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Based on observations, review of policy and interview, it was determined the facility failed to ensure:

1. All supplies/medications available for patient use were not expired.
2. Multi dose medications were labeled when opened.

This had the potential to negatively affect all patients served at the facility.

Findings include:

Policy: Multi Dose Vials
Procedure: The multidose vial shall be labeled with the date opened and the initials of the health care professional first entering the vial...Medications that have exceeded the expiration date or those that appear to be contaminated must be discarded.

The following expired supplies and medications were observed in the Emergency Department during the initial tour on 6/26/12 at 8:55 AM:

Medication Room:
Sore Throat Spray expired 4/2012
Catheter insertion tray expired 5/20/12
Lidocaine 1% open with no date when opened
Xylocaine 2% open with no date when opened

Trauma Room:
Laryngeal Masks Size 7 expired 1/2011
Size 2.5 expired 1/2011
Size 2.0 expired 12/2011
Size 4.0 expired 2/2008
Interosseous infusion needle expired 10/2011

Crash cart # 3:
Extension set expired 10/2008

Exam room # 3:
Optima Urine Specimen collection kit expired 2/29/12

The following expired supplies and medications were observed during the initial tour of the Geriatric Psychiatric Unit on 6/26/12 at 11:00 AM:

Crash Cart:
CO 2 Detector expired 12/1/2011
Non-conductor connecting tube expired 3/20/12
AG B Multi Leuver CVC kit expired 3/20/12
ECG electrode adult expired 1/28/12

Medication Room:
Haloperidol 5 milligram/milliliter vial was open without a label or date when opened.

The following expired supplies were observed during a tour of the Medical Surgical Unit on 6/26/12 at 12:30 PM:

Monoject safety syringes 1 milliliter (8) expired on 11/2011 and (6) expired on 4/2011.

An interview, conducted on 6/27/12 at 2:00 PM with Employee Identifier (EI) # 1, Chief Nursing Officer, confirmed the aforementioned findings.


20228


An initial tour of the Surgery Department was conducted on 6/26/12 at 9:00 AM. The surveyor observed located in the Recovery Area the following opened multidose vials with no documentation of a date or the initials of the person who opened them:
2% Lidocaine 20 mg/ml (milligrams/milliters) - 50 ml bottles (3 bottles)
Marcaine 0.5% - 50 ml bottle - (1 bottle)
Marcaine 0.5% - 30 ml bottle - (1 bottle)
1% Lidocaine - 50 ml bottle - (1 bottle)
0.9% Sodium Chloride - 30 ml bottle - (1 bottle)

On 6/28/12 at 10:10 AM, the surveyor returned to the Surgery Department and observed located in the medication preparation room, the following bottles, which were open and unlabeled:
Strong Iodine Solution - 16 ounce bottle with approximately 30 ml remaining in the bottle
Ferric Sulfate Solution
Carbolic Acid - 2 ounce bottle.

During this observation time, the surveyor asked EI # 2, Surgery Manager; when were the above bottles opened. EI # 2 stated he/she didn't know because they were not labled.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.

Findings include:

Refer to Life Safety Code violations.

Based on observations on the Geriatric Psychiatric Unit and Physical Therapy Department and interviews the facility failed to:

1. Ensure the visual monitors for the seclusion room were functioning.
2. Ensure furniture was continually maintained.
3. Maintain logs for the hydroculator and a portable whirlpool.

This had the potential to affect all patients.

The findings include:

An initial tour was conducted on the Geriatric Psychiatric unit, with Employee Identifier (EI) # 3, Outreach Coordinator, on 6/26/12 at 10:20 AM, with the following areas identified:

1. A dining room table surface was observed with the top layer peeling.

2. The visual monitors located at the nurses station failed to include the camera located in the seclusion room.

3. Room 203 had chipped laminate on the front patient sink area.

An interview with EI #1, Chief Nursing Officer, on 6/28/12 at 1:30 PM confirmed the above findings.


20228


A tour of the Physical Therapy Department was conducted on 6/28/12 at 9:45 AM. During this tour, the surveyor observed the facility had a hydroculator and a portable whirlpool.

On 6/28/12 at 9:45 AM, an interview was conducted with EI # 3, Physical Therapy Director. The surveyor asked how often the hydroculator temperature was checked and cleaned. EI # 3 replied that he/she did not have a set policy for how often the hydroculator was to be cleaned and that he/she checked the temperature on a monthly basis. EI # 3 verified there was no documentation of either the cleaning or temperature checks.

The surveyor asked EI # 3 about the cleaning of the portable whirlpool. EI # 3 explained the procedure for cleaning the whirlpool and stated he/she cultures the whirlpool monthly. EI # 3 verified neither the cleaning nor the culture results were documented.

