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A. Based on a tour of three patient care units, review of policies and procedures, and interviews with administrative staff, it was determined that expired medical supplies and medication were available for use.

Findings include:

1. A tour of the STCF (Short-Term Care Facility) psychiatric unit on the afternoon of 1/19/22 revealed:

a. Wall cabinet above the counter in the Nurses Station medication area contained:

(i) Two (2) "Remel MicroTest M4RT For transport of viruses and chlamydia" glass tube containers with an expiration date of 2021-05-23 (5/23/2021).

(ii) Two (2) BD (Becton Dickinson) dark green cap Vacutainer blood collection tubes with an expiration date of 2020-11-30 (11/30/2020).

(iii) One (1) BD red cap Vacutainer blood collection tube with an expiration date of 2021-03-31 (3/31/2021).

(iv) One (1) BD red cap Vacutainer blood collection tube with an expiration date of 2021-04-30 (4/30/2021).

(v) Six (6) BD clear cap Vacutainer blood collection tubes with an expiration date of 2020-10-31 (10/31/2020).

(vi) One (1) BD light green cap Vacutainer blood collection tube with an expiration date of 2020-11-30 (11/30/2020).

(vii) One (1) BD purple cap Vacutainer blood collection tube with an expiration date of 2020-02-28 (2/28/2020).

(viii) One (1) yellow cap Vacutainer blood collection tube with an expiration date of 2020-10-31 (10/31/2020).

b. Wall cabinet above the Pyxis Machine in the Nurses Station medication area contained:

(i) Two (2) BD Insyte Autogard 18 GA (gauge) 1.16 IN (inch) 1.3 x (by) 30 mm (millimeters) IV (intravenous) catheters with an expiration date of 2020-10-31 (10/31/20).

(ii) Two BD Insyte Autogard 22 GA 1.00 IN 0.9 x 25 mm IV catheters with an expiration date of 2021-03-31 (3/31/2021).

(iii) One (1) BD Insyte Autogard 20 GA x 1.00 IN 1.1 x 25 mm IV catheter with an expiration date of 2021-06-30 (6/30/2021).

(iv) One (1) BD Vacutainer Luerhole Access Device with an expiration date of 2021-06-30 (6/30/2021).

2. A tour of the Emergency Department on morning of 1/19/22 revealed:

a. North Side Nurses Station:

(i) One (1) BD Insyte Autogard needle pack with an expiration date of 2021-2-28 (2/28/2021) was found in a cabinet.

(ii) One (1) Auvi-q epinephrine injection 0.1mg auto injector with an expiration date of 02 JAN 2022 (1/2/22) was found in a drawer.

3. Administrators #1 and #6 agreed with the findings.

B. Based on a tour of three patient care units, review of policy and procedure and interview with administrative staff, it was determined that the glucometer glucose control solutions are not maintained according to manufacturer's instructions for use (IFU).

Findings include:

Reference: Policy and procedure titled "NOVA Biomedical StatStrip PROCEDURE FOR USE" states: .....
EQUIPMENT AND MATERIALS:
.....
Meter and Base Unit Storage, Maintenance and Handling - Meters, system components and reagents are stored, maintained and handled according to manufacturer's instructions and in compliance with all established safety, infection control, and regulatory guidelines.
.....
* StatStrip Test Strips - Open expiration stable for 180 days. .....
* StatStrip Glucose Control Solutions - Open expiration stable for 90 days. .....
....."

1. A tour of the MHU (Mental Health Unit) on the afternoon of 1/19/22 revealed:

a. A glucometer kit in a cabinet above the sink contained one (1) opened bottle of Nova Biomedical Stat Strip Xpress Glucose Control Level 1 solution and one (1) opened bottle of Nova Biomedical Stat Strip Xpress Glucose Control Level 3 solution. There was no information entered on either of the bottles to indicate when they were opened or the discard date.

b. Administrator #1 agreed with the findings.

2. A tour of the STCF (Short-Term Care Facility) psychiatric unit on the afternoon of 1/19/22 revealed:

a. A glucometer kit in the Nurses Station medication area contained two (2) opened bottles of Nova Biomedical Stat Strip Xpress Glucose Control Level 1 solution. There was no information entered on either of the bottles to indicate when they were opened or the discard date.

b. Administrators #1 and #6 agreed with the findings.

C. Based on a tour of three patient care units, review of policies and procedures, and interviews with administrative staff, it was determined that policies and procedures for food safety are not implemented.

