circumstances and exhibiting behavior supporting the decision for restraint usage in the plan of care. C. Alternatives attempted or other less restrictive interventions that apply to the specific patient scenario. D. Type of restraint. E. Patient's response to the intervention used. ... l. Revisions/Updates to the plan of care. ...H. Documentation of behavioral restraint use: 1. Each episode of use of behavioral health restraints in the acute care setting shall be documented in Notes and in the Renewal of Orders. Orders for restraints include: a. Date and time restraint initiated b. Type of restraint ... d. Reason of clinical justification for restraint ... VII. Staff Training and Competency: 1. All clinical staff with a role in the implementation of restraint/seclusion procedures must be trained and demonstrate competency in prevention, proper and safe usage. ... "
Review of MR1 "History and Physical," dated December 4, 2014, revealed "Chief complaint syncope ... Medical History ... (3) Dementia ...(6) Risk for falls (7) syncope ... ."
Review of MR1 physician's order, dated December 6, 2014, timed at 5:00 AM, revealed "Haloperidol Lactate (also known as Haldol- a antipsychotic medication used to treat psychosis and that can have sedating effects) 5mg/1 ml vial." Further review of the physician's order revealed that it was a one-time order, but was without clinical indication/reason for use on this patient.
Review of MR1 "Nurses Notes," dated December 6, 2014, timed 06:00 AM, revealed " Pt is awake, alert, oriented x1, Pt is very confused forgetful, anxious and agitated. Pt is getting out of bed frequently. Reoriented Pt frequently. Pt denies pain. Pt refused Tele Monitor and IV Fluid. Pt stated, ""You are giving me poison and I want to call the police. "" Notified Dr. [EMP7] and Haldol 2mg IV (intravenously) given as ordered. IV fluids started as ordered ... ."
Review of MR1 "Psychiatric Consultation," dated December 6, 2014, timed 1405 (2:05PM), revealed "Reason for Consultation: Worsening dementia. ... as I [psychiatrist] see it, [pt] major issue is that [pt] is alone in a place which [pt] does not recognize and in which [pt] feels is alien to [pt]. [Pt] has no trust of the staff and has verbalized to me that we will harm [pt]. ... " Further review of the "Psychiatric Consultation" revealed no mention of the administration of Haldol, nor was there any previous history of the patient being treated with Haldol to indicate that this medication was administered as a standard treatment for the patient's condition.
Further review of MR1 revealed no documented evidence that appropriate alternatives or that least restrictive measures were attempted first, that the patient's representative was consulted prior to the administration of the medication, nor was there documented evidence that an assessment was completed after the administration to monitor the effect of the medication in order to ensure the patient's well-being.
This finding was reviewed with EMP2, during an interview on December 8, 2014, at 11:40 AM.
Review of MR2 "History & Physical," dated November 23, 2014, revealed "History Limitation: Language Barrier ... Chief Complaint SOB (shortness of breath) worsening SOB past two weeks ... Review of Systems Psychiatric: Anxiety ... Medical History: (1) Anxiety ...(14) SOB ... ."
Review of MR2 "Care Activity- Assessments," dated November 30, timed 00:00 (midnight), timed 04:00 AM, and timed 12:54 PM, revealed "Anxious not Aggressive ... no delirium." November 30, timed 13:00 was blank/incomplete.
Review of MR2 "Nurses Notes," dated November 30, 2014, timed 05:14 AM, revealed "patient constantly out to bed to chair and back, every 15-30 minutes. Patient jumping off side rail, pulling off oxygen, and cardiac monitor. Patient desats to 70s immediately without oxygen. Patient urinated on floor and jumped out. ... Received order to initiate 1:1 supervision. ... "
Review of MR2 physician order, dated November 30, 2014, acknowledged 12:39 PM, revealed "Haloperidol (Haldol) Lactate 2.5 MG (0.5LM) IV Q4H (every four hours) PRN (as needed) for agitation."
Review of MR2 "Nurses Notes," dated December 1, 2014 timed 1:30 AM, revealed "confused & restless. Medicated w/Morphine 1mg IV& Haldol 2.5MG IV. Slept for several hours in the chair after medicated. "
Review of MR2 revealed no documented evidence that appropriate alternative measures were attempted prior the administration of this medication to address this patient's confusion and restlessness. There was no documented evidence that the administration of this medication, which resulted in the patient sleeping "for several hours," allowed the patient to function more effectively in the environment.

