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Based on observation, interview and document review, the facility's segerated IV Room, where compounding is performed, does not meet the 797 USP guidelines, specifically with regard to the preparation of parenteral nutrition. Staff did not wear appropriate PPE when preparing a medication.

FINDINGS:

The IV Room has no ante room, buffer area or any ares of demarcation between the clean and dirty areas. There is also a hand washing sink in this area.

The mixing of an antiobiotic under the laminar flow hood was observed on 11/27/17. The only PPE (Personal Protective Equipment) donned was a gown. Required hair and shoe covers were not worn.

Upon interview on 11/29/17 at 1pm, Staff J explained that very few custom parenteral nutrition formulas are actually compounded in the Pharmacy. Staff J stated parenteral nutrition could be compounded, if needed.

The Pharmacy policies and procedures are not consistent with the construction of the IV room, and the compounding activity that is being performed in this Room. Based on interview, staff would compound solutions with 3 or more ingredients.

Based on observation and interview, the facility failed to implement infection control measures.

FINDINGS:

1. The Pharmacy was toured on 10/27/17 at 10:30am. A room described by Staff J as a storage/supply room contained partially opened cardboard shipping boxes. The boxes were sitting on shelves and contained unopened bags of IV fluids. AAMI standards require supplies be removed from shipping containers before they are placed in supply rooms.

2. A tour of the Endoscopy Unit was conducted on 11/29/17 at 10:00 am with Staff O. In Procedure Room 1, a roll top style scope storage cabinet was noted to be open. The cabinet, containing clean scopes, was left open during an endoscopic procedure. Upon interview on 11/29/17 at 10:30, Staff O indicated that the cabinet should be closed during procedures to prevent possible contamination.

Facility policy titled Endoscope cleaning, reference # E 04, effective 4/28/17, Section V, line "E", instructs; "Store the endoscope in the cabinet." The policy does not address when the cabinet the door should be opened or closed.

Based on interview and document review, there was no evidence that the Respiratory Department is under the direction of a physician.

Findings:

Upon interview with Staff K, on 11/27/17 at 1:30 pm, it was verified that currently there is no designated medical provider to supervise and delegate the activities of the Respiratory Department. Problems are brought forth to the Hospital Medical Director by the Respiratory staff for resolution.

Interview with Staff R on 11/29/17 at 9:30am, further verified this finding.