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Based on observation, review of documents, and interviews with facility staff, the facility's governing body failed to ensure that the services performed under a contract were provided in a safe and effective manner as expired food products were found in the dietary department and expired medical supplies were found in the frozen section room, both of which were contracted services. This was in violation of facility policy and potentially could have caused harm to patients, staff and visitors.

The findings were:
The Bylaws of the Board of Managers dated 8/19/08 were reviewed on 3/11/13 and reflected in part "The Board of Managers will ensure services provided by consultation, contractual or other arrangements are provided safely and effectively."

The facility's contracted dietary company policy entitled "Food and Supply Storage Procedures" #B006 dated 6/09 was reviewed on 3/12/13 and reflected in part "Policies: All food, non-food items and supplies used in food preparation shall be stored in such a manner as to maintain the safety and wholesomeness of the food for human consumption. Procedures: Most products contain an expiration date. The words 'sell-by' or 'use-by' should precede the date. The 'sell-by' date is the last date that the food can be sold; do not sell products in retail areas or place on patient trays/resident plates past the date on the product. The 'use-by' date is the last date that a food can be consumed; do not sell products in retail areas or place on patient trays/resident plates past the date on the product. Foods past the 'use-by' date should be discarded."

In an interview in a conference room on 3/11/13 at 10:20 am, staff # 2 stated that the dietary department was managed by a contracted company. During a tour of the dietary department on the morning of 3/11/13 in the company of staff # 2 and 26, two 4 oz. containers of yogurt with an expiration date of 2/19/13 were found in a refrigerator behind the cafeteria serving line which contained milk, yogurt and desserts. In an interview during the tour on 3/11/13 at 11:50 am, staff # 26 acknowledged that the two containers of yogurt were expired and available for consumption.

The Pathology Medical Services Agreement dated 3/9/05 was reviewed on 3/12/13 and reflected in part "Medical Services ...the Pathologists shall provide timely and complete clinical and anatomic pathology medical services to the patients of the Facility. Such services shall be consistent with the usual and customary standards and requirements of quality patient care."

During a tour of the facility on the afternoon of 3/11/13 in the company of staff # 2 and 13, the following expired medical supplies were found in the frozen section room available for patient care use:

1. Cytology spray fixative, 4 oz. bottle, 1 expired 12/10, 1 expired 12/11.
2. OCT embedding compound, 4 oz. bottle, expired 9/11.
3.Cryostat embedding medium, 4 oz. bottle, 2 expired 2/12.
4.Formalin solution, 1 gallon bottle, expired 11/10.

In an interview during the tour of frozen section room on 3/11/13 at 3:00 pm, staff #13 acknowledged that the above listed supplies were expired and available for patient care use. Staff # 13 stated that the frozen section room was used and maintained by staff of the facility's contracted pathology group.

Based on observation, review of documentation and interviews with facility staff, the facility failed to secure the anesthesia medication kit after a surgical procedure for patient #6.

Findings were:

Facility policy entitled "Drug Storage" stated, "14. All floor stock narcotics and controlled drugs assigned to individual nursing units are to be stored under conditions of restricted access from unauthorized personnel."

During a tour of the Surgical Department in operating room titled "Stars" the afternoon of 3/11/13 in the company of staff # 1 and #5 revealed an unsecured and unlocked anesthesia medication kit on top of the anesthesia cart for patient #6. Some medication examples were:

1. Rocuronium Bromide 10mg/ml (found on top of the anesthesia cart).
2. Atropine 0.4mg/ml.
3. Benadryl 50mg/ml.
4. Ephedrine 50mg/m.l
5. Epinephrine 1mg .
6. Labetolol 5mg/ml.
7. Lidocaine 1% 50ml.
8. Naloxone 0.4mg.
9. Toradol 30mg/ml.

In an interview during the tour of the Operating Room the afternoon of 3/11/13, staff #5 acknowledged that the anesthesia medication kit was unsecured and unlocked. Staff #5 confirmed it was facility policy and procedure to secure the medications after each surgical procedure.

