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Based on observation, record review, and interview, the facility failed to keep the premises clean, in that:
(A) the floor of 1 of 1 housekeeping closet in the restricted area had paper trash, dark gray spots, and the top wall had areas where sheetrock paper were peeling off;

(B) in the substerile room, the seam of 1 of 1 blue rectangular plastic container labeled "Cidex" bucket had thick layers of yellowish dark brown particles. The overall condition of the container had white stains and scattered black spots and lines. The container contained water and cidex solution for reprocessing the endoscopes; and

(C) the seal of 1 of 1 refrigerator in the laboratory that only stored pints of blood was covered with black blemishes.

Findings included:

During a tour in the surgical unit on 1/14/15 at approximately 10:10 AM with Personnel #9 (surgical technician) the following was observed:
(A) The housekeeping closet located in the operating area (OR) had paper trash on the floor, scattered dark gray spots, and the middle wall's upper section had several sheetrock papers peeling off the wall. Personnel #9 who was with the surveyor during the tour confirmed the findings and stated he would inform housekeeping to clean the area.

(B) In the substerile room, the seam of a blue rectangular plastic container which contained water and cidex solution for reprocessing the endoscopes had thick layers of yellowish dark brown particles. The overall condition of the container had white stains and scattered black spots and lines. The surveyor asked for a clean wet cloth and cleaned the container's lid and seam. The white stains and the yellowish dark brown particles came off. Personnel #9 who was with the surveyor confirmed the findings. Personnel #9 was asked who was responsible for cleaning the container and how old was the container. He replied that he does the cleaning and stated "it's been here since I was here, about 13 years" in reference to the container.

(C) During a tour in the laboratory on 1/14/15 at approximately 10:25 AM with Personnel #3 (CNO-Chief Nursing Officer) it was observed that the refrigerator's seal was covered with black blemishes. The sole purpose of this refrigerator was to store pints of blood for emergency use. Personnel #12 (Laboratory Director) was requested to clean the seal. Personnel #12 cleaned the seal and the black blemishes came off. Personnel #12 was asked who was responsible for cleaning the refrigerator and she replied that it was the laboratory personnel.

Policy: "Operating Room Cleaning" adopted 8/2007 required "III. Procedure A. Sweep and mop floors..."

Policy: "Laboratory Area Cleaning" adopted 8/2007 did not indicate the cleaning of the refrigerator.

Based on record review and interviews, the hospital failed to: 1) provide training to instruct personnel in the use of fire-fighting equipment for the year 2014; and 2) failed to conduct one fire drill per shift per quarter, in that, there were no fire drills for the second shift for 1 of 4 quarters in 2014 (4th quarter of 2014).

Findings included:

1) Review of the hospital's fire safety information for the year 2014 did not include fire extinguisher training.

During an interview the afternoon of 1/15/15 at 12:05 PM, Personnel #7 was asked if a fire extinguisher training had been conducted for the year 2014. Personnel #7 confirmed the training had not been conducted for the year 2014.

The hospital's Fire Prevention Checklist policy dated 04/2002 reflected, "...All employees are instructed in the fire prevention programs and facilities of the institution, in the use of fire fighting apparatus..."

2) The fire drills conducted during the first quarter were on 10/03/14 at 6:30 PM; on 11/14/14 at 2:07 PM; and on 12/03/14 at 3:00 PM.

During an interview on 1/14/15/14 at 2:00 PM, Personnel #3 confirmed there was no second shift fire drill for the 4th quarter. Personnel #3 stated the hospital had 2 shifts that were from 7 AM until 7 PM, and from 7 PM until 7 AM.

The hospital's Fire Prevention Checklist policy dated 04/2002 reflected, "...Fire drills, not involving patient participation, are rehearsed by hospital personnel at least four times a year, for each shift..."

