HospitalInspections.org

Based on observation, it was determined that the hospital failed to ensure that the patient areas were maintained in a safe and sanitary manner.

Findings were:

? Tour of the facility on 3/16/10 revealed a nonfunctioning call light in the patient bath area.
? The same tour revealed a door in a patient area that led outside was found unclosed. The surveyor was unable to close the door completely. This unclosed door left a ? inch of space surrounding the door that could possibly allow entry of insects into the patient area.

In an interview with the Charge Nurse during of the tour on 3/16/10, the nonfunctioning call light was confirmed. The IT Director acknowledged that a door in the patient area was unable to completely close.

Based on review of documentation, it was determined that the facility failed to maintain accurate records concerning drug dispensation.

Findings were:

Facility policy entitled " Consultant Pharmacist " stated under " specific duties of the consultant pharmacist " that the pharmacist will " supervise all compounding, packaging, and dispensing of drugs and biologicals consistent with state and federal laws. "

The following drugs were individually packaged from bulk floor stock by staff member # 1 (LVN/Pharmacy Technician) on 2/26/10, but were not cosigned for release by the pharmacist:

? I-Caps Eye Vitamin (Quantity 32)
? Vitamin E -1000 Units (Quantity 27)
? Atenolol 25 MG tabs (Quantity 32)
? Avapro 300 MG tabs (Quantity 32)

In an interview with staff member # 1 (LVN/Pharmacy Technician), it was confirmed that the medication packaging log was not signed by the pharmacist in the above cases.

Based on observation, it was determined that the facility failed to properly label containers used for sterilization of equipment.

Findings were:

Facility policy entitled " Contaminated Instruments-Transport to CS (Central Supply) " stated in its sterilization procedure, " Place the blade in the container and cover with Cidex solution. "

Facility policy entitled " Autoclave (Sterilization of Instruments) " stated in its sterilization procedure, " Put instruments in white basket and place basket carefully in clear tub that has Surgi-Stain solution. Solution needs to be refilled every three months (if looks dirty). Solution contains 1 bottle of Surgi-Stain and distilled water. Leave instruments in Surgi-Stain solution for 15-20 minutes or longer depending on instrument load and how dirty they are. "

Tour of the facility on 3/16/10 revealed a large, unlabeled container of fluid in Central Supply. The Central Supply clerk stated that the container was for sterilizing equipment. The same staff member said, " I mix the solution myself about once a month. I do not keep a log of when the solution is mixed. "

Staff member # 2 (Charge Nurse) confirmed the above finding of a container of sterilization fluid. It was acknowledged that the container was not labeled as to content, the name or initials of the person who mixed the solution and the date that the solution was mixed.