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

Findings were:

1. The patient bathing/shower area did not have an emergency pull cord in the patient shower.
2. 2 of 5 plinth tables in the Physical Therapy department had tears in their coverings, making disinfection impossible and cross contamination likely.

In an interview with the Facility Administrator on 6/29/19, the above patient safety concerns were acknowledged.

Based on observation, it was determined that the Facility failed to secure its biohazardous waste making it accessible to the general public.

Findings were:

Multiple red plastic bags containing biohazardous waste were found inside a shed located behind the hospital. The door to the shed was unlocked making the biohazardous waste easily accessible to the general public.

In an interview with the Head of Support Services on 6/29/10, the above findings were confirmed.

Based on record review it was determined that the Facility failed to follow their policy in 1 of 9 staff records reviewed relating to tuberculin skin testing for direct patient care staff.

Findings were:

The Facility failed to follow their policy entitled "Employee Health/Infection Control", which stated "All employees of McCamey Hospital, Home Health and Out Patient Clinics shall be evaluated annually via PPD skin tests. New employees must provide proof of prior skin test. If they are unable to provide proof of prior skin testing a Two-Step testing method shall be applied."

Staff member # 8 had no evidence of an annual PPD(tuberculin) skin test.

In an interview with the Director of Nurses on 6/30/10, it was confirmed that staff member #8 had no evidence of an annual PPD skin test.

Based on observation and interview, it was determined that the Facility failed to ensure that outdated medications were not available for patient use.

Findings Were:

The Facility failed to follow their policy entitled "Expired Medications", which stated "Expired medications will be stored separately from active inventory in such a manner that will insure that they cannot be dispensed." The same policy lists the procedure for inspecting the medications, "Inspect the pharmacy and medication storage areas monthly and remove all expired or questionable quality medications from the active inventory."

The Facility failed to follow their policy entitled "Open Multi-dose Medications", which stated "All multi-dose medications should be dated at the time they are opened as well as initialed by the nurse who opened them."

1. In the medication refrigerator located in the Nurses Station, the survey team found one open multi use vial of Lantus insulin. This vial was not labeled as to when it was opened or as to who opened the vial. Further, there were two multi use vials of Regular insulin that were labeled with opening dates but had no initials of the person who opened the vials.

2. In the pharmacy medication refrigerator, 10 multi use vials of Tetanus Toxoid with an expiration date of March 2010 were found in an area readily available for patient use.

In an interview with the Charge Nurse (RN) on 6/29/10, the above findings were confirmed.

Based on review of Facility policy and procedure manuals, it was determined that the Facility failed to annually evaluate their Laboratory Policy and Procedure Manual.

Findings were:

The Facility's Laboratory Policy and Procedure Manual had not been reviewed by the Governing body since 9/04/08.

In an interview with the Director of Laboratory and the Director of Nursing on 6/30/10, it was confirmed that the above Policy and Procedure manual had not been reviewed annually.