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Based on facility policies and procedure, tour, observation and an interview it was determined that the facility failed to conduct monthly medication inspections of the emergency cart and pharmacy.

Finding were:

Review of facility policy entitled Drug Storage Area Inspections, no policy number, effective date 09/17/05 revealed that the director of pharmacy or qualified designee will conduct at least monthly inspections of all drug storage areas. Inspections will be done by the pharmacist or an appropriately trained or experienced individual under the supervision of the pharmacist. The policy further revealed emergency drugs are in adequate and proper supply within the pharmacy and in designated areas.

Review of facility policy entitled Drug Procurement/Inventory Control, no policy number, effective date 09/17/05 revealed that the responsibility for control of medications within this hospital rests with the pharmacy department. Policies and procedures are designated to ensure the safe and accurate dispensing of medications throughout the hospital. The policy also revealed that these policies will be approved by the pharmacy and therapeutics committee. The policy revealed expired, damaged and/or contaminated medications will be removed from the drug storage areas within the hospital during the pharmacy inspections and will be returned to the pharmacy department for proper disposal.

During a tour of the pharmacy on 05/08/18 at 11:0 a.m. it was revealed that ten (10) 250 milliliter (ml) bags of normal saline were expired with a date of 10/17/17.

During an inspection of the emergency cart on 05/07/18 at 03:00 p.m. with the nurse manager (#6) it was revealed that two (2) vials of Levophed (a medication that treats low blood pressure) were expired with a date of 10/01/15. The Nurse Manager (#6) confirmed these findings.

During an interview on 05/09/18 at 10:45 a.m. in the conference room with the director of pharmacy (#8), the pharmacist indicated that the emergency cart was to be checked on a monthly basis by the charge nurse. The pharmacist stated that the the tray of medications in the cart are to be opened and checked individually and understood that the policy indicates this. The pharmacist stated that the medication Levophed was on back order for over a year (not available). The pharmacist indicated that he was not sure how the expired bags of normal saline were in the open box of unexpired normal saline. The pharmacist went on to state that normal saline has not been used in two (2) years. The pharmacist confirmed that the above bags of normal saline were expired.

Based on observation, record review, and interview, the facility failed to have procedures for the proper routine storage and prompt disposal of trash.

Findings were:

During the tour of the kitchen on 05/08/18, there were multiple trash bags in an open bin without a lid. Several live pests, including but not limited to flies were observed near the uncovered trash bin, and kitchen doors to the facility.

A review of the facility's policy titled, "Collection and Disposal of Waste" effective January 2018, showed no documentation of how trash would be covered to prevent pests.

During an interview on 05/08/18 with the Dietary Services Manager (Employee #13) outside the facility kitchen near the trash collection area, Employee #13 stated the trash was not covered, and that the trash was in the open cart and would be transported at least once a day to the dumpster. The dumpster was observed approximately 50 feet away from the kitchen.

Based on observation, record review, and interview, the facility failed to have written fire control plans that contain provisions for extinguishing fires; protection of patients, personnel and guests.

Findings were:

During the tour of the adult psychiatric unit on 05/07/18 at 3:30 p.m., a fire extinguisher next to the entry doors of the department unit was locked inside the fire extinguisher cabinet.

A review of the facility's policy titled, "General Fire Plan" under the facility's Life Safety Management Plan, revised 01/2017, showed no documentation of who had access to unlock the fire extinguishers in the event of a fire.

During an interview with the Mental Health Technician (Employee #12) on 05/07/18 at 3:35 p.m. inside the adult psychiatric unit, Employee #12 stated he/she did not have a key to unlock the fire extinguisher cabinet. Employee #12 further stated, he/she did not know how to unlock the cabinet and could not describe his/her role in the event the facility had a fire.

During an interview with the Maintenance Technician (Employee #10) on 05/07/18 at 3:38 p.m., inside the adult psychiatric unit, Employee #10 stated that only the charge nurses had keys to the fire extinguisher cabinets.

Based on review of policy and procedures, observation of the emergency medical cart and interview with the clinical nurse manager, the facility failed to ensure emergency equipment and supplies were maintained at an acceptable level of safety and quality.

Findings were:

Review of facility policy entitled DRUG STORAGE AREA INSPECTIONS, no Policy Number, Effective Date 09/17/2005, revealed the director of pharmacy or qualified designee will conduct at least monthly inspections of all drug storage areas. Inspections will be done by the pharmacist or an appropriately trained or experienced individual under the supervision of a pharmacist.

Observation of the contents of the emergency medical cart on 05/07/18 at 3:00 p.m. with the Nurse Manager, Staff #6 revealed:
--Two (2) vials of Levophed (medication used to control blood pressure in certain cases when the blood pressure is low) four (4) milligrams (mg) in four (4) milliliters (ml) expired October 1, 2015
-- Six (6) 24 Gauge (size) Intravenous (IV) (direct access to a vein) catheter (thin tube made of medical grade materials that can be inserted into the body to deliver fluids and/or medications)
--Four (4) 18 Gauge IV catheter expired 03/18
--Three (3) 20 Gauge IV catheter expired 2/18;
--Two (2) 20 Gauge IV catheter expired 04/18
--Two (2) clave connector (enclosed connection system to eliminate accidental needle sticks of people and protect the introduction of infections into an IV line) expired 1/18
--Two (2) clave connectors expired 12/17
--One (1) soft nasopharyngeal (airway expired 6/17
--(1) soft nasopharyngeal (tubular structure from the nose to the soft part of the back of the throat) expired 10/17
-- Three (3) Electro cardiogram (ECG) electrodes (connection sticker that will allow the heart's electrical activity to be sent to a monitor for viewing) patches expired 3/18.
--The plastic box that held electrodes had a layer of dust
--The top of the emergency medical cart and suction machine had dust.

The Nurse Manager, Staff #6, confirmed all the above and made the comment, that the inside of the emergency medical cart was last checked in May 2017.

Based on observation, record review, and interview the facility failed to provide proper ventilation controls in appropriate areas.

Findings were:

During the physical tour on 05/07/18, the room that held the facility's red bag waste was observed to be under positive pressure with respect to its surrounding areas. A tissue was placed on the bottom of the door of the red bag waste room and the tissue was observed to flow outward, away from the door displaying positive pressure. In addition, the central sterile supplies room was a pass through area into the room where the red bag waste was contained. Employee #9 and Employee #10 confirmed tissue paper of the biohazard room door flowed outward into the central sterile supplies room.

A review of the facility's policy titled, "Collection and Disposal of Waste" showed no documentation of proper ventilation for rooms that contained biohazard waste.

A review of the American Society for Healthcare Engineering's website, listed Room Pressurization as: "Positively pressurized rooms are usually designed to protect a patient, clean supplies, or equipment within the room. Negative pressure is used to contain airborne contaminants within a room." The website further lists, central medical and supply sterile storage areas are to be under positive pressure and soiled workrooms, holding rooms should be under negative pressure.

During an interview with the Director of Central Sterile, Materials Management (Employee #9) on 05/07/18 at 3:10 p.m., Employee #9 stated housekeeping brought in the red bag waste through the central sterile supplies room into the room that held the red bag waste. Employee #9 further stated, 1-2 times a month, their facility's waste vendor would pick up biohazard waste from the room. Employee #9 stated there was only one room into and out of the room that contained the biohazard waste.