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.

Intensive Care Unit

During an observation on 01/07/2020 after 11:02 a.m., sterile 5 liter bags of the renal replacement solution Phoxillum were stored in unlocked plastic bins in an alcove in the hallway.

According to the labels the solution was to be stored at 68 to 77 degrees Fahrenheit and they were sterile.

Staff #26 confirmed the observation and said that they were told by environmental services to keep the solutions in the hall.

Emergency Department (ED)

During an observation on 01/07/2020 the following was found:

Supply storage room

Sterile and non-sterile supplies were found in a storage room. The room had a temperature and humidity gauge in it. The room contained such sterile supplies as paracentesis / thoracentesis drainage trays, central venous catheter kits, and intravenous administration sets used for fluid/blood warming.

At the end of the supply room was the staff's breakroom. The supply room and breakroom were adjoining and the door to the breakroom was open. While standing in the supply room staff could be seen in the breakroom.

During an interview on 01/07/2020 Staff #7 and 38 confirmed the findings. Staff #7 said staff had to walk through the supply room to get to the breakroom. That was the only entrance to the breakroom.

The supplies were kept in a high traffic area and keeping the door open could affect the temperature and humidity.

ED Clean equipment room

A monitor and a suction machine were stored on a bottom shelf in the room and there was no protective splash guard underneath the equipment. The monitor was designated as being clean, but the suction machine had no strip on it to indicate it was clean. The equipment was placed next to a soiled tool box.

Staff #7 confirmed the observations and said that the suction equipment was clean. When the suction equipment was checked it was found to be covered in dust and debris.

There was also an intravenous pump pole in the room next to the shelf which was soiled and had rusted wheel casters. The pole could not be sanitized with the rust on it.

The facility failed to correct this deficiency which was cited on the visit with an exit date of 09/09/2019 which had a plan of correction completion date of 11/04/2019.