The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Based on observations, interviews and policy review the hospital failed to store drugs in a secure manner to prevent unauthorized access. This failed practice increased the risk of access to medications by unauthorized individuals. Findings:

Medication Room

An observation on 8/28/12 at 10:05 am on 5 North revealed an unlocked, unsupervised medication room.

During an interview on 8/28/12 at 10:06 am, Nurse Manager #1 confirmed that because the medication room was unsupervised, it should have been locked.

Anesthesia Carts

Observation on 8/29/12 at 11:25 am in an unoccupied Operating Room (OR) revealed an unlocked, unsupervised anesthesia medication cart.

Observations on 8/29/12 at 11:35 am in a different OR revealed 3 unlicensed surgical staff were performing turnover cleaning. There were no licensed staff in the room, and the anesthesia cart was unlocked. Two prefilled, unlabeled syringes were sitting on top of the cart.

During an interview on 8/29/12 at 11:35 am, the OR Manager confirmed that, because there were no licensed staff in the rooms, the prefilled syringes should have been discarded and the anesthesia carts should have been locked.

During interviews on 8/29/12, at 11:45 am with Anesthesiologist #1, and at 11:48 am with Anesthesiologist #2, they both confirmed prefilled syringes of medications should be labeled and secured in the anesthesia cart and the carts should be locked.

Review of the hospital policy "Medication Storage", dated 8/12/11, revealed "All medications are secured, either by direct continuous observation of storage area or by security devices (locked cabinets, Pyxis Medstations, etc.). Access to secured medication storage areas is restricted to authorized staff...Unauthorized staff (i.e., facilities) may have access to medications only if they are under observation of or escorted by authorized staff."

Based on observations, interviews and policy review the hospital failed to ensure patient rooms prepared for new admissions were maintained in a sanitary manner. This failed practice increased the risk for transmission of infection and communicable diseases among patients, healthcare personnel, and visitors. Findings:

Observations on 8/28/12 from 10:00 am - 12:00 pm of rooms that had been terminally cleaned and ready for new admissions revealed the following:
?Dirty bed rails in room #s 521, 545, and 490;
?Dried substance on the side of a desk with peeled laminated top in room #470;
?Dried yellow substance on the carpet and side of the desk in room #488;
?Dried adhesive tape on the floor in room #545;
?Trash and crumbs on the carpet in room #467;
?Fingerprint smudged bathroom mirror in room #533; and
?A worn, cracked couch cushion in room #438.

During an interview on 8/28/12 at 11:43 am housekeeping staff #1 described terminal cleaning as "wiping down all furniture, cleaning the floors in bathroom and patient room and wiping the mirror with glass cleaner".

An interview was conducted on 8/28/12 at 3:10 pm with the Managers of EVS (Environmental Services) and Laundry Services and the EVS Supervisor. When asked how they monitored the quality of terminal cleaning of patient rooms the EVS Supervisor stated they performed unannounced monthly inspections using the "Assessment of Demonstrated Competency" form.

Review of the "Assessment of Demonstrated Competency" form used for terminal room cleaning inspections revealed it included the following items:
?"Furniture ... cleanliness/placement bed s/rails",
?"Floors ... debris & spots removed", and
?"Mirrors ...spots, smudges, fingerprints, etc."

An additional observation was conducted in the Maternity Unit on 8/29/12 at 9:50 am. Observation in Maternity room #1, ready for a new admission, revealed the couch and chair had torn cushions.

During an interview on 8/29/12 at 9:55 am Maternity staff #s 1 and 2 confirmed that torn cushions could retain body fluids. Maternity staff #2 added that "you can't clean them".

During an interview on 8/29/12 at 2:07 pm, the Infection Preventionist stated that furniture with torn surfaces can't be cleaned and should be removed from service.

During an interview on 8/28/12 at 3:20 pm, the Managers of EVS and Laundry Services stated they had not been notified of any furniture on the units that needed repair or removal.

Review of the hospital policy "Cleaning and Disinfecting Non-Critical Patient Care Equipment", dated 2/11/12, revealed "Furniture that cannot be cleaned due to wear or breakage must be removed immediately for repair or replacement."