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Based on a tour of the facility, review of available documentation and interviews, the facility failed to ensure that outdated medication was not available to patients and that multi dose vial were dated and initialed upon opening.

Findings were:

Facility policy titled Unusable and Outdated Drugs states, in part, " All discontinued patient drugs; outdated drugs, contaminated drugs, improperly stored drugs and containers with worn, illegible, or missing labels shall be returned to the Pharmacy Department for proper disposal. "

Facility policy titled Subcutaneous Injections states, in part, " All multi-dose vials should be dated and initialed at the time it is initially opened and discarded within 30 days of that date. "

During a tour of the medication room on 1-17-12, 4 out of 5 multi-dose vials insulin were open and undated (Humulin 70/50, Humalog, and Lantus) or expired (Humulin R dated 10-11-11), that were still available for patient use.

In an interview on 1-18-12, the Director of Nursing and Director of Medical Records confirmed that outdated medication was available for patient use and multi-dose vials were not properly dated when opened.

Based on observation and a tour of the facility on on 1-17-12, the hospital failed to provide a sanitary environment for the storage of supplies; walls were not intact, ceiling tiles were stained and chipped, and a food preparation table in the kitchen was not able to be properly cleaned.

Findings were:

During a tour of the facility on 1-17-12 the following infection control issues were observed:
? In the Central supply area there were 11 boxes of supplies stored on the floor.
? Ceiling tiles throughout all areas of the hospital were water stained and in need of replacement and/or repair.
? In the physical therapy department in the area where new hot water pipes were installed, there were two open areas -- one in the wall and the second in the ceiling around the same pipes, these areas had not been repaired after the pipes had been installed. In a storage closet, the other area where the pipes went into the wall also had open areas around the same pipes. These areas had not been repaired after the installation of the pipes.
? In the kitchen area - the edges of the food preparation table had loose areas and were held in place with tape; this poses an infection control problem as the areas of tape cannot be properly cleaned or sanitized.

The above findings were confirmed in interview with the nursing director on 1/17/12 during a tour of the hospital.

Based on a review of available documentation and interviews, the facility failed to ensure that fire drills were conducted to train staff in handling emergencies, fires and where necessary, evacuation of patients, personnel, and guests, and cooperation with fire fighting and disaster authorities;

Findings were:

Facility fire drill policy did not include a frequency for fire drills performed.

The facility was only able to provide documentation of 6 fire drills performed in the past year: 2-28-11 at 1100, 3-31-11 at 2300, 4-14-11 at 0825, 6-16-11 at 0625, 8-19-11 at 1609, and 9-11-11 at 0306.

In an interview on 1-18-12, the Director of Nursing and Director of Medical Records confirmed that fire drills had not been performed as per licensure requirements.

Based on a review of documentation, clinical record review, and interviews the facility failed to ensure that medical record entries were completed promptly and accurately documented.

Findings were:

An Amendment to the Medical Staff Bylaws states in part, " ...At the time of discharge the physician shall see that the record is complete, state final diagnosis, supply discharge summary, sign hospital records in all places where his signature is required or needed within 15 working days from the date the record is placed in the physician ' s file for completion. "

Physician progress notes were found unsigned and undated in 6 out of 15 inpatient clinical records reviewed: Patients # 2, 3, 12, 13, 14, and 15.

History and Physicals were found unsigned and undated by the physician in 6 out of 15 inpatient clinical records reviewed: Patients # 1, 3, 12, 13, 14, and 15.

No Discharge Summary was present in 5 out of 15 inpatient clinical records reviewed: Patients # 8, 12, 13, 14, and 15.

In an interview on 1-18-12, the Director of Nursing and Director of Medical Records confirmed that medical records were not completed in a timely manner.