Based on review of facility policy and procedures, review of medical records (MR), and interviews with staff (EMP), it was determined that the facility failed to ensure the use of restraints was in accordance with the order of a physician or other licensed independent practitioner who was responsible for the care of the patient in five of 19 restraint records reviewed (MR4, MR12, MR13, MR21, and MR22).

Findings include:

Review on December 10, 2014 of facility policy "Restraint Policy MHS," reviewed June 2014 revealed " ... C. Procedure for Use of Medical-Surgical restraint is as follows: ... 2. An order is placed in the medical record from the physician. 3. If the nurse has initiated the restraints, the physician must complete a face to face evaluation within 1 hour. Subsequent orders must be obtained at least once every 24 hours ... "

Review of MR4 "Restraint Order and Evaluation," dated December 12, 2014, timed 11:30 PM, revealed " ...Reason for Restraints Medical/Surgical (Non-Emergent/Crisis Management): Necessary for the patient 's well-being to receive effective treatment when less restrictive interventions have been ineffective; behavior related to the underlying medical condition or anticipated result of treatment ...Type of Restraint Limb Upper extremities left and right ... ."
Review of MR4 "Nurse Notes," dated November 13, 2014, timed 00:00 (12:00AM), revealed "pt pulled out NGT [nasogastric tube] ... soft wrist restraints applied for safety."
Review of MR4 "Nurse Notes," dated November 13, 2014, timed 03:00, revealed "pt pulled out the NGT again ... reinserted without any difficult."
Review of MR4 "Restraint Flow Record," dated November 14, 2014 and November 15, 2014, revealed that the facility maintained the patient in bilateral soft wrist restraints from November 14, 2014 at 12:00AM until November 15, 2014 at 11:55AM, without a physician' s order.
Review of MR12 "Restraint Flow Record" revealed nursing documentation indicating that the patient was in bilateral soft limb restraints on January 5, 2014, at 12:00 AM and that they were removed at 10:00 AM. Further review of the "Restraint Flow Record" revealed nursing documentation that the restraints were reapplied on January 5, 2014, at 8:00 PM. There was no documented evidence that a new physician's order had been obtained for the the restraints on January 5, 2014, starting at 8:00 PM.

Review of MR13 "Restraint Flow Record" revealed nursing documentation indicating that the patient was in bilateral soft limb restraints on March 23, 2014, from 12:00 PM through March 24, 2014 at 12:00 PM. Further review of MR13 revealed no documented evidence that a physician's order had been obtained for the use of restraints on March 23, 2014, from 12:00 PM through March 24, 2014 at 12:00 PM.

Interview on December 10, 2014, at 11:30 AM, with EMP9 confirmed there was no documentation of physician orders in MR12 and MR13 for the specific dates and times physical restraints were applied to these two patients.

Review of MR21 "Restraint Flow Record" revealed nursing documentation indicating that the patient was in bilateral upper extremity soft limb restraints on December 8, 2014, from 12:00 AM through 11:00 PM. Further review of MR21 revealed no documented evidence that a physician's order had been obtained for the use of restraints on December 8, 2014.

Review of MR22 "Restraint Flow Record" revealed nursing documentation indicating that the patient was in bilateral soft limb restraints on November 30, 2014, from 12:00 AM through 6:00 AM and again from 8:00 PM through 11:00 PM. There was no documentation of a new physician order for the initiation of restraints on November 30, 2014, at 8:00 PM.

Interview on December 11, 2014, at 10:00 AM, with EMP9 confirmed there was no documentation of physician orders in MR21 or MR22 for the specific dates and times physical restraints were applied to these two patients.

Based on review of facility policies and procedures, medical records (MR), and interviews with staff (EMP), it was determined that the facility failed to discontinue the use of physical restraints at the earliest possible time and failed to provide adequate justification for the continued use of physical restraints for five of 19 restraint records reviewed (MR3, MR4, MR11, MR22, and MR24).

