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Based on observation and interview, the facility failed to ensure expired medications were not available for patient use.

Findings include:

On 03/24/10, an inspection of the crash cart (A-2) located on the B-Pod on the 4th floor, contained 6 ampules of Amiodarone (150 milligrams/3 milliters), which expired 01/2010.

On 03/24/10 in the afternoon, interview with the Director of Pharmacy Services, revealed the crash cart medications were checked monthly for expired medications.

Based on a review of laboratory procedures, the laboratory failed to have a written policy which stated which tissue specimens require a macroscopic examination and which tissue specimens require both macroscopic and microscopic examination.

Findings include:

The laboratory failed to have a policy, approved by the medical staff and a pathologist, which stated which tissue specimens require a macroscopic examination and which tissue specimens require both macroscopic and microscopic examination.

Based on a review of the laboratory look-back policy, the laboratory failed to have in effect a system to take appropriate action when notified that blood or blood components it received are at increased risk of transmitting HIV or HCV, which was sufficiently detailed to meet the current regulatory requirements.

Findings include:

The laboratory written look-back policy and accompanying forms and information did not include:

1) A notification process lasting twelve weeks;

2) Mention of a relative of the patient being a potential person to be notified;

3) Who in addition may be notified in the case of a competent patient;

4) Provision for notification for a minor patient; and

5) A list of counseling programs or places.

Based on observations, interview and document review, the facility failed to ensure temperature controls were maintained for perishable foods in the dietary area.

Findings include:

1. On the morning of 3/23/10, the temperature of the walk-in refrigeration unit was 45 degrees Farenheit (*F). The daily temperature log for the walk-in refrigeration unit documented readings of 45*F, 45*F, 45*F and 48*F for the previous four days. The Dietary Manager indicated that there should have been documentation on the log to correct the daily temperatures. There was no documentation on the log to rectify the high temperatures of the walk-in refrigeration unit.

2. The temperature of 8 hard boiled eggs at the self service salad bar area had a reading of 58*F. The Dietary Manager indicated that the eggs would not be served and were immediately disposed.

Based on observation, interview and document review, the facility failed to ensure persons designated as the Infection Control Officer implemented facility policies governing control of infections for patients in isolation rooms.

Findings include:

At approximately 2:15 PM on 3/24/10, two Case Managers were observed in Room #404 talking to Patient #1 for a period of approximately 10 minutes. Room #404 had a contact isolation sign posted on the front of the doorway and protective gowns, gloves and masks were observed available at the entrance of the door.

On the morning of 3/25/10, at approximately 9:10 AM, the Infection Control Officer indicated in an interview that for patients placed on contact isolation, anyone who entered the room should at least be wearing protective gloves.

The Transmission Based Precautions policy, with an approved and effective date of 3/9/09, stated under section (C) Contact Precautions (3) Personal Protective Equipment, "Wear a gown every time you enter the patient's room. You must wear a gown and gloves whether they are colonized or infected."