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Based on observation and interview, the facility failed to remove expired medication from the medication refrigerator at the Nurse's station.

The findings included:

Observation of the floor stock medication in the Nurse's station refrigerator revealed an unopened box of Humalog 75/25 insulin with an expiration date of July 2018.

During an interview on 11/7/18 at 9:58 AM, the pharmacist verified the medication was expired.

Based on observation and interview, the facility failed to ensure a sanitary environment for clean linen storage and failed to ensure expired skin antiseptic scrub was not available for use on patients in the Emergency and Surgery Departments.

The findings included:

1. Observations in the clean linen room on 11/5/18 at 2:30 PM revealed 2 Housekeeping cleaning carts sitting next to the uncovered storage rack of clean linen. One housekeeping cart had used mop water and a mop still on the cart.

During an interview in the clean linen room on 11/5/18 at 2:33 PM, the Director of Environmental Services verified the mop water had been used because she knew the housekeeper was currently on her break.

During an interview in the clean linen room on 11/5/18 at 2:34 PM, the Housekeeping Supervisor verified the housekeeping carts are routinely stored in the clean linen room without being cleaned because there was no where else to store the carts when not in use.

2. Observations in Emergency Room (ER) Treatment Room 2 on 11/6/18 at 1:20 PM revealed a bottle of PVP Scrub (Povidone Iodine solution), approximately half full, with an expiration date of 3/2018.

Observations in ER Treatment Room 3 on 11/6/18 at 1:23 PM revealed 1 half-full bottle of PVP scrub with an expiration date of 8/2017, 1 full bottle and 1 half-full bottle of PVP scrub with an expiration date of 3/2018 and 1 full bottle of Bactoshield scrub with an expiration date of 2/2018.

During an interview in the ER on 11/6/18 at 1:30 PM, the ER Registered Nurse verified the bottles of scrub solution were expired.

During an interview in the conference room on 11/7/18 at 9:50 AM, the ER Nurse Manager stated the scrub solution should be discarded after opening.

3. Observations in the Surgery area on 11/7/18 at 8:18 AM revealed 4 bottles of PVP Scrub with an expiration date of 3/2018.

Observations in Operating Room 2 on 11/7/18 at 8:25 AM revealed 2 bottles of PVP Scrub with an expiration date of 6/2017.

During an interview in the Surgery area on 11/7/18 at 8:26 AM, the Director of Environmental Services verified the bottles of PVP Scrub were expired.

Based on policy review, record review, and interview, the facility failed to obtain general consent for medical treatment for 4 of 20 (Patients #3, 6, 18 and 19) sampled patients.

The findings included:

1. The facility policy "Consent for Treatment" revealed, "...It shall be the policy of [named facility] to require a written informed consent for treatment upon admission to the hospital..."

2. Medical record review for Patient #3 revealed an admission date of 10/26/18 for Physical Therapy for Strengthening and Weakness.

There was no documentation Patient #3 gave informed consent for treatment upon admission to the hospital.

During an interview in the conference room on 11/6/18 at 3:10 PM, the Medical Records Manager verified Patient #3 did not have a Consent for Treatment.

3. Medical record review for Patient #6 revealed an admission date of 9/26/18 with diagnoses which included Reduced Functional Status and Debility.

There was no documentation Patient #6 gave informed consent for treatment upon admission to the hospital.

During an interview in the conference room on 11/6/18 at 3:19 PM, the Medical Records Manager verified Patient #6 did not have a Consent for Treatment.

4. Medical record review for Patient #18 revealed an admission date of 10/11/18 with diagnoses which included Cat Bite with Cellulitis and Hypertension.

There was no documentation Patient #18 gave informed consent for treatment upon admission to the hospital.

During an interview in the conference room on 11/6/18 at 2:54 PM, the Medical Records Manager verified Patient #18 did not have a Consent for Treatment.

5. Medical record review for Patient #19 revealed an admission date of 10/7/18 with diagnoses which included Pneumonia, Hypertension, and Dysphagia.

There was no documentation Patient #19 gave informed consent for treatment upon admission to the hospital.

During an interview in the conference room on 11/6/18 at 3:12 PM, the Medical Records Manager verified Patient #19 did not have a Consent for Treatment.

Based on interview, the facility failed to address patient population and type of services available in the emergency preparedness plan.

The findings included:

During an interview in the conference room on 11/7/18 at 8:00 AM, the Chief Executive Officer verified the facilty Emergency Preparedness Plan did not address the patient population or type of services available and was not reviewed annually.

Based on interview, the facility failed to develop policies and procedures for the subsistence needs for staff and patients whether they evacuate or shelter in place, in the preparedness program.

The findings included:

During an interview in the conference room on 11/7/18 at 8:00 AM, the Chief Executive Officer verified Provision of Subsistence Needs was not part of the facility Emergency Preparedness plan.

Based on interview, the facility failed to develop a plan to track location of on-duty staff and sheltered patients in their care.

The findings included:

During an interview in the conference room on 11/7/18 at 8:00 AM, the Chief Executive Officer verified the facility's emergency preparedness plan did not have a method for tracking location of on-duty staff and sheltered patients.

Based on interview, the facility failed to address a method to preserve and maintain patient information during an emergency.

The findings included:

During an interview in the conference room on 11/7/18 at 8:00 AM, the Chief Executive Officer verified the facility emergency preparedness plan did not have a procedure for preserving and maintaining patient information during an emergency.