Based on observation, review of documentation and interviews with facility staff, the facility failed to ensure specific food and dietetic services organization requirements were met as expired food products were found in the dietary department available for consumption. This was in violation of the facility's contracted dietary company policy and potentially could have had harmful effects on patients, staff or visitors.

The findings were:
The facility's contracted dietary company policy entitled "Food and Supply Storage Procedures" #B006 dated 6/09 was reviewed on 3/12/13 and reflected in part "Policies: All food, non-food items and supplies used in food preparation shall be stored in such a manner as to maintain the safety and wholesomeness of the food for human consumption. Procedures: Most products contain an expiration date. The words 'sell-by' or 'use-by' should precede the date. The 'sell-by' date is the last date that the food can be sold; do not sell products in retail areas or place on patient trays/resident plates past the date on the product. The 'use-by' date is the last date that a food can be consumed; do not sell products in retail areas or place on patient trays/resident plates past the date on the product. Foods past the 'use-by' date should be discarded."

During a tour of the dietary department on the morning of 3/11/13 in the company of staff # 2 and 26, two 4 oz. containers of yogurt with an expiration date of 2/19/13 were found in a refrigerator behind the cafeteria serving line which contained milk, yogurt and desserts. In an interview during the tour on 3/11/13 at 11:50 am, staff # 26 acknowledged that the two containers of yogurt were expired and available for consumption.

Based on observation, review of documentation and interviews with facility staff, the facility failed to ensure that supplies were maintained to an acceptable level of safety and quality as expired supplies were found in patient care areas available for patient use. This was in violation of facility policy and potentially could have resulted in unsafe medical supplies being used for patient care.

The findings were:

The facility policy entitled "Disposal of Unusable Drugs and Supplies" dated 9/28/11 was reviewed on 3/12/13 and reflected "Purpose: To define handling of unusable drugs and supplies. Policy: Unusable drugs and supplies will be discarded in clearly marked biohazard containers and removed by the facility's biohazard disposal contractor."

During a tour of the facility on the morning of 3/11/13 in the company of staff # 2 and 15, the following expired medical supplies were found in the radiology department available for patient care use:

1. Pakter curved disposable needle set, expired 11/11.
2. BD safety glide 18 gauge 1-1/2 " needle, 19, expired 5/12.
3. Blue top lab tubes, 7, expired 12/12.
4. Quaditrode electrodes, 17, expired 12/12.

In an interview during the tour of the radiology department on 3/11/13 at 11:25 am, staff # 15 acknowledged the above listed supplies were expired and available for patient care use.

During a tour of the facility on the afternoon of 3/11/13 in the company of staff # 2 and 13, the following expired medical supplies were found in the frozen section room available for patient care use:

1. Cytology spray fixative, 4 oz. bottle, 1 expired 12/10, 1 expired 12/11.
2. OCT embedding compound, 4 oz. bottle, expired 9/11.
3. Cryostat embedding medium, 4 oz. bottle, 2 expired 2/12.
4. Formalin solution, 1 gallon bottle, expired 11/10.

In an interview during the tour of frozen section room on 3/11/13 at 3:00 pm, staff #13 acknowledged that the above listed supplies were expired and available for patient care use. Staff # 13 stated that the frozen section room was used and maintained by staff of the facility's contracted pathology group.

During a tour of the facility on the afternoon of 3/11/13 in the company of staff # 1and 4, the following expired medical supplies were found on the Nursing Unit:

1. Aerobic Blood Culture bottle x1 expired 12/31/2012.
2. Culture swabs for Aerobes and Anaerobes x2 expired 2/2013.
3. Compound Tincture of Benzoin x2 expired 12/2012.
4. Argyle Trocar Thoracic Catheter x3 expired 2/2013 (located in the crash cart).
5. Argyle Trocar Thoracic Catheter x1 expired 1/2013 (located in the crash cart).
6. Bone Marrow Needle x1 expired 6/2011 (located in the crash cart).

In an interview during the tour of the Nursing Unit the morning of 3/11/13, staff #4 acknowledged that the above listed supplies were expired and available for patient care use.

