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Based on observation, record review and interview, facility ' s nursing
staff failed to secure multiple unattended medication in locked areas in two areas of the operating room.
The facility failed to develop guidelines for securing medication in all areas of the facility where medication is used.

Findings:

During observation on 3/9/10 at 2:40 pm in the operating room department, the following observations were made: An unlocked medication cart with multiple drugs; Flagyl, Cleocin and ampicillin (antibiotics). Lidocaine Jell and Lidocaine injection( local anesthetics). Nasal decongestant spray. Sodium Chloride inhalation solution. Albuterol sulfate, protropium bromide (inhalation therapy). One box containing 150, 500 milligram (mg) tablets and a bottle of Tylenol 500 mg caplets was located on a shelf in the recovery room area.

Further observation revealed the unlocked carts were in the passageway and medications were accessible to unauthorized persons.

On the second hall way there was an unattended unlocked red medication cart with multiple drugs and other pharmaceuticals, such as Narcan, benadryl, isoproternol, heparin lidocaine and dopamine.

The Operation Room staff were not in the department except for the cleaning person and the nurse manager.

During an interview on 3/9/10 at 2:55pm with Staff # 56 (OR Nurse Manager) she stated the red cart was a transition crash cart. According to the Nurse Manager the tylenol were for staff use and she did not think they had to be locked up.

Review of the facility's policy/procedure # A11075 revised October 2003 discussed security of emergency medication in the ER, ICU and OB GYN Units the policy did not address the security of medication on all units.

Based on observation and interview, facility's staff failed to ensure expired medication and supplies were not utilized for patient care

Findings:

On 03/09/10 at 3:50 p.m. during tour of the facility ' s physical therapy department
a cupboard was observed stocked with medical supplies and ointments.

During an interview with physical therapist assistant (A)on 03/09/2010 at 3:50 p.m. in the physical therapy department, he stated that the supplies in the cupboard were used for wound care of patients.

Observation on 03/09/10 at 3:50 p.m. of the medical supplies in the cupboard revealed the following supplies were expired:

I packet of adoptic non adhesive dressing, lot # 404423 expired 10/2009
1 bottle Iodoform packing strip ? X 5 yard, lot # 72320301, expired 08/2009
1 bottle Iodoform packing strip ? X 5 yard, lot # 551-56, expired 09/2001
2 tubes multidex , lot # 46-702 expired 8/2007
1 tube Neosporin ointment , lot # 44715L expired 12/2006
1 tube Equate triple antibiotic ointment lot # 304056, expired 04/2006
1 tube Equate triple antibiotic ointment , lot # L703014 expired 2/09
1 tube Equate triple antibiotic ointment , lot # L710114 expired 10/09
1 tube Silver Sulfadiozine cream , lot # 498884-605-85, expired 12/2008





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Observation in the operating room on 3/9/10 at 2:15 pm revealed the following expired medication in a crash cart:

Two bags of pre- mix Heparin 2500 units in 250 millimeters ( ml) expired October 2009
two bags pre- mix Dopamine in 250 mls expired December 2009
2 vials Lidocaine 2 grams in 500 mls expired January 2010
1 vial Verapamil 5mg in 2.5 mls expired January 2010.

During an interview on 3/9/10 at 2:25 pm in the operation room (OR) with Staff # 56 ( OR Nurse Manager), the crash cart was new and she was transitioning medication from another cart. According to the Nurse Manager the expired drugs were missed during the transfer.

Review of the facility's policy/procedure titled Unusable Drugs # ALL326 revised October 2003, paragraphs 1 ,2 & 4 gave the following information:

" Items which are unusable will be removed from stock areas within the hospital, pharmacy storage areas and RHCs. Pharmacy personnel will make monthly inspections of all medication storage areas and remove outdated or unusable drugs.
Items that are being held for credit by the manufacturer will be isolated from regular stock in an area designated by the pharmacist in charge".