Findings include:

Review of facility policy "Restraint Policy," dated June 2014, revealed "MHS is committed to preventing, reducing, and striving to eliminate the use of restraint(s); preserving the individual's safety and dignity when restraint is used; using alternative measures as preferred interventions; ... limiting the use of restraint to emergencies in which there is imminent risk of an individual physically harming himself or herself or others, and/or interference with healing. ... II. Policy A. ... Alternatives will be used as a first line intervention prior to the use of restraints. B. When alternatives measures are assessed as ineffective or no longer feasible, and the safety and well-being of patients and/or staff is threatened, restraint may be utilized following established policies and procedures. The decision to restrain a patient is driven not by diagnosis, but by comprehensive individual assessment which concludes that for this patient, at this time, the use of less intrusive measures poses greater risk than the risk of using restraint or seclusion. Focused behavior assessments shall address history and clinical symptoms of abuse, or violence and medical/psychiatric issues that may be pertinent to restraint practices. The comprehensive assessment should include a physical assessment to identify medical problems that may be causing behavior changes in the patient. C. The least restrictive method of restraint that meets the patient's need will be utilized. Patient rights and dignity will be preserved ... E. Patients have the right to be treated with respect and dignity in a safe, humane, culturally sensitive, and developmentally appropriate manner that respects patient choice and maximizes self-determination. F. Staff must assess and monitor a patient's condition on an ongoing basis to ensure that the patient is released from a restraint or seclusion at the earliest possible time. Restraint or seclusion may only be employed while the unsafe situation continues. Once the unsafe situation ends, the use of restraint or seclusion should be discontinued. ... H. The patient and family are recognized as integral members of the care team. Staff will attempt to contact the family or medical decision maker to inform them of the restraint episode either when authorized by the patient or when the patient lacks capacity to make his/her own medical decisions. ... IV. ... 2. Medical Management: A mechanism to promote medical or surgical healing in a non-violent and/or non-aggressive patient to ensure necessary procedure(s) or treatment(s) when other alternatives have proven ineffective. ... 4. When choosing the type of restraint, the least restrictive type of restraint will be chosen to optimize individual mobility. VI. Procedures A. Alternative Measures Alternative measures are to be considered prior to application of restraint device. ... If alternative methods cannot be used prior to restraint use, or have failed, clear detailed documentation of rationale for restraint use will be noted on the Restraint Flow sheet in the medical record. Examples of Alternative Measures 1. Staff will evaluate and implement appropriate alternatives. Suggestion for alternatives include: Companionship: family or friend, Modify Environment, Decrease Stimuli/Noise Reduction, Assessment for underlying physiological problems ... E. Documentation of the use of medical surgical restraints 1. Each episode of use of medical surgical restraints shall be documented on the Restraint Flow Record and in the Interdisciplinary Plan of Care. ... 2. Documentation in the patient's medical record will include: a. Evaluation for restraint b. Specific circumstances and exhibiting behavior supporting the decision for restraint usage in the plan of care. C. Alternatives attempted or other less restrictive interventions that apply to the specific patient scenario. D. Type of restraint. E. Patient's response to the intervention used. ... l. Revisions/Updates to the plan of care. ...H. Documentation of behavioral restraint use: 1. Each episode of use of behavioral health restraints in the acute care setting shall be documented in Notes and in the Renewal of Orders. Orders for restraints include: a. Date and time restraint initiated b. Type of restraint ... d. Reason of clinical justification for restraint ... VII. Staff Training and Competency: 1. All clinical staff with a role in the implementation of restraint/seclusion procedures must be trained and demonstrate competency in prevention, proper and safe usage. ... "

Review of MR3 "Restraint Order and Evaluation," dated November 27 and November 28, 2014, timed 09:00, revealed "...Reason for Restraints Medical/Surgical (Non-Emergent/Crisis Management): Necessary for the patient's well-being to receive effective treatment when less restrictive interventions have been ineffective; behavior related to the underlying medical condition or anticipated result of treatment ...Type of Restraint Limb Upper extremities left and right ...".

Review of MR3 revealed no documented evidence that a "Restraint Flow Record" was completed on November 27, and November 28, 2014. Further review of MR3 revealed no documented evidence describing the patient's clinical needs supporting the continued use of physical restraints or that physical restraints were released at the earliest possible time.

This finding was confirmed in an interview on December 9, 2014, at 3:00 PM, with EMP2.

