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Based on observation and staff interview, the facility failed to ensure that patients received care in a safe setting by failure to ensure expired or open supplies were not available for use in two (2) out of eight (8) departments surveyed: Inpatient Physical Therapy Department, Outpatient Physical Therapy Department.

Findings Include:

Inpatient Physical Therapy

An observation on 07/18/2022 at 4:15 p.m. of the Inpatient Physical Therapy Department treatment room with Chief Nursing Officer (CNO), revealed the following supplies were found open in a wound care tray with no documentation of when it was opened: Two (2) Aquacel AG dressings, One (1) Silver anti-microbial wound dressing, One (1) Tube of Santyl, One (1) Bottle of Vitamin E oil, One (1) Wound Vacuum Tegaderm dressing. The following supplies were found expired in the wound care tray: One (1) Phytoplex antifungal powder, expired 06/2019; O250017ne (1) Sterilized sharp curved scissors, expired 6/12/18; One (1) Hibiclens eight (8) ounce bottle, expired 11/2016; One (1) Meflex self-adhesive fabric tape, expired 5/2019; One (1) package of Steri-Strips, expired 05/2017.

An Interview on 07/18/2022 at 4:16 p.m. with Physical Therapist #1, revealed they don't do wound care very often, and she has not been keeping up with the supplies as she should.

Outpatient Physical Therapy

An observation on 07/18/2022 at 4:25 p.m. during a tour of the Outpatient Physical Therapy Department with the CNO revealed the following expired supplies in a cabinet in the Hydro Room: 16 boxes of Iontophoresis electrodes, expired in 2019.

An interview on 07/18/2022 at 4:27 p.m. with the Director of the Outpatient Physical Therapy Department revealed the department no longer uses the expired Iontophoresis electrodes, and he is not sure why they are still being kept in the cabinet.

During Exit Conference on 07/21/2022 at 3:30 p.m., survey findings were discussed and no further documentation was submitted for review

Based on staff interview, personnel record review, and policy and procedure review the facility failed to comply with the facility's policy for employee TB testing for three (3) of seventeen (17) employee records reviewed, Lab Technician #1, #2, Pharmacist #1.

Findings Include:

An interview on 07/20/2022 at 1:50 P.M. with the Employee Health Nurse confirmed Lab Technician #1, #2, and Pharmacist #1, last annual TB skin test was in 2019.

A review of employee health records for Lab Technician #1, #2, Pharmacist #1 revealed no evidence of a current TB skin test for 2020, 2021, and 2022 in health records.

Review of the facilities "Immunization for Employees" policy dated, 02/07/2022 revealed: " ...A TB skin test is administered to all employees annually ...".

During Exit Conference on 07/21/2022 at 3:30 p.m., survey findings were discussed and no further documentation was submitted for review.