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Based on observation, interview and review of facility policy it was determined the facility failed to ensure drugs were properly stored. Observation of storage of medications in the nurses' station and in two (2) emergency carts revealed fifty-four (54) narcotic medications not stored under double-lock, eighty-three medications not labeled for date of expiration, and five (5) syringes of saline solution out of date. In addition, the facility had no policy for the storage of narcotic medication requiring refrigeration.

The findings include:

Observation of the medication area of the nurses station at 3:15pm on 06/23/10 revealed the area to be adjacent to the reception/records area that opened to the hallway of the hospital's nursing unit. The area had no door. Observation of the medication area revealed the medication refrigerator to have only one lock to secure all medications, including narcotics. Contained in the refrigerator were twenty-four one-milliliter vials of injectable Lorazepam 25 ml and thirty (30) Merinol 2.5 mg tablets (both controlled substances requiring storage under double lock).

In addition, the medication refrigerator contained one (1) opened foil pouch containing eleven (11) syringes of straw-colored liquid and a second unopened foil pouch labeled to contain seventy-two (72) syringes. The pouches indicated the medication contained in the syringes was "Lidoderm, Tetracaine, and Epinephrine" and had a date at the top of the label, "09/08".

Observation of the emergency cart in the nurses' station revealed two (2) 10cc syringes of saline solution with expiration dates of 04/09.

Interview with the Pharmacy Technician at 3:50pm revealed that nursing staff counted the narcotics contained in the refrigerator each shift and there had been no problems with the count. She said she was unaware of the need for the drugs to be secured with an additional lock. She stated the medications stored in foil pouches were specially compounded for use in the facility for pain relief when patients received sutures. They were received in September, 2008 but should have been labeled by the outside pharmacy with an expiration date. Further interview with the Pharmacy Technician revealed she checked the emergency cart weekly but missed the expired syringes because they were pushed back in the drawer.

Observation of the emergency cart in the radiology department on 06/24/10 at 8:30am revealed three (3) 10cc syringes of saline solution labeled with an expiration date of 04/09.

Interview with a radiology technologist at this time revealed that the director of the department (then out of the hospital on vacation) checked the cart monthly. The technologist said the syringes were likely missed because they were not included on the medication contents list maintained for the cart.

Review of the hospital policies and procedures Form 11-01/MJ (Storage of Refrigerated Medications) and Form 10/01 (Controlled Narcotics) revealed the policies did not address the storage of narcotic medications requiring refrigeration.

Based on observation and staff interviews the facility failed to ensure the operating room was clean as required.

The findings include:

Observation on 06/23/10 at 12:25pm of the operating room (OR) revealed the one window in the room had mini-blinds hanging with a build-up of dust. The window sill had unidentified black particles with cobwebs in the corners. Two small dead insects with wings were observed to be lying on the window sill. The outside casing covering the overhead surgical pull-down light had a film of dust.

Interview on 06/23/10 at 12:25pm with the recovery room nurse revealed she could see the dust and when she wiped the overhead light a grayish dust covered the white wash-cloth. She stated the OR was terminally cleaned prior to the scheduled surgery day and after the end of the surgeries. She stated the dust, black particles, and dead insects should not be in the facility.

Interview on 06/23/10 at 3:30pm with the Housekeeping staff responsible for terminally cleaning the OR revealed he removed everything and terminally cleaned the OR from top to bottom prior to the day of surgeries and again after the surgeries. He stated he had been on vacation the week before and he had probably missed cleaning the window sill, blinds, and overhead light as required.

Interview on 06/23/10 at 3:40pm with the Director of Housekeeping revealed the nurse manager responsible for the OR had been on vacation and no one had been in the OR to assure it had been cleaned as required. She stated the OR was not used in between cleanings as they only schedule surgical procedures every other Friday. She stated she should have verified the OR was ready for use in the absence of the OR nurse manager.