Review of MR4 "Restraint Order and Evaluation," dated November 12, 2014, timed 11:30 PM, revealed " ... Reason for Restraints Medical/Surgical (Non-Emergent/Crisis Management): Necessary for the patient's well-being to receive effective treatment when less restrictive interventions have been ineffective; behavior related to the underlying medical condition or anticipated result of treatment ...Type of Restraint Limb Upper extremities left and right ... " .
Review of MR4 "Restraint Flow Record," dated November 13, 2014, revealed "... Removing medical devices Removing dressings ... Type of Restraint: Soft Limb Wrist Right and Left. ..."
Review of MR4 "Nurse Notes," dated November 13, 2014, timed 00:00 (12:00AM), revealed "pt pulled out NGT [nasogastric tube] ... soft wrist restraints applied for safety. "
Review of MR4 revealed inadequate documentation, from November 13, 2014, timed 03:00 AM through November 14, 2014 timed 22:33 (10:33PM), describing the patient's clinical needs supporting the continued use of the physical restraint.
Review of MR4 "Nurse Notes," dated November 15, 2014, timed 02:00 AM, revealed "patient pulled out NGT. ..."
Review of MR4 "Nurse Notes," dated November 15, 2014, timed 04:00 AM, revealed "...can hold reinsertion of NG at this time. ..."
Review of MR4 "Restraint Flow Record," dated November 15, 2014, revealed that the facility maintained the patient in bilateral soft wrist restraints until 8:00 AM on December 16, 2014.
Further review of MR4 revealed no documented evidence justifying the continued use of physical restraints or that this physical restraint was released at the earliest possible time.
Review of MR11 "Restraint Order and Evaluation" dated February 10, 11, and 12, 2014, revealed physician orders for the use of physical restraints. Further review MR11 revealed no documented evidence that a "Restraint Flow Record" had been completed, nor was their adequate justification for the continued use of physical restraints or that physical restraints were released at the earliest possible time.

Review of MR22 "Restraint Flow Record" revealed nursing documentation indicating that the patient was in bilateral soft limb restraints on November 30, 2014, from 12:00 AM through 11:00 PM. Further review of the "Restraint Flow Record" revealed no documentation of nursing assessments from 6:00AM to 8:00PM justifying the continued use of physical restraints or that the restraint was released at the earliest possible time.

Review of MR24 "Restraint Order and Evaluation" dated October 21, 22, and 23, 2014, revealed physician orders for the use of physical restraints. Further review of MR24 revealed no documented evidence that a "Restraint Flow Record" had been completed, nor was their adequate justification for the continued use of physical restraints or that physical restraints were released at the earliest possible time.

Interview on December 10, 2014, at 2:00 PM, with EMP9 and EMP10 confirmed no documentation of a "Restraint Flow Record" for nursing assessments or that physical restraints were released at the earliest possible time for the dates indicated in MR11, MR22 and MR24.

Based on review of facility documents, medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure that nursing documentation was pertinent, accurate and concise in order to contribute to the continuity of patient care for three of 53 medical records reviewed (MR27, MR28, and MR29).

Findings include:

Review of facility policy "Documentation of Nursing Assessments and Patient Care," dated June 2014, revealed "Purpose: To describe the process for documenting initial and ongoing assessment findings, patient care needs, the plan for addressing those needs, the nursing interventions, ... Policy: ... 3. Nursing documentation is entered in the electronic medical record. ... Interventions ... 1. Interventions constitute the electronic work list for nurses and include care that must be performed as a result of the Standard of Care, Care Plans, and physician orders. ... "

Review of facility policy "Guide to Wound Products and Application," dated November 1, 2014, revealed " ... The following product directory provides a quick reference for wound care products available through Material Management/SPD and Pharmacy or Medical Supplier. Brief information on product use and application is included. Terminology referred to in the following pages includes: Primary dressing ... Secondary dressing ... Packing wounds ... Products Available through Materials Management, Pharmacy and Medical Supplier ... Type of Product ... Moisture Barrier ... Product Example ... Protective Ointment ... Type of Product ... Hydrofiber ... Product Example ... Aquacel ... Type of Product ... Calcium Alginate ... Product Example ... Kaltostat Melgisorb ... Type of Product ... Anti microbial / Bactericidal ... Product Example ... Aquacel Ag ... Type of Product ... Enzymatic Debrider ... Product Example ... Collagenase-Santyl ... "

Review of MR27 revealed the patient was ordered "Santyl" for wound care on December 5, 2014. Further review of MR27 revealed on December 6, December 7, December 8, and December 9, 2014, "Alginate" was documented as being administered to the patient.

