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Based on observation, record review, document review and staff interview it was determined the facility failed to ensure all drugs and biologicals were under the supervision of nursing or other personnel in accordance with the approved medical staff policies and procedures. This deficient practice was identified in one (1) of ten (10) records reviewed (patient #8). Failure to ensure all medications are under the supervision of nursing or other personnel has the potential to impact care at the facility including the improper use of unsecured medications.

Findings include:

1. A tour conducted on 7/2/18 at 2:40 p.m. on the 3 North-Telemetry Unit revealed a labeled patient belonging bag (for patient #8)containing clothing and a plastic bag with bottles of patient medication. The items were observed to be in a cabinet under the sink in the medication room.

2. Review of the medical record for patient #8 revealed she had been a patient at the facility from 1/6/18 to 1/8/18. On 1/8/18, she was transferred to another hospital without her personal belongings and medications.

3. An interview was conducted with the Director of Nursing on 7/4/18 at 8:50 a.m. She confirmed all personal belongings and medications should go with the patient upon discharge/transfer.

4. A review of the facility policy entitled "Medication Distribution-Home Medications Brought to the Hospital", last revised 5/16/17, revealed it stated in part: "POLICY: If the medications cannot be returned home, preferably, the patient's medications will be secured as with other patient valuables until they can be sent to the Pharmacy for storage ..."

5. An interview was conducted on 7/4/18 at 8:45 a.m. with the Regulatory Compliance Coordinator and she concurred the medication policy was not followed regarding the proper storage of medications.

Based on observation and staff interview it was determined the facility failed to maintain proper storage of clean supplies to avoid sources and transmission of infection and communicable diseases. This failure has the potential to adversely affect all patients.

Findings include:

1. A tour of the Telemetry Unit conducted on 7/2/18 at 2:40 p.m. with the Regulatory Compliance Coordinator, Acting Director of the Telemetry Unit and the Nurse Manager revealed the soiled utility room on the Telemetry Unit had three (3) three thousand (3000) milliliter bags of normal saline irrigation solution and thirty-four (34) boxes of Sani - wipes stored in the cabinets in the soiled utility room for patient use. The Nurse Manager stated no supplies for patient use should be stored in the soiled utility room.

2. An interview was conducted on 7/3/18 at 12:40 p.m. with the Infection Control Officer. She stated she is involved in all policies related to infection control. When asked about storing clean supplies in the soiled utility room for patient use she stated only soiled supplies are to be kept in the soiled utility room. She stated every staff member is trained concerning the proper storage of clean and soiled supplies. She concurred the facility failed to maintain proper storage of clean supplies.

3. An interview was conducted with the Regulatory Compliance Coordinator on 7/3/18 at 8:00 a.m. She concurred the facility failed to maintain proper storage of clean supplies to avoid sources and transmission of infection and communicable diseases.