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Based on observations, policy review, and staff interview, the facility failed to ensure that all essential patient care equipment and supplies were maintained in safe operating condition in 1 of 2 emergency department treatment rooms and 1 of 1 medical floor supply storage areas. Findings include:

1. On 5/21/13, the surveyor began the review of the emergency department at 7:15 a.m. The surveyor located the following patient care items available for use:
-two open 4.25 ounce tubes of Surgilube with the manufacturer's expiration dates of April 2009 and May 2011.
-three sterile packages of 1/8 inch by 3 inch Steri-Strip wound closures with the manufacturer's expiration date of 1/2013.
-one Kendall Foley catheter tray with the manufacturer's expiration date of 3/2012.
-five three swab packets of Povidone-Iodine swabsticks with the manufacturer's expiration dates of 4/2011 (2) and 3/2012 (3).
-three sterile Heimlich valves for pericardiocentesis with the manufacturer's expiration date of 1/2013.
-fifteen 3 gram foil packages of Surgilube with the manufacturer's expiration date of 9/2012.
-two Vaseline .6 ounce tubes with the manufacturer's expiration dates of 12/2010 (1) and 5/2012 (1).
-one open 8 ounce bottle of Hibiclens (Chlorhexidine) solution with the manufacturer's expiration date of 6/12. (open) and 9/12 (sealed).

Staff member C, the Director of Nursing, was present intermittently during the review of the emergency department and verified the expiration dates of the identified supplies.

2. On 5/21/13 at 2:20 p.m., the surveyor reviewed the contents of the medical floor supply room and noted the following:
-one sealed 8 ounce bottle of Hibiclens (Chlorhexidine) solution with the manufacturer's expiration date of 9/12.
-one open, partially used, 20 milliliter single dose vial of normal saline on the intravenous insertion tray. The vial was not dated as to when the vial was opened or first accessed.

Review of the facility policy labeled "Medication and Supply Outdates" with a review/revision date of 9/14/10 included the policy statement "When a medication or supply has an expiration date and only the month and year is given, it is the policy of RMC (Roosevelt Medical Center) to remove the expired product from use on the last day of the month it expires."

During an interview with staff member N, a staff nurse, on 5/21/13 at 2:30 p.m., the staff member verified that there was no opened on date marked on the vial, but it should have been discarded after it was accessed. The staff member also stated that the night shift staff nurses check supplies in the emergency department monthly and the CNAs stock the floor.

Based on observations, facility staff failed to properly handle food items during a meal service. Findings include:

On 5/22/13 at approximately 8:15 a.m., the surveyor observed staff member Q during the breakfast meal service. Staff member Q wiped down the counter and tray line lids with a liquid saturated cloth and then picked up and filled a coffee mug for a patient. Staff member Q did not remove her gloves or wash her hands before handling the coffee mug.


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During the observation of the breakfast meal service on 5/22/13 at 7:28 a.m., staff member Q was at the serving line during breakfast in the main dining room.

Staff member Q walked out of the kitchen with plates of food for 2 patients. Staff member Q set the plates on the table in front of the patients, bent down to talk to a patient and rested her gloved hands on the front of her legs. Staff member Q then returned to the kitchen without changing her gloves and continued to dish up patients' plates. Staff member Q then went to the walk-in freezer, opened the door with her gloved hand, removed yogurt, picked up a clean plate, and picked up fresh orange slices with her gloved hand and set the slices on the plate. She then went to the refrigerator, removed a loaf of bread, went back to the serving line and opened the bread. Staff member Q removed 2 slices of bread with her gloved hand and put the bread slices into the toaster.

Staff member Q did not remove or change her gloves between any of the above tasks she completed.

Based on document review and staff interview, the facility failed to ensure that 5 (#s B, D, E, H, and L) of 6 members of the Radiology Department staff were not exposed to radiation hazards. Findings include:

During the review of the Radiology Department on 5/21/13 beginning at approximately 10:00 a.m., the surveyor requested the most current radiation badge reports for the staff that worked in the department. Staff member B, a radiology technician, located and provided the reports to the surveyor. After reviewing the forms labeled "Occupational Radiation Exposure Report", with the wear periods of 10/15/12 through 1/14/13 and 1/15/13 through 4/14/13, the surveyor noted that the reports contained a total accumulated dosage for only one named individual and a control badge. The surveyor noted that there were a total of six employees in the department.

Review of the facility policy labeled "Personal Dosimetry Film Badges" with the last review/revision date of 4/26/2009 revealed that the policy stated; "Whenever a worker could receive 10% or more of the annual total effective dose limit, that person must be provided with a radiation monitoring device.
Film Badges are radiation monitoring devices designed to measure occupational dose to health care workers, supply an official legal record of radiation exposure, and provide protection."
The first bullet point under basic rules to ensure accuracy of the badge's readings included the following item; "RMC employees are encouraged to wear their badges on the outside of the collar, facing forward.
Page 2 of the policy included the following language: "Health care professionals 18 years old or older are not allowed by law to receive more than 5 rem (Roentgen equivalent man), (5000mrem) of occupational radiation exposure annually.
Badge reports are received quarterly. Quarterly and yearly cumulative badge reports are kept in the Department file cabinet available for review at any time, by any employee of the department. The yearly reports are available to each employee for personal records.
The Radiology Department Manager is responsible for badge distribution, as well as observations and evaluations of all exposure reports."

During an interview with Staff member B on 5/21/13 at approximately 10:15 a.m., staff member B stated that she did not have a radiation dosimetry badge at the facility. Staff member B stated that at her job as a radiology technician at another facility, she had a badge there, but had never received one at this facility. When asked why only one staff member was documented on the report, staff member B was unable to explain why only the department manager (staff member V) was on the exposure report.

Based on observation, record review, and staff interview, the facility failed to assess 1 (#23) of 6 sampled swing bed patients for the use of restraints, obtain informed consents for, and care plan the use of the restraints. Findings include:

During observations of resident #23 at 8:10 a.m. and 1:40 p.m. on 5/22/13, patient #23 was observed to be in bed with full length side rails in the up position.

Review of the medical record on 5/22/13 at 2:00 p.m., lacked evidence of an assessment for the use of side rails and the active Care Plan did not address the use of side rails.

Review of the Policy for restraints: "restraints should only be utilized only after careful assessment."

During an interview with staff member A, the administrator on 5/22/13 at 2:30 p..m., she stated "we do not have an assessment for side rails for [patient name]."

Based on record review and staff interview, the facility failed to assess 1 (#23) of 6 swing bed patients for Social Services needs on admission.

During the review of patient #23's electronic medical record on 5/22/13 at 2:00 p.m., the surveyor was unable to locate the initial assessment for Social Services for patient #23.

During an interview with staff member A, the administrator, on 5/22/13 at 2:45 p.m., she stated "I believe he was admitted when we did not have a Social Services staff member. I am unable to find where nursing did an assessment for Social Services."

During an interview with staff member I, Social Services, on 5/22/13 at 3:30 p.m., she stated "I am unable to find an admission Social Services assessment for [patient name]."