HospitalInspections.org

Based on observations and interviews the facility failed to ensure outdated medications were removed from patient care areas.
The findings were:
Observation on 7/15/14 at 11:20 a.m. in the Radiology Department revealed two bottles of Barium Sulfate Suspension that were expired. One bottle of Barium Sulfate Suspension expired 9.2013 and the second bottle of Barium Sulfate Suspension expired 6/2014.
Interview on 7/15/14 at 11:25 a.m. with S 14 confirmed the 2 bottles of Barium Sulfate Suspension were expired. S 14 stated they normally look at the dates to ensure no expired medications are available and that these 2 bottles were over looked.

Based on inspection, interviews and record review, the facility failed to maintain areas of the hospital's physical environment in such a manner that the safety and well-being of patients were assured.

The facility's failure could affect the well-being of all patients.

The findings were:

Inspection of the facility on 07/15/14 at approximately 2:30 p.m. revealed the following:

· Ceiling tiles had dark grapefruit sized stains with signs of water damage and deterioration.

· Damaged walls in janitorial closets near patient rooms with evidence of water damage, dark stains and deterioration.

· Patient Room 202 with section of wall removed at bottom next to toilet with signs of water damage, dark stains and deterioration.

Interview with Environmental Services Director on 07/16/14 at 1:30 p.m. confirmed the physical environment areas were not adequately maintained by the facility and were in need of repair. The physical environment could affect the safety and well-being of patients in the areas.

Review of the facility's Safety Policy and Procedure dated January 1993 required staff to report hazards, defective or broken equipment and to assist in providing a safe, secure environment for all individuals in the workplace.

During the exit conference on 07/16/14, the facility was given an opportunity to provide additional information relating to the facility's physical environment. No additional information was given.

Based on inspection, interview and record review, the facility failed to assure the proper routine storage of bio-hazard waste.

The facility's failure could affect the safety of all personnel.

The findings were:

Inspection of the facility's bio-hazard waste storage area on 07/16/14 at approximately 1:30 p.m. revealed bio-hazard containers with waste were stacked and stored in a small portable structure outside the facility. The structure had wooden floors with evidence of water damage, stains and wood rot. The structure's entry door and frame were not intact and appeared damaged from weather exposure.

Interview with the Physical Plant Maintenance Aide on 07/16/14 at 1:45 p.m. confirmed the bio-hazard storage area was not safe and secure to store the bio-hazard waste containers and to prevent possible leaks and or spillage.

Review of the facility's undated Regulated Waste Procedure required staff to safely handle, store, transport or ship bio-hazard waste.

During the exit conference on 07/16/14, the facility was given an opportunity to provide additional information relating to the facility's bio-hazard waste storage. No additional information was given.

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Based on a tour of the facility and interviews, the facility failed to ensure an acceptable level of safety for staff and patients.
The findings were:
1. Observation on 7/15/14 at 11:30 a.m. in the facility Dark Room of the Radiology Department revealed:
a. A large area on the floor which resembled brown rust and corrosion under a large container labeled " The Film " .
b. In the corner of the Dark Room, water damage and mildew under water hoses that lead to the mixing station. The base boards were separating from the wall and the wall paint was peeling.
Interview on 7/15/14 at 11:35 a.m. with Staff 15 confirmed the water damage, mildew and the rusty stain on the floor. Staff 15 revealed the Mixing Station backed up several months ago which caused a water leak. Staff 15 stated they " spoke with environmental services several months ago, but they still haven't done anything yet to repair the damage " .
2. Observations on 07/15/14 at 1:45 p.m. and 2:00 p.m. revealed dark particles on clean linen supplies stored on shelves in clean linen rooms. The clean linen did not have drapes or covers to protect against dust and other particulates from ceiling vents.

Review of the facility's undated Folding Room Cleaning policy required staff to cover folded clean linen on carts. No additional procedure was documented to cover clean linen in clean linen rooms to assure safe and clean linen to all patients.

Interview on 07/16/14 at 11:00 a.m. with the Environmental Services and Laundry Director confirmed the clean linen supplies did not have covers or drapes in the clean linen rooms.

During the Exit Conference on 07/16/14, the facility was given an opportunity to provide additional information related to acceptable level of safety for staff and patients. No additional information was given.