Interview on December 11, 2014, at 2:00 PM, with EMP14 confirmed that Santyl was ordered for MR27 but Alginate was documented as being administered to the patient.

Review of MR28 revealed the patient was ordered "Aquacel Ag Rope" for wound care on December 5, 2014. Further review of MR28 revealed on December 6, December 7, December 8, and December 9, 2014, "Alginate" was documented as being administered to the patient.

Interview on December 11, 2014, at 2:10 PM, with EMP14 confirmed that Aquacel Ag Rope was ordered for MR28, but Alginate was documented as being administered to the patient.

Review of MR29 revealed the patient was ordered Skin Protective Ointment for wound care on December 1, 2014. Further review of MR29 revealed on December 1, December 2, December 3, December 4, and December 5, 2014, Vasolex was documented as being administered to the patient.

Interview on December 11, 2014, at 2:20 PM, EMP14 confirmed that Skin Protective Ointment was ordered for MR29, but Vasolex was documented as being administered to the patient.

Based on observation, review of facility documents and interview with staff (EMP), it was determined that the Director of Food Service failed to ensure safety practices for food handling were maintained in the kitchen.
Findings include:
Review on December 9, 2014, of policy "Food Safety Standards & Requirements," dated, July 30, 2013, revealed " ...6. All foods prepared in operation must be covered and labeled as to contents and date of preparation prior to storage in refrigerators and freezers. ... "
Review on December 12, 2014, of policy "Food Safety Product Labeling & Dating Guide," dated July 29, 2014, revealed " ... Sodexo standard: Food left over after meal service: Use within 2 days (for quality reasons). ... "
Review on December 12, 2014, of correspondence from EMP3 to EMP1 and EMP2, dated December 10, 2014, revealed " ... our current practice [for dating and labeling food], as outlined in the HACCP Manual 2012, is to wrap the item and date it with the date we are wrapping it, not a use by date. ... we then have 5 days for advance production and 2 days for leftovers. ... "
Review on December 12, 2014, of EMP3's "Position Profile," created, August 2003, revealed " ... Responsibilities: ... Maintains and implements sanitary and food safety conditions ... Duties: ... Directs daily food service operations including: ... food preparation and storage. Maintains kitchen and storage facilities to meet/exceed sanitary conditions ... . "
Observation tour on December 9, 2014, of the Dietary Department/Kitchen, at 9:45 AM, with EMP3, EMP4 and EMP5, revealed the following in the walk in freezer: one steel sheet pan, containing leftover plain muffins, dated November 25; and 3 large "cooling paddles" laying, uncovered, on top of a shipment box of frozen food.
Interview on December 9, 2014, at 9:55 AM, with EMP4, revealed that the cooling paddles are used to rapidly cool down freshly prepared soup. EMP4 indicated that staff bring the soup into the freezer and place the "cooling paddle" inside the pot of soup and proceed to stir the soup with the "cooling paddle." EMP4 confirmed that the "cooling paddles" are kept inside the freezer, but there is no covering or container to keep them in, in order to prevent cross-contamination.
Observation tour at 10:05 AM, with EMP3, EMP4, and EMP5, revealed the following in the walk in refrigerator: one small steel pan containing left-over cooked pasta, undated; a small steel pan containing left over "sausage gravy," dated December 6, 2014; a block of Swiss cheese, opened and undated, and one tub of liquid (not clearly identifiable), unlabeled.
At 10:11AM, an open package of "brown sugar" and an open package of "sunflower seeds" , which the contents was identified by EMP6, did not contain proper labels (for clear identification), open dates, nor were they stored in proper containers to prevent contamination.
In a small freezer, there was an open pack of two pizzas and an open bag of "popcorn chicken." These items were not dated or covered appropriately in order to prevent contamination and spoiling.
In a small refrigerator there was a bin containing leftover "cooked chicken strips," that was dated December 4, 2014, and a bin containing left over "jalapeno peppers," that was also dated December 4, 2014.
Observation at 10:20 AM, of the three compartment sink and the dish machine, revealed several soiled pots and a cart containing trays and bins of food left-over from the breakfast meal. In the middle of this area was a rack containing pots, pans, steel trays/serving bins, and serving utensils. Interview with EMP4 indicated that the items on this rack were considered "clean."
Observation of the rack revealed six steel bins that contained various "clean" utensils. The steel bins, containing the "clean" utensils, were noted to be soiled with a white residue, food particles and other debris, such as plastic wrap reminiscence. Further interview with EMP4, indicated that the steel bins, containing the "clean utensils," are cleaned every Saturday.