During a tour of the facility on the afternoon of 3/11/13 in the company of staff # 1and 5, the following expired medical supplies were found in the Surgical Department:

1. Chlorhexidine Gluconate, 4 fl oz, x2 expired 1/2013.
2. Radiation Attenuating Gloves x2 expired 5/2012.
3. Betadine/Iodine/Povidone Stain Remover bottle x1 expired 5/2009.
4. Pedi Pak Quik Combo Pacing Defibrillator ECG Electrodes x2 expired 9/28/2011.

In an interview during the tour of the Surgical Department the afternoon of 3/11/13, staff #5 acknowledged that the above listed supplies were expired and available for patient care use.

Based on observation, review of documentation and interviews with facility staff, the facility failed to ensure that there was an effective system in place for identifying healthcare associated infections and communicable diseases between patients and personnel.

Findings were:

Facility document entitled "Job Description: Infection Control/Employee Health Nurse" stated, "Directs and coordinates infection control and employee health programs in the hospital and safety to all patients, visitors and personnel" "Adheres to APIC (Association for Professionals in Infection Control) Professional and Practice Standards and Code of Ethics ...Advises and consults with physicians, nurses, and hospital personnel concerning precautions to be taken to protect patients, staff, and other persons from possible contamination or infection ....Provides supervision for the Infection Control Program and supervises the activities required to plan, develop, and maintain the Infection Control Program; Provides for the management and surveillance of the infection control program to include assessment, trending, and evaluation of the efficacy of the program ..."

Facility policy entitled "2013 Pine Creek Medical Center Infection Control Plan" stated, "To reduce the risk of acquiring and transmitting healthcare associated infections (HAIs) in patients, employees, physicians, volunteers and visitors." "Responsibilities and Functions of the Infection Control Program: B. Types of surveillance: 5. Sterilization/disinfection practices; 11. Environmental rounds ..."

Facility document entitled "Infection Control Surveillance Form For Compliance" revealed that on 2/22/2013 and 3/8/2013, the infection control officer surveyed the PACU and found the clean supplies were separated from sterile supplies.

During a tour of the facility on the afternoon of 3/11/13 in the company of staff # 1, and 5, the following clean unopened medical supplies were found in the soiled utility room of the Post Anesthesia Care Unit (PACU) and were available for patient and personnel use:

1. Blood and Bodily Fluid Spill Kit x2
2. Chemo Therapy Spill Kit x1
3. Venaflow Elite Foam Calf Cuff x2
4. Sharps container w/ Lids x7
5. Gloves- unopened x2
6. Kleenex box x1
7. Moisturizing hand lotion, 16 fl oz, x1
8. Lotion Soap 33.8 fl oz x1
9. Patient wrist bands x635
10. Striker Glide x1
11. 5 bags of facility Polo style T-shirts used for Agency staff

In an interview during the tour of the PACU on the afternoon of 3/11/13, staff #5 acknowledged that the above listed supplies were available for patient and personnel use. Staff #24 confirmed that infection control surveillance was conducted weekly and the above listed supplies were missed on 3/8/2013.

Facility document entitled "Infection Control Surveillance Form For Compliance" revealed that on 2/22/2013, the infection control officer surveyed the OR (Operating Room). There was no evidence on the document that the surgical instruments were inspected for proper sterilization.

During a tour of the Sterile Processing Area the afternoon of 3/11/13 in the company of staff #1, #5, #6, and #7, approximately 80 sterilized surgical instruments were found closed and available for patient care use.

In an interview during the tour of the Sterile Processing Area the afternoon of 3/11/13, staff #6 and #7 acknowledged that the instruments were closed and were available for patient care use. Staff #6 confirmed that the instruments should be sterilized in the opened position.

During a tour of the facility on the afternoon of 3/11/13 in the company of staff # 1and 4, the following infection control issues were found on the Nursing Unit:

1. Reddish/Brown stain which appeared to be a blood stain was found on a call light in a patient room that was clean and ready for a patient admit.
2. In patient rooms were 2 beige vinyl recliners with multiple torn areas on the left arm rest exposing netting and foam underneath which made proper cleaning impossible and a possibility for infection.

In an interview during the tour of the Nursing Unit the morning of 3/11/13, staff #1 and 4 acknowledged the reddish/brown stain and the torn recliners were an infection control issue.