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Based on observation, interview, and facility policy review the facility failed to ensure medications were properly discarded after the expiration dates.

Findings:

During a tour of the pharmacy medication storage room on May 14, 2018 at 10:40 AM with the Director of Nursing (DON) it revealed there were nine (9) vials of Humulin NPH Insulin stored in the refrigerator with an expired date of March 2018.

During an interview with the DON on 5/14/2018 at 10:41 AM she confirmed that the nine (9) vials of Humulin N had expired. The DON stated that there is a separate container to store returns and expired medications and the storage bin is empty at this time.

During an interview with the Consultant Pharmacist, (Pharm.D) on 5/15/2018 at 10:17 AM he stated he has been the Contract Pharmacist at the Centers since 2001. Pharm.D stated that he comes to the Center at least once or twice a week. He stated his responsibilities include developing, supervising, and coordinating all the activities of the pharmacy services. I over - see all dispensing and storage. I make sure the temperatures and storage are done properly. When asked how expired medications are handled, Pharm.D stated, the expired medications, controlled and non-controlled medications are sent to Reverse Distributor, the company that destroys our medications. I do an inventory, make a spread sheet and send them out by UPS (United Parcel Service) mail.

Review of the Medication Storage policy and procedure, Page 1 of 4 of the policy read: It is the center's policy to ensure that adequate precautions are taken to store medications under proper sanitation, temperature, light, moisture, ventilation, segregation and security. It is the policy of the center to ensure that drug preparation and storage areas are well lighted and are located where staff will not be interrupted when handling drugs. Page 3 of 4 of the policy Section III read: It is the policy of the Medication Management Department that nursing unit medications dispensing areas (medication rooms, medication carts, medication storage closets, medication refrigerators, etc.) be in compliance with all State and Federal law and local standards of practice, all to the betterment of patient care. The Procedure read: At least monthly, but more often if necessary, each nursing medication unit dispensing area will be inspected by a Registered Pharmacist. Letter D read: Medications sorted on the unit as floor stock will have current date and medications that are expired will be removed immediately from the medication stock and placed in the expired bin by the assigned nurse for the pharmacist to take and destroy in the proper fashion.

Based on Governing Board review and interview, the facility failed to have a designated and qualified professional who has been approved by the Governing Body to be the Infection Control Nurse to develop and implement policies governing control of infections and communicable diseases.

Findings:

During an interview on 05/16/2018 at 8:30 AM with the Director of Nursing (DON), when asked if she was the Infection Control Nurse and if she had been approved by the Governing Body, she replied, "Yes I am the Infection Control Nurse, but I have not been approved by the Governing Body."

During an interview on 05/16/2018 at 10:00 AM with the Director of Quality Management when asked if the DON had been approved by the Governing Body as the Infection Control Nurse, she stated, "No, she has not."

Review of the Governing Body meeting minutes for the period of June 26, 2017 to April 3, 2018, confirmed the Governing Body had not designated an Infection Control Nurse.

Based on interview and Governing Body review the facility failed to ensure that accurate up-to-date Infection Control data was complete. Failure to utilize current and complete Infection Control data places patients at risk of facility acquired infections.

Findings:

During an interview on 05/15/2018 at 8:10 AM with the Director of Nursing (DON) when asked regarding infection control reports to the Quality Assurance Committee, she replied, "I have not done any reports to the Quality Assurance Committee for Infection Control."

During an interview on 05/15/2018 at 12:00 PM of the Director of Quality Management when asked regarding infection control reporting, she stated, "No, there has not been any up-to-date Infection Control data submitted from the Infection Control Committee for the period of July, 2017 to April, 2018. There was no information present of a hospital-wide quality assessment and performance improvement (QAPI) program and training programs to address problems identified by the infection control officer. She further stated, "the Governing Body has not reviewed any infection control data to be able to implement any corrective action plans for affected problem areas that may have been identified."

Review of the Governing Body meeting minutes for the period of July, 2017 through April, 2018 it showed there was not up-to-date Infection Control data submitted from the Infection Control Committee.