This condition level deficiency was cited during a Division of Life Safety survey completed on December 23, 2014. Further details are provided in the Division of Life Safety report.

Based on observations, review of facility policy, manufacture's instructions and interview with staff (EMP), it was determined that the facility failed to ensure that supplies were maintained to ensure an acceptable level of safety.

Findings include:

1) Review of facility policy "Proper Storage of Syringes and Needles," dated August 2014, revealed "Purpose: Nursing practice shall reflect the use of appropriate safety measures for the storage and locking of syringes and needles. ... Policy: Syringes shall be stored and locked in appropriate areas, and be available to authorized personnel only. ... "

Observation on December 8, 2014, of the Emergency Department trauma bay revealed the following unlocked needles: 20 Spinal needles and two Safety IV catheters.

Interview on December 8, 2014, at 10:20 AM, with EMP13 confirmed the above mentioned needles were unlocked.

2) Observation on December 8, 2014, of the Emergency Department trauma bay revealed the following expired supplies: one Bivona Silicone Tracheostomy tube marked expired September 2014; two Cuffed Emergency Cricothyrotomy Catheter set's marked expired November 2014; a Carbon Dioxide detector for the placement of Gastric tubes marked expired February 2010; and a BD vacutainer marked expired October 2013.

Interview on December 8, 2014, at 10:30 AM, with EMP13 confirmed the above mentioned supplies were expired.

Observation on December 8, 2014, of the Emergency Department's nutrition refrigerator revealed a four ounce container of milk marked expired November 27, 2014.

Interview on December 8, 2014, at 10:40 AM, with EMP13 confirmed the above mentioned milk container was expired.

Observation on December 8, 2014, of the Progressive Care Unit (PCU) Nurses station nutrition refrigerator revealed a 32 ounce milk container marked expired November 18, 2014, and Observation of the PCU's storage cabinet revealed 12 BD Vacutainers marked expired November 2014.

Interview on December 8, 2014, at 11:30 AM, with EMP13 confirmed the above mentioned products and supplies were expired.

Observation of the ICU clean supply room on December 8, 2014, revealed the following expired supplies: two Epistaxis packets marked expired June 2012; two Biopatch Protective Disk with CHG containers marked expired October 2014; 15 Steristrip packets marked expired February 2013; and 30 Chlorascrub swabs marked expired February 2014.

Interview on December 8, 2014, at 2:15 PM, with EMP13 confirmed the above mentioned products and supplies were expired.

3) Review of the Kendall Foam Electrode manufacturer instructions dated May 2010, revealed " ... Precautions: ... Do not open package until immediately prior to use. ... "

A request was made to EMP1 on December 8, 2014, for a facility policy or procedure related to the use of the Kendall Foam Electrode packages once the package was opened. EMP1 confirmed the facility did not have a policy or a procedure.

Observation on December 8, 2014, of the Intensive Care Unit (ICU) revealed an opened Kendall Foam Electrode package and the package did not have a date when the package was opened.

Interview on December 8, 2014, at 1:45 PM, with EMP13 confirmed that the above mentioned Kendall Foam Electrode package did not have a date when the package was opened.

4) Review of Facility policy "Procedure: Receipt of Reagents," dated May 2014, revealed " ... Purpose: To ensure that all reagents, controls and solutions are properly labeled as applicable and appropriate. ... Procedure: ... 3. All reagents, controls and solutions should be properly labeled with the following elements: ... d. expiration date. ... Procedure Note: A new expiration date and/or storage requirement must be recorded if opening the container changes the expiration date and/or storage requirement. ... "

Review of the facility's Laboratory revealed a "Fast Reference Guide For Expiration ... ", no date, which revealed " ... Enzyme Diluent - 7 days ... Alec/Amon - 20 days ... "

Observation on December 9, 2014, of the Laboratory's refrigerator, where control solutions were stored revealed an opened bottle of Liquichek Ethanol / Ammonia control which was not dated, and an opened bottle of Siemens Enzyme Diluent control which was dated November 28, 2014.

Interview on December 9, 2014, at 1:30 PM, with EMP14 confirmed the above mentioned control solutions were not stored according manufacturer recommendations and facility policy.

