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Based on observation and staff interview, it was determined the CAH failed to ensure drugs and biologicals were appropriately stored. This had the potential to result in the loss or contamination of medications. Findings include:

1. On 7/18/13 beginning at 10:00 AM, a tour of hospital medication storage areas was conducted with the pharmacist. Rooms 1 and 2, labor and delivery rooms, were each noted to contain unlocked carts with drawers containing vials of medications including vials of Marcaine, Vitamin K, Terbutaline, Cytotech, and tubes of Erythromycin ophthalmic ointment. The medications were in the bottom drawers of the carts and were accessible to obstetrical patients and visitors, including children.

During the tour, the pharmacist confirmed the area and the carts were easily accessible to obstetrical patients and visitors.

The CAH failed to appropriately store and secure obstetric medication.

2. A policy addressing drug storage in non-secure areas outside of the pharmacy, such as the obstetric rooms, was requested from the pharmacist on 7/19/13 at 9:00 AM. He stated the CAH had not developed a policy to address drug storage in non-secure areas.

The CAH failed to develop policies for drug storage in non-secure areas.

Based on observation and staff interview, it was determined the CAH failed to ensure a system for controlling infections in the endoscopy suite had been developed. This had the potential to result in hospital acquired infections. Findings include:

A colonoscopy was performed on Patient #31 on 7/17/13 beginning at 10:14 AM and ending at 11:00 AM, including pre procedure preparation and post procedure recovery. All phases of the procedure occurred in the procedure room. All phases of the procedure were observed by the surveyor. CAH staff participating in the procedure were the physician, the nurse anesthetist, and the registered nurse.

From the door, Patient #31 was in the middle of the room and the nurse anesthetist was to his left. The physician performed the procedure on Patient #31's right. A sink was not located in the room. The anesthetist was stationed between the patient and an anesthesia cart. He did not have a hand sanitizer on the anesthesia cart. An alcohol based hand sanitizer was located on the wall by the nurse but a cart with supplies for the procedure was underneath the dispenser. This prevented the nurse from using the hand sanitizer.

During the procedure, the anesthetist was observed to prepare his supplies, prep the patient's arm, start an IV, drop an alcohol prep pad on the floor and pick it up to dispose of it, administer at least 2 separate doses of IV medications, and document on a clipboard at least 3 times without performing hand hygiene. The nurse was observed to assist with positioning the patient, hand supplies to the physician, check on equipment, and gather specimens from the procedure without performing hand hygiene.

Following the procedure, the anesthetist was interviewed on 7/17/13 beginning at 11:15 AM. He confirmed he had not performed hand hygiene during the procedure. He confirmed he had no way to perform hand hygiene without leaving the patient he was responsible for monitoring. He stated he was not aware of a formal procedure which described how hand hygiene should be performed in the procedure room.

The CAH had not developed procedures to ensure staff performed hand hygiene in the procedure room.

Based on staff interview and medical record review, it was determined the hospital failed to ensure 2 of 2 patients (#4 and #10), who had surgery under general anesthesia and whose records were reviewed, were evaluated for proper anesthesia recovery by a qualified practitioner. This had the potential to allow patients with post-anesthesia complications to go undiagnosed. Findings include:

1. Patient #4's medical record documented a 53 year old female who was admitted to the hospital on 6/06/13 and discharged on 6/11/13. She was initially admitted for laparoscopic gall bladder surgery. The operative report, dated 6/06/13, stated during the surgery, the laparoscopic procedure was abandoned and Patient #4 required an abdominal incision to complete the procedure. The "ANESTHESIA RECORD," dated 6/06/13, documented the surgery was performed under general anesthesia. A form labeled "PREANESTHESIA EVALUATION," dated 6/06/13, contained a section for a "POSTANESTHESIA NOTE." This section was blank. A post-anesthesia visit was not documented.

The anesthetist was interviewed on 7/17/13 beginning at 11:15 AM. He confirmed a post-anesthetic visit was not documented for Patient #4.

A post-anesthesia visit was not conducted for Patient #4.

2. Patient #10's medical record documented a 48 year old female who was admitted to the hospital on 1/28/13 and discharged on 2/02/13. She had surgery to remove her uterus and ovaries on 1/28/13. The "ANESTHESIA RECORD," dated 1/28/13, documented the surgery was performed under general anesthesia. A form labeled "PREANESTHESIA EVALUATION," dated 1/28/13, contained a section for a "POSTANESTHESIA NOTE." This section was blank. A post-anesthesia visit was not documented.

The anesthetist was interviewed on 7/17/13 beginning at 11:15 AM. He confirmed a post-anesthetic visit was not documented for Patient #10.

A post-anesthesia visit was not conducted for Patient #10.