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Based on observation, interview, and document review, it was determined for 1 of 2 insulin vials (Novolin R) in the 5 South medication refrigerator, the Hospital failed to ensure the expired medication was not available for use. This potentially affected 4 diabetic patients on the unit.

Findings include:

1. During an observational tour of the 5 South Med/Surg Unit on 11/29/16 between 9:00 AM and 11:00 AM, it was observed that one (1) vial of Novolin R insulin with a "Do not use beyond 11/20/16" date.

2. The 5 South Unit Manager stated during an interview on 11/29/16 at approximately 10:30 AM, the medication was beyond the expiration date and should have been removed.

3. Hospital policy entitled, "Medication Administration," (effective date 11/10/16) reviewed on 11/30/16 at approximately 11:00 AM, required, "...B. Procurement of Medication for Administration...3. Unit Dose Delivery...c. Supplies and use of stock injectable on the nursing units must comply with Pharmacy guidelines as follows: I. Multi-dose injectable products will be dated with a beyond use date of 28 days, from the date of opening..."

Based on document review, observational tour, and interview, it was determined, for 34 of 34 containers of spice, 4 of 6 packets of cheese, and 1 of 1 package of 12 hard-boiled eggs, the Hospital failed to ensure food's open and/or preparation dates were identified on the package/container label, to avoid use of spoiled food, potentially effecting 108 patients on census.

Findings include:

1. On 12/1/16 at 2:00 PM, the "Food Product Shelf Life Guideline", issued 1/30/12, was reviewed. The guidelines required, "For purchased products, always follow the manufacturer's expiration date or packaging date... For products without manufacturer's expiration date, use the shelf life guidelines listed below... Spices - 6 months... Best used within 3 months... Hard Cheeses (i.e. Cheddar, Swiss) - opened package: 3 to 4 weeks... Shell eggs - 3 to 5 weeks... "

2. On 12/1/16 between 10:30 AM and 11:25 AM, an observational tour was conducted in the Dietary Department. These food items were not labeled with open or preparation date:

- 34 of 34 open spice containers (twenty seven containers weighing 16 ounces and seven containers weighing 1 pound) on the spice shelf.

- 4 of 6 open packages of Swiss and Provolone cheese (approximately 100 slices) in the food preparation area.

- 1 of 1 unopened package of 1 dozen hard boiled eggs (shells removed) in refrigerator W2 in the lower level.

3. On 12/1/16 at 11:20 AM, an interview was conducted with the Regional Director of Food and Nutritional Services (E #5). E #5 stated the spices were not labeled and open dates not known, the cheese packages should have been labeled with the open date, and the egg package was removed from a box container, which had the preparation date, which was 2 days ago.

Based on observations during the survey walk-through, staff interview, and document review from the Life Safety Code portion of a Full Survey Due to a Complaint conducted on November 29-30, 2016, the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation during the survey walk-through, staff interview, and document review from the Life Safety Code portion of a Full Survey Due to a Complaint conducted on November 29-30, 2016, the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags.

Based on observation, interview, and document review it was determined for 1 of 1 Certified Registered Nurse Anesthetist (CRNA #1), the Hospital failed to ensure, intravenous (IV) medications were administered as required.

Findings include:

1. During an observational tour of the Surgical Department on 11/30/16 between 9:15 AM and 11:15 AM, the following was observed in OR #7: At approximately 10:10 AM, CRNA #1 was observed administering IV sedation and IV antibiotics without cleansing the injection port prior to accessing.

2. The Surgical Services Manager (E #3) stated during an interview on 11/30/16 at approximately 11:00 AM that the port should have been cleaned.

3. Mosby's Clinical Skills entitled, "Medication Administration: Intravenous Bolus." (Copyright 2006-2016), reviewed 11/30/16 at approximately 12:15 PM required, "...Intravenous Push (existing line)...10. Clean injection port with antiseptic swab."

4. The Director of Systems Quality/Outcomes Management stated during an interview on 11/30/16 at approximately 12:15 PM that the CRNA is held to the same standard as anyone else. Additionally, the Director also stated that the Hospital references Mosby's Clinical Skills (Medication Administration: Intravenous Bolus) in their practice.

Based on document review, observation, and interview, it was determined for 1 of 1 isolation patient (Pt. #2) on the 3 South Unit, the Hospital failed to ensure isolation techniques were maintained.

Findings include:

1. The Hospital's policy entitled "Transmission Based Isolation precautions" (revised 07/2014) was reviewed on 11/29/16 at approximately 11:00 AM and required, "Droplet precautions...Wear a regular mask upon entering the room...Contact precautions...Wear gloves upon entering the room...Wear a gown when entering the room..."

2. On 1129/16, between 9:45 AM and 10:45 AM, an observational tour of the 3 South telemetry unit was conducted. The doorway to room 3062 contained signage indicating that Pt. #2 was on contact and droplet precautions. At approximately 9:55 AM, the nurse (E #2) was observed standing in Pt. #2's room (room 3062) talking to Pt. #2 at the bedside with no gown, gloves, or mask in place.

3. On 11/29/16 at approximately 9:56 AM, an interview was conducted with E #2. E #2 stated that she was called into Pt. #2's room and did not don gloves, gown, or mask before entering. E #2 stated that she did not touch the patient but still should have donned the appropriate personal protective equipment (PPE) prior to entering Pt. #2's room.

4. During an interview with the 3 South Manager (E #1) on 11/29/16 at approximately 10:00 AM, E #1 stated that anyone who enters an isolation room should be wearing the required PPE for the type of isolation in place.

Based on document review, observation, and interview it was determined for 1 of 2 physicians (MD #1) the Hospital failed to ensure adherence to the dress code while in the operating room (OR).

Findings include:

1. Hospital policy entitled, "Surgical Attire," (last review date 4/15/16) reviewed on 11/29/16 at approximately 2:00 PM required, "...B. Head and hair covers are worn in the semi restricted and semi restricted surgical areas. 2. Head and facial hair covers should cover all head and facial hair."

2. During an observational tour of the Hospital's Surgical Department on 11/30/16 between 9:15 AM and 11:15 AM, it was observed that in OR #7 at approximately 10:12 AM, a Surgical Resident (MD #1) entered the suite with his beard exposed on the side of his face.

3. The Surgical Services Manager (E #3) stated during an interview on 11/30/16 at approximately 11:00 AM that the resident's beard should have been covered.