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Based on observations, facility policy review and staff interview, it was determined the facility failed to ensure that all medications available for patient use in the facility were not expired and stored as stated in the policy. This had the potential to affect all patients at the facility.

Findings include:

Policy Number 050 Effective Date:10/2009
Subject: Storage of Medications in Patient Care Areas

A. Policy.....7. Medications bearing an expiration date will not be dispensed or distributed beyond the expiration date....Multiple Dose Vials must be discarded 28 days after it is opened.

1. An initial tour of the Emergency Department was conducted on 4/2/13 at 2:45 PM. During this tour the following outdated supplies were observed:

Catheter trays (2) expired February 2013.

2. An initial tour of the Surgery Department was conducted on 4/3/13 at 9:40 AM. During this tour the following outdated medications were observed in the emergency cart:

Lidocaine with Epinephrine (1) 20 milliliter vial expired 2/2013.
Hydromorphone (3) 2 milligram/milliliter (mg/ml) vials expired 11/2012
Phenergan (2) 25 mg/ml vials expired 11/2012

During the tour of the operating room # 1 on 4/3/13 at 9:50 AM observations of the anesthesia cart revealed the following:

Anectine (1) 200mg/ml open vial with no date or initials when opened.
Esmolol (1) 100mg/10ml open vial with no date or initials when opened.

An interview conducted on 4/3/13 at 11:55 AM with Employee Identifier (EI) #1, Director of Nursing, confirmed the aforementioned findings.

Based on observations during the facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.

Findings were:

Refer to the Life Safety Code survey report for findings.

Based on observation and staff interviews, it was determined the facility failed to assure the operating rooms were monitored for safe parameters of humidity and temperature for 1 of 1 operating rooms (OR). This had the potential to negatively affect all patients who had surgical procedures performed at the facility.

Findings include:

A tour of the Surgery Department was conducted on 4/3/13 at 10:25 AM. The surveyor observed 1 OR suite in the surgery department.

An interview was conducted on 4/3/13 at 5:15 PM with Employee Identifier (EI) # 3, Director of Surgery. The surveyor asked EI # 3 how the temperature and humidity was monitored for the OR suite. EI # 3 was not aware of the need to monitor and verified they were not recording temperatures or humidity for the OR suite.

An interview conducted on 4/4/13 at 1:30 PM with EI # 1, Facility Administrator, confirmed there was no policy for monitoring temperature and humidity in the OR suite.

Based on observations, interviews and review of the facility policy for Infection Control, it was determined the infection control officer failed to ensure all infection control policies and standards were followed by the staff. This affected Patient Identifier (PI) #'s 13 and 14 and had the potential to negatively affect all patients served by this facility.

Findings Include:

Policy: Infection Control
Use Standard Precautions for the care of all patients.
........
Handwashing:
1. Must wash hands before and after patient contact, after removal removal of gloves or other barriers (gowns, masks, etc), after exposure to contamination
2. Must wash other skin surfaces after contact or contamination
........
Date of revision: 01/13.
........

An observation was conducted of Employee Identifier (EI) # 4, the Licensed Practical Nurse (LPN), administering medication. During the observation, EI # 4 obtained medication from the PYXIS (medication cart) for two different patients, PI # 13 and # 14.

EI # 4 was not observed washing hands before retrieving the medications.

After retrieving the medications, EI # 4 placed the medications in a bag on top of the Cart On Wheels (COW) and preceded to PI # 14's room. Upon entrance to the room EI # 4 scanned the patient's arm band, assessed the patient's lung sounds and obtained vital signs. EI # 4 then prepared the patient's breathing treatment and handed it to the patient. EI # 4 documented in the COW and departed PI # 14's room. EI # 4 did not wash his/her hands at any time during the observation.

EI # 4 went directly to PI # 13's room. Upon entrance to PI # 13's room, EI # 4 scanned the patient's arm band, scanned the medication and applied the medication patch to the patient's back. The patient removed the previously placed patch and discarded. EI # 4 departed the room after documenting in the COW. EI # 4 did not wash his/her hands at any time during the observation.

An interview was conducted on 4/3/13 at 1:40 PM with EI # 1, Director of Nursing, who confirmed EI # 4 did not follow the facility policy for Infection Control.