Based on observation, record review, and interview, the facility failed to identify the following problems that could affect patient health and safety:
(A) the Emergency Department (ED) had 3 of 3 oral drugs (Aspirin chewable 81 mg [milligrams], Acetaminophen oral solution, and Amoxicillin oral suspension) were outdated and/or opened medication bottles had no date when it was opened and no initial as to who opened it;

(B) 2 of 2 departments (ED and OR-operating room) had sterile hinged instruments that were found to have closed tips; and

(C) 1 of 2 registered nurses (RNs) did not perform hand hygiene on 2 occasions after taking off her soiled gloves.

Findings included:

(A) During a tour in the ED on 1/14/15 at 9:20 AM with Personnel #8, the medication room was found to have oral medications ready for patient use, the following were:
-Aspirin chewable 81 mg #36 was open and did not have a date and initial as to when and who opened the medication.
-Acetaminophen oral solution for children, 16 fluid ounces was opened on 8/11/13. The expiration date of the drug was on 9/2014.
-Amoxicillin oral suspension 250 mg/5 ml (milliliters), 80 ml constituted was opened on 12/20/14 and not refrigerated.

In an interview on 1/14/15 at 9:20 AM, Personnel #8 confirmed the findings. She stated the outdated medications should have been discarded and the opened medication bottle should have been dated and initialed.

In an interview on 1/14/15 at 10:45 AM, Personnel #13, Pharmacy Technician was informed of the above findings. Personnel #13 was asked if Amoxicillin suspension was appropriate to administer after it was opened on 12/20/14. Personnel #13 replied that it should have been discarded after 7 days and should have been stored in the refrigerator after it was opened.

Policy Pharmacy Services "Medication Expiration Dates" undated required "Expired date: Medications will be discarded according to date open expiration or according to manufacturer's expiration date, whichever comes first...Multi-dose vials...should be dated and initialed when opened by licensed staff..."

(B) During a tour of the ED and OR on 1/14/15 at 9:20 AM and 10:10 AM respectively, the following sterile hinged instruments were found with their tips closed:
ED - 3 nasal speculums, 3 alligator forceps, and 3 "Gelpi" retractors
OR - 1 suture scissors and 1 blade holder

In an interview on 1/14/15 at approximately 10:15 AM, Personnel #9 who was responsible for sterile processing was informed of the above findings. He was asked if he was aware that instruments had to be sterilized with open tips. Personnel #9 replied that he knew about it.
Policy "Cleaning Instruments" revised 8/2011 included sterilization of instruments but did not indicate instruments should be sterilized with open tips.

Centers for Disease Control and Prevention (CDC) Guidelines for Disinfection and Sterilization in Healthcare Facilities, 2008 at "http://www.cdc.gov/hicpac/Disinfection_Sterilization/13_11sterilizingPractices.html" required "Sterilizing Practices...Packaging. Once items are cleaned, dried, and inspected, those requiring sterilization must be wrapped or placed in rigid containers and should be arranged in instrument trays/baskets according to the guidelines provided by the AAMI and other professional organizations454, 811-814, 819, 836, 962. These guidelines state that hinged instruments should be opened..."

(C) During a medication pass in the in-patient floor on 1/14/15 at approximately 1:48 PM Personnel #11 was observed not performing appropriate hand hygiene after taking off her soiled gloves on 2 occasions, the first time was at 1:50 PM and at the second time was at 1:55 PM.

In an interview on 1/14/15 at 3:00 PM, Personnel #3 was informed of the above findings and was asked to provide a policy and procedure. Personnel #3 confirmed the findings.

Policy "Hand Washing Technique" revised in 2004 required "N...4. Always wear gloves and wash hands afterwards..."

Morbidity and Mortality Weekly Report dated October 25, 2002 / Vol. 51 / No. RR-16 " Guidelines for Hand Hygiene in Healthcare Settings " pages 24 and 33 required " Hand hygiene is required regardless of whether gloves are used or changed ...handwashing or disinfection should be performed after glove removal ...7 ...B. Monitor HCWs ' adherence with recommended hand-hygiene practices and provide personnel with information regarding their performance ... "