Findings include:

Reference #1: Policy and Procedure titled "FOOD STORAGE CHART" states:
"Expiration dates printed by the manufacturer apply until the product is opened. Sealed packages within the master case follow the manufacturer's date until that package is opened. Once opened, use these time limits unless the manufacturer's date is earlier. Add the time in this chart to the date of opening/preparation to determine expiration.
.....
REFRIGERATED STORAGE
Use Manufacturer's Exp. (Expiration) Date
+ 3 days * Grab-n-go items that are prepared at an ACC or similar facility monitored by the USDA. Products are prepared in a cold room with the documented chain of temperature maintenance through delivery to the account(s)
....."

Reference #2: Policy and procedure titled "NURSING UNIT STOCK" states:
POLICIES:
* Food and Nutrition Services Department stocks unit pantries daily.
* Some hospitals require ALL items, even those that are not food safety concerns, to be labeled and dated. A best practice includes:
.....
- Complete an orange label for each type of pc item and place the label on the outside of the zip lock bag or plastic container.
.....
* Cleaning and care of the pantry area is the responsibility of the Food & Nutrition Department [sic]
* Food and Nutrition Services personnel are responsible for daily monitoring of unit refrigerator(s) on a posted temperature sheet. When refrigerator temperature does not register within the appropriate temperature range, sample temperatures of product will be taken to determine if the product temperatures have been compromised (above 41F°) [41 degrees Fahrenheit]. Product that is above 41F° is removed. Action is taken to correct refrigeration temperature before new product is added.
....."

Reference #3: Instructions on NOURISHMENT ROOM REFRIGERATION/FREEZER TEMPERATURE LOG sheets states: ".....
RECORD REFRIGERATION TEMPERATURES ON THE GRAPH BY PLACING AN 'X' IN THE BLOCK CORRESPONDING TO THE OBSERVED TEMPERATURE. RECORD FREEZER TEMPERATURES BY WRITING THE ACTUAL TEMPERATURE UNDER THE CORRECT DATE.
.....
1. Check thermometer daily. Graph & document temperatures and record initials.
2. If temperature is out of range, circle temp (temperature) and document action. See codes below.
.....
Action Codes: 1 = recheck temperature in 30 minutes 2 = temperature recheck within range
3 = contact maintenance

NOURISHMENT ROOM SANITATION CHECKLIST - Monitor daily, initial all areas have been checked and action taken. Document action taken.
1. Drawers, cabinets, microwave, refrigerator, freezer, sink & countertops are organized and clean. Organize, wipe down/sanitize or notify appropriate personnel.
2. Monitor freezer for frost, alert appropriate personnel if freezer requires defrosting.
3. Only patient food items stored in nourishment room. Remove staff items.
4. Food items are within expiration dates. Remove expired items.
5. Patient food brought in from outside is properly labeled, dated, and discarded after 48 hours."

1. During a tour of the STCF (Short-Term Care Facility) psychiatric unit on the afternoon of 1/19/22 a NOURISHMENT ROOM REFRIGERATION/FREEZER TEMPERATURE LOG for the Month of December 2021 was observed and reviewed. The following was revealed:

a. The only refrigerator temperature documented on the graph with an "X" was on 12/4. All other entries on the graph were either check marks or slash marks.

b. There were no actual freezer temperatures recorded for any of the days on the log except for 12/7 when the entry '6' was made. The other dates just had a check mark or a slash mark entered.

c. There were no initials entered on the log between 12/10 and 12/17 and between 12/20 and 12/31.

d. 42° (degrees) was the temperature entered on the graph for 12/2. Although the instructions state that the 'temperature' be circled, for the refrigerator temperatures a temperature need not be entered. The check mark made for this date was not circled nor was there documentation that any action was taken.

2. Administrators #1 and #6 agreed with the findings.

Based on a tour of three patient care units and an interview with administrative staff, it was determined that patient clinical information is not maintained in a confidential manner on 1 of 3 units.

Findings include:

1. During a tour of the Emergency Department on the morning of January 19, 2022, a regular trash can in the Nurses Station contained:

a. A printed sheet of 27 stickers with the name, date of birth, age, and medical record number of Patient #10 on them.

b. A sheet of paper with the handwritten name of Patient #11 and the entries "9/4/1963" and "2A COVID" written next to it.

c. A printed sheet of stickers with the name, date of birth, age, and medical record number of Patient #12. The stickers also included the entries "S: Clean catch urine" and "UA (Urinalysis) W (With) CULT (Culture)."

d. A printed sheet of 27 stickers with the name, date of birth, age, and medical record number of Patient #13 on them.

2. On the morning of January 19, 2022, Administrator #8 stated that documents containing confidential patient information should be placed in the recycle bin which was located in the Nurses Station.