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Based upon observation and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of the patients and was found not in substantial compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 483.70(a), Life Safety from Fire, and the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care. Findings include

See the individually and below cited K-tags dated March 17, 2016.
K-0018
K-0022
K-0025
K-0029
K-0038
K-0050
K-0063
K-0076
K-0147

Based on observation, interview, and document review the facility failed to ensure supplies and Labor and Delivery discharge rooms are maintained at an acceptable level of safety and quality resulting in the potential for poor patient outcomes for all patients served. Findings include:

On 03/15/2016 at 1100 during observational tour on the third floor Medical/Surgical unit, the high and low control solution vials for the glucose meter were noted to be opened and undated, The package insert, to check for manufacture recommendations for the safety of the controls after opening, was not readily available.

On 03/15/2016 at 1110 Staff Q and R were asked if they knew how long the controls were safe to use after opening and if they knew when the control vials were opened. Staff Q and R responded "No" to both questions.

On 03/16/2016 at 1300 review of procedure #5.82 titled "Whole Blood Glucose using Roche Accu-check Inform II" dated June 15, 2015, revealed on page 2 of 14 "....2. Date the vial when it is opened.....Control solutions are stable for three months after opening...."

On 3/16/2016 at 0835 during observations in the operating room (OR) the Pediatric Broselow Crash Cart at post anesthesia care unit (PACU) B was found to have expired supplies in all 6 level drawers dating as far back as 04/2014. This was verified by Staff HH on 3/16/16 at 0835.

On 3/17/2016 at 0800 review of the policy #MM.01.26 titled "Tier 2: Emergent Drug Carts, Trays, Boxes and Kits." revealed on page 4 of 9 "...It is the responsibility of the person restocking the crash cart to check for used or expired items...."

On 03/15/2016 at 1415 during the tour of the labor and delivery unit, post Cesarean section room A310 was found to be unoccupied. The crib in the room had a label with an infant name and date of birth still in the holder on the head of the crib and a patient name remained on the outside of the room door. On 3/15/16 at 1415 Staff Q and R were asked if the room was available for patient use. Staff Q stated "This room is supposed to be clean and ready to admit a new patient."

On 03/16/2016 at 1500 the Procedure titled "Labor and Delivery Discharge Room." on page 2 of 4 states "...10...clean patient room door.. clean crib.."

Based on observation, interview and document review the facility failed to provide a clean environment and monitor for compliance with infection control policies, procedures and protocols resulting in the potential for the spread of infectious disease among all patients served. Findings include:

On 03/15/2016 between 1030 and 1500 during tour of the Garden Intensive Care Unit (ICU), Labor and Delivery unit, Medical/Surgical unit, and Post partum-Medical/Surgical units, the medication dispensing cabinets (Pyxis) were found to have heavy dirt, dust and debris covering the floor of the cabinet that contained the sterile intravenous (IV) fluid bags. Staff Q and R were queried on 3/15/16 at 1045 if the pyxis cabinet was on a cleaning schedule, they responded "We will have to find out."

On 03/17/2016 at 0900 the document titled "Unit Inspections Results Jan/Feb 2016" was reviewed. It listed unit inspections including the Pyxis but not a cleaning schedule. Staff Q and R stated "We do not have a cleaning schedule that includes the floor of the pyxis cabinet."

On 03/15/2016 at 1100 during tour of the ICU room C041 it was noted the patient's IV tubing and two IV sites (left antecubital and right forearm) were not labeled with date, time and initials for when they were initiated. Staff Q and R were queried on 3/15/16 at 1105 about the facility's policy to label tubing and IV sites. Staff Q stated "Yes. They are supposed to be labeled with date, time and initials when they are initiated."

On 03/17/2016 at 0930 review of the policy #510.00 dated approved July 2013 revealed on page 1 of 7 "The Registered Nurse (RN) will label the insertion site with the date, time and his/her initials." and on page 3 of 7 "D. 7. All tubing shall be labeled with date and time it was hung."

On 03/15/2016 at 1315 during observation of insertion of a peripherally inserted central catheter (PICC line) staff V scrubbed the insertion site from the inside out then returned to the inside and worked outward 2 more times with the same contaminated ChloraPrep.

On 03/15/2016 at 1345 staff Q and R were queried about the procedure of returning to the center with the contaminated swab stated "We will have to look into the manufactures recommendations."

On 03/16/2016 at 1600 review of the policy #6.12 titled "Prevention of Intravascular Catheter-Related Infections." revealed on page 4 of 9 "Antiseptics should be applied and allowed to dry according to the manufacture's recommendations..." The package insert was also reviewed for the "ChloraPrep One-Step." It states " gentle repeated back and forth strokes for 2 minutes...discard after single use."