Based on observation, interview and record review, facility's infection control officer failed to ensure nursing staff practiced infection control techniques to prevent cross contamination in 4 of 23 sampled patients;
Failed to implement operating room cleaning guidelines to ensure staff cleaned anesthesia machine and carts, overhead lamps , and the microscope arms in two (2) of three operating rooms # 1 and 3.
Patient #s 2, 4, 6, 20

Findings:

Patient #4
On 03/10/2010 at 8:20 a.m. licensed vocational nurse (D) was observed administering medication to patient #4 in his room. Observation during the drug pass revealed a sign on the patient's door indicating that he was on contact isolation.
During the drug pass, licensed vocational nurse (D) removed a bottle of artificial tears from the medication cart used for general patient population and brought it to patient #4's room. She placed the bottle of artificial tears on the bedside table of the patient and left the room.

At approximately 8:35 a.m. licensed vocational nurse (D) returned to patient # 4's room, donned her glove, picked up the artificial tear and instilled it into the patient's eye. She touched the patient's face and eyelid during administration of artificial tears. She then covered the bottle using the contaminated glove and then she then proceeded to fill out the patient ' s menu. The menu was in direct contact with the linen covering the patient. The patient skin wounds were uncovered.
Licensed vocational nurse (D) place the contaminated artificial tear bottle along with the menu on the clean medication cart out side the patient's room.

Subsequent observation on 03/10/2010 at 8:35 a.m. revealed patient # 4 was observed sitting in a chair in his room
The patient had a Foley catheter in place with a drain bag attached. The patient's drain bag was anchored to the garbage can beside the patient's bed. The external blue port of the drainage bag was directly on the floor.

On 03/10/2010 at 8:37 a.m. the surveyor informed licensed vocational nurse (D) that she had observed that she the nurse had returned contaminated items from the room of the patient on contact isolation to the clean medication cart used for general patient population.
Licensed vocational nurse acknowledged that the contaminated items should not have returned to the clean medication cart

Review of patient #4 ' s clinical record (history and physical) revealed he was admitted to the facility on 03/08/2010 with diagnosis of " urinary tract infection, possible pneumonic process and multiple skin sores.


Further review of the patient's clinical record revealed laboratory results dated 2/28/2010 which were positive for staphylococcus aureus in his wound and Morganella morganii and Escherichia coli in his urine.

Patient #2
Observation on 03/10/2010 at 8:40 a.m. revealed patient # 2 was observed sitting in a chair in his room
The patient had a Foley catheter in place with a drain bag attached. The patient's drain bag was anchored to the garbage can beside the patient's bed. The external blue port of the drainage bag was directly on the floor.

Review of patient #2's clinical record (history and physical) revealed he was admitted to the facility on 03/08/2010 with diagnosis of " urinary tract infection. "


Patient #6
On 03/10/2010 at 7:58 a.m. registered nurse (C) was observed in the patient # 6's room examining the patient's post operative site on her abdomen. During the examination, registered nurse (C) placed the clipboard with the patient's assessment on the patient's bed.

After the examination, the nurse picked up the contaminated clipboard from off the patient's bed, washed her hands, then returned the contaminated clipboard to the nurses station.

During an interview with registered nurse ( C) on 03/10/2010 at 8:15 a.m., the surveyor informed registered nurse (C ) that she had observed her placed the clipboard on the patient 's bed, handled the clipboard with her contaminated hands, used to examine patient's post operative site, then returned the contaminated clipboard to the nurses station.
Registered nurse (C) stated " I won't do it again. "

Patient # 20
On 03/10/2010 at 9:25 a.m. licensed vocational nurse (B) was observed administering medication to patient #20 in the patient's room. The licensed nurse placed the medication administration record of the patient on the patient's bed, washed her hands, picked up the contaminated medication administration record and placed it on top of the clean medication cart.

On 03/10/2010 at 9:26 a.m., the surveyor notified licensed vocational nurse (B) that she had observed cross contamination of the medication administration record on the patient's bed and the clean medication cart. Licensed vocational nurse stated " I am sorry "

Review of facility's current policy and procedure # 610 -1- 10 on Transmission Base Precaution directed staff as follows: " All used linen and patient trash is considered contaminated and is handled according to standard precautions and our hospital exposure control plan. Reusable equipment will be retained in the rooms of patients on transmission - based precautions until patient is dismissed or precautions are discontinued."