Review of the facility policy for OR cleaning revealed the purpose of the policy was for the procedure to maintain operating rooms in an antiseptic condition. The cleaning for the OR was to be done after "dirty" operations and at the end of the daily operating schedule. The policy identified at #3 was for the staff to vacuum all horizontal surfaces and wall surfaces including vents and #6 was to clean all surfaces of equipment, furniture, and fixtures.

Based on observation, staff interviews, and record review the facility failed to ensure appropriate humidity levels were maintained within acceptable levels for the operating room.

The findings include:

Observation on 06/23/10 at 12:25pm of the operating room hygrometer revealed the humidity level was 69%. Acceptable standards established by the Association of Operating Room Nurses (AORN) and the American Institute of Architects (AIA) are 30% to 60% for humidity levels.

Review of the facility logs for monitoring the humidity levels on 06/23/10 revealed the temperatures and humidity levels were monitored weekly. The last documented check was done on 06/10/10 with the humidity level documented at 54%.

Interview with the Director of Maintenance on 06/24/10 at 8:40am revealed he had missed a week of checking the temperature and humidity levels. In addition, he stated he was on leave and failed to assign his assistant to monitor the levels in his absence. He stated that during the Life Safety Code inspection on 06/23/10 the humidity level was observed to be 63%. Additional observation on 06/24/10 revealed the humidity level was increasing. He stated he thought there might be a problem with the valve. He stated there had been no surgeries performed since 06/11/10. He stated the facility did not have an official policy for monitoring temperatures and humidity in the operating room.

Based on observation, interview and review of facility policies and procedures the facility failed to ensure recognized dietary practices were followed in the storage of refrigerated and dry foods. Four (4) large containers of prepared salad and dressings were found without the dates they were opened. One (1) large container of sweet-and-sour sauce intended for use was labeled as being opened over one and one-half years ago. Bags of brown sugar, tortilla chips, peanut granules and shredded coconut were found open but without dates they were opened. The hospital had no policy regarding length of time non-opened containers of food without expiration dates could be kept.

The findings include:

Observation of the hospital's refrigerators during kitchen tour on 06/23/10 at 11:40am revealed the following products that were opened, partially used, and stored without having been labeled with the date of first use: One (1) five-pound container of tuna salad, one (1) five-pound container of pimento cheese spread, one (1) five-pound container of cottage cheese, and one (1) five-pound container of sour cream.

Observation in the dry food storage area on 06/23/10 at 12:10pm revealed the following products opened, partially used, and stored without having been labeled with the date of first use or with its packaging torn:
Two (2) plastic bags of light brown sugar that were hard to the touch (one of the bags was opened, the other bag had a half-inch tear in the seam of the bag),
One (1) large bag of tortilla chips,
One (1) thirty-two (32) ounce bag of peanut granules with delivery date of 11/08 typed on the box in which it was stored.
One (1) large bag of shredded coconut with a delivery date, 09/19/07, typed on the box in which it was stored. It and another unopened bag of coconut appeared light brown in color and had no expiration dates.

Interview on 06/23/10 at 12:00pm with a food service worker responsible for dating food in the refrigerator revealed she forgot to date the containers in the refrigerator when she opened them.

Interviews with the dietary manager on 06/23/10 at 12:00pm and 12:10pm revealed the sweet-and-sour sauce was only used for board meetings and was still all right for use. She stated it was her responsibility to ensure items were dated but failed to do so. She revealed the sugar was hard because, due to low census, the hospital did not go through it quickly. She was not aware the tortilla chips and shredded coconut were undated but would discard them. She stated the peanut granules were last used the previous month. She did not know when they were opened but returned them to the shelf for use.

Further interview with the dietary manager revealed the facility had no policy on maximum storage time for unopened food.

Review of the facility's policy entitled, "Food Preparation and Safety" (#8.14 Martha Gregory and Associates, Inc 2006) revealed leftover foods were to be labeled, dated and refrigerated immediately at 41 degrees Fahrenheit or below.

Review of the Kentucky Department for Public Health Food Safety Branch recommendations for pantry shelf storage times revealed a storage time of one (1) year for coconut and nine (9) months for nuts.