Based on observations, review of facility policies and procedures, CDC's recommendations and interviews with staff (EMP) it was determined that the facility failed to develop and implement an appropriate infection control system to prevent inadvertent contamination in the morgue and during the administration of medications for three of three patients observed (MR5, MR6, and MR53).

Findings include:

Review of CDC's "Injection Safety," dated May 2, 2012, revealed " ... A simple rule for safe care: ... Insulin Administration ... Multi-dose vials of insulin should be dedicated to a single person whenever possible. If the vial must be used for more than one person it should be stored and prepared in a dedicated medication preparation area outside of the patient care environment and away from potentially contaminated equipment. ...".

Review of facility policy "Injectable Vial Policy," dated August 2014, revealed "Purpose: To establish a uniform manner to utilize multi-dose and single dose vials. ..." Further review of the policy revealed no procedure regarding the safe preparation of medication utilizing a multi-dose vial to be completed outside of the patient care environment in order to prevent contamination.

Review of MR5 Medication Administration Record (MAR), dated December 8, 2014, revealed that the patient was to receive Novolog, 6 units of insulin with meals. Further review of the MAR revealed an order for additional coverage, pending blood sugar results, to be administered per sliding scale: BS 176-225 = 2units, BS 226-275= 3units, BS 276-325= 4units, 326-375= 5units, 376-399= 6units, over 400 Call M.D. .

Observation on December 8, 2014, at 12:00 PM, with EMP8 revealed EMP8 transporting a multi-dose vial of insulin (Novolog) to MR5 patient room. EMP8 was observed preparing the medication, 9 units of Novolog, in a patient care area, the patient's room, instead of outside the patient care environment as per CDC recommendations to prevent inadvertent contamination.

Review of MR6 MAR, dated December 9, 2014, revealed that the patient was to receive Novolog with meals, pending blood sugar results, to be adminstered per sliding scale: BS 176-225 = 2 units, BS 226-275= 3units, BS 276-325= 4units, 326-375= 5units, 376-399= 6units, over 400 Call Physician.

Observation on December 9, 2014, at 11:50 AM, with EMP10 revealed EMP10 transporting a multi-dose vial of insulin to MR6 patient room. EMP10 was observed preparing the medication, 2 units of Novolog, in a patient care area, the patient's room, instead of outside the patient care environment as per CDC recommendations to prevent inadvertent contamination.

Interview on December 9, 2014, at 11:55AM, with EMP2 confirmed that the facility does not have a procedure in place to address the concern of using multi-dose vials of medications and preparing injections in the patient care area. EMP2 confirmed that the facility's current practice was not consistent with CDC recommendations to prevent inadvertent contamination.

2) Review of facility policy "Injectable Vial Policy," dated August 2014, revealed "Purpose: To establish a uniform manner to utilize multi-dose and single dose drug vials. ... 3. Aseptic technique is to be utilized for all reconstitutions and when drawing up all doses. ... "

Observation on December 8, 2014, revealed EMP16 did not disinfect the rubber septum with alcohol prior to piercing a vial of Heparin, which was ordered and administered to MR53.

Interview on December 8, 2014, at 2:00 PM, with EMP13 confirmed EMP16 did not disinfect the rubber septum, with alcohol prior, to piercing the vial of Heparin.

3) Review of facility policy "Hand Hygiene," dated November 2013, revealed "Purpose: To assure proper hand hygiene practices are utilized by employees (including students, volunteers and licensed independent practitioners) during all activities including patient care, and to prevent the transmission of infectious pathogens. Hand washing helps to physically remove infectious pathogens from hands. Hands can also be decontaminated by using waterless alcohol hand sanitizer. .. "

Observation on December 9, 2014, of the facility's Morgue revealed a deceased patient, which had been placed in a body bag and covered with a blanket. EMP15, who was not wearing gloves, was observed removing the blanket off the deceased patient and manipulating the body bag with bare hands.

Further observation of the Morgue revealed no readily accessible, Alcohol-based hand rub or wash station to disinfect hands.

Interview on December 9, 2014, at 2:00 PM, with EMP14 confirmed EMP15 removed the blanket off the deceased patient and manipulated the body bag with bare hands. EMP15 confirmed that after manipulating the body bag, EMP15 did not immedietly wash or disinfect hands.