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Operation Room # 1
Observation on 3/9/10 at 2:10 pm in Operating Room ( OR) # 1 revealed there was a heavy build up of dust with dust webs on the entire anesthesia machine. There was a heavy build up of dust on the lamp over the operating table. The Surveyor touched the lamp and dust web was floating around.

OR # 3
Observation on 3/9/10 at 2: 17 pm In Operating Room # 3 revealed the anesthesia machine, anesthesia cart, and the microscope arm were dirty with dust web and black particles.

During an interview on 3/9/10 at 2:25 pm with Staff # 56 (OR Nurse Manager), she stated the ORs were ready for the next day. The OR Manager further stated the equipment should be cleaned on a daily basis. According to the Staff there was a cleaning protocol and schedule that the staff did not follow.

Review of the facility's policy/procedure manual revised January 2010 titled Cleaning/Sanitation Procedure--OR, sub title Cleaning of OR Daily revealed the following information: "Prior to first scheduled procedure of the day all flat surfaces should be damp dusted with a disinfectant solution. This includes floors, equipment,overhead lamps,and other ceiling and wall mounted equipment."

Further review of the policy revealed there was a daily cleaning schedule that instruct staff to "wipe flat surfaces and damp mop" The form did not capture all the required items in each area that should be cleaned.

Based on record review and interview, facility's infection control officer failed to maintain a log of infections and communicable diseases.

Findings:

Review on 03/10/2010 of the facility's infection control log provided by the facility's infection control officer revealed the last documented incident of infection in the facility was dated 09/01/2007.

During an interview on 03/10/2010 at 3:47 p.m. in the facility's conference room, the surveyor requested from the infection control officer a current log of infections. The infection control officer stated " I do not have a log. I have a list of patients in my meeting minutes."
The infection control officer said she did not keep a log.

Based on record review and interview the facility ' s operation room staff routinely flash sterilize sets of instruments for scheduled eye surgery for the period December 1, 2009 through March 2, 2010.

Findings:

Review of sterilization logs, surgery logs and scheduling logs revealed the following information:

Cataract sets used for eye surgeries were flash sterilized for several scheduled cases.

On 12/1,2009 5 eye surgeries were scheduled, 1 cataract set was flash sterilized

12/8/09- 6 cases were scheduled, 2 cataract sets were flashed sterilized
12/16/09 -6 cases were scheduled, 2 cataract sets were flashed sterilized
12/17/09 -10 cases were scheduled, 6 cataract sets were flashed sterilized
12/29/09 6 cases were scheduled, 2 cataract sets were flashed sterilized

On 12, January 2010 seven cases were scheduled and three cataract sets were flashed sterilized.
1/14/10- 5 cases were scheduled and one cataract set was flashed sterilized
1/21/10 - 8 cases were scheduled and 4 cataract sets were flashed sterilized
1/26/10- 9 cases were scheduled and 5 cataract sets were flashed sterilized

On 2/2/10- 8 cases were scheduled and 4 cataract sets were flashed sterilized

2/4/10- 8 cases were scheduled and 4 cataract sets were flashed sterilized

On 3/10 9 cases were scheduled and 5 cataract sets were flashed sterilized

During an interview on 3/9/10 at 3:10 pm in the operation room with Staff # 56 (Nurse Manager) regarding the frequent use of flash sterilization of Cataract sets, she stated the cataract sets were flash sterilized because the facility had only four sets and on occasion more than four cases were scheduled. When asked if the eye surgeries were emergency cases the Staff stated all the cases were electively done.

Review of the facility ' s sterilization policy/procedure # A11145 dated January 2010, revealed the following information: "Flash sterilization should only be done in emergency situation".

Review of a memo from Centers for Medicare and Medicaid Services (CMS) dated October 2009 revealed the following guidelines: "flash sterilization should not be the norm, but rather should only be used in the event of an urgent and unpredicted need for a specific device, such as to clean an instrument that was dropped on the ground during a procedure".