Based on observations on the Geriatric Psychiatric Unit and Physical Therapy Department and interviews the facility failed to:

1. Ensure the visual monitors for the seclusion room were functioning.
2. Ensure furniture was continually maintained.
3. Maintain logs for the hydroculator and a portable whirlpool.

This had the potential to affect all patients.

The findings include:

An initial tour was conducted on the Geriatric Psychiatric unit, with Employee Identifier (EI) # 3, Outreach Coordinator, on 6/26/12 at 10:20 AM, with the following areas identified:

1. A dining room table surface was observed with the top layer peeling.

2. The visual monitors located at the nurses station failed to include the camera located in the seclusion room.

3. Room 203 had chipped laminate on the front patient sink area.

An interview with EI #1, Chief Nursing Officer, on 6/28/12 at 1:30 PM confirmed the above findings.


20228


A tour of the Physical Therapy Department was conducted on 6/28/12 at 9:45 AM. During this tour, the surveyor observed the facility had a hydroculator and a portable whirlpool.

On 6/28/12 at 9:45 AM, an interview was conducted with EI # 3, Physical Therapy Director. The surveyor asked how often the hydroculator temperature was checked and cleaned. EI # 3 replied that he/she did not have a set policy for how often the hydroculator was to be cleaned and that he/she checked the temperature on a monthly basis. EI # 3 verified there was no documentation of either the cleaning or temperature checks.

The surveyor asked EI # 3 about the cleaning of the portable whirlpool. EI # 3 explained the procedure for cleaning the whirlpool and stated he/she cultures the whirlpool monthly. EI # 3 verified neither the cleaning nor the culture results were documented.

Based on observations, review of policy and interview, it was determined the facility failed to ensure:

1. All supplies/medications available for patient use were not expired.
2. Multi dose medications were labeled when opened.

This had the potential to negatively affect all patients served at the facility.

Findings include:

Policy: Multi Dose Vials
Procedure: The multidose vial shall be labeled with the date opened and the initials of the health care professional first entering the vial...Medications that have exceeded the expiration date or those that appear to be contaminated must be discarded.

The following expired supplies and medications were observed in the Emergency Department during the initial tour on 6/26/12 at 8:55 AM:

Medication Room:
Sore Throat Spray expired 4/2012
Catheter insertion tray expired 5/20/12
Lidocaine 1% open with no date when opened
Xylocaine 2% open with no date when opened

Trauma Room:
Laryngeal Masks Size 7 expired 1/2011
Size 2.5 expired 1/2011
Size 2.0 expired 12/2011
Size 4.0 expired 2/2008
Interosseous infusion needle expired 10/2011

Crash cart # 3:
Extension set expired 10/2008

Exam room # 3:
Optima Urine Specimen collection kit expired 2/29/12

The following expired supplies and medications were observed during the initial tour of the Geriatric Psychiatric Unit on 6/26/12 at 11:00 AM:

Crash Cart:
CO 2 Detector expired 12/1/2011
Non-conductor connecting tube expired 3/20/12
AG B Multi Leuver CVC kit expired 3/20/12
ECG electrode adult expired 1/28/12

Medication Room:
Haloperidol 5 milligram/milliliter vial was open without a label or date when opened.

The following expired supplies were observed during a tour of the Medical Surgical Unit on 6/26/12 at 12:30 PM:

Monoject safety syringes 1 milliliter (8) expired on 11/2011 and (6) expired on 4/2011.

An interview, conducted on 6/27/12 at 2:00 PM with Employee Identifier (EI) # 1, Chief Nursing Officer, confirmed the aforementioned findings.


20228


An initial tour of the Surgery Department was conducted on 6/26/12 at 9:00 AM. The surveyor observed located in the Recovery Area the following opened multidose vials with no documentation of a date or the initials of the person who opened them:
2% Lidocaine 20 mg/ml (milligrams/milliters) - 50 ml bottles (3 bottles)
Marcaine 0.5% - 50 ml bottle - (1 bottle)
Marcaine 0.5% - 30 ml bottle - (1 bottle)
1% Lidocaine - 50 ml bottle - (1 bottle)
0.9% Sodium Chloride - 30 ml bottle - (1 bottle)

On 6/28/12 at 10:10 AM, the surveyor returned to the Surgery Department and observed located in the medication preparation room, the following bottles, which were open and unlabeled:
Strong Iodine Solution - 16 ounce bottle with approximately 30 ml remaining in the bottle
Ferric Sulfate Solution
Carbolic Acid - 2 ounce bottle.

During this observation time, the surveyor asked EI # 2, Surgery Manager; when were the above bottles opened. EI # 2 stated he/she didn't know because they were not labled.