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Based on observation, interview and policy review the staff failed to follow the facility policy when staff did not dispose of narcotic medications in one of one anesthesia cart observed and when two bottles of Omnipaque a contrast medium, were left in Operating Room (OR) #1. This had the potential for drugs to be available for use for the wrong patient. The facility census was 19.

Findings included:

1. Review of the facility policy titled "Rules and Regulations" Anesthesia revised 04/01/2010 stated that the anesthetist is responsible at the end of anesthesia to discard all unused and opened drugs and that discarded narcotics will be recorded on the narcotic sheet as "wasted" and two (2) registered nurses will sign the sheet.

2. Observation on 01/08/13 at 12:40 PM in OR #1 showed an anesthesia cart (a rolling cart with several drawers used to store tools that are necessary for aid during procedures that require administration of anesthesia) with two full syringes in the top drawer. One 10 cc (cubic centimeters, unit of measure; one cc = 0.2 teaspoons) syringe was labeled "Morphine" (a narcotic pain medication). One 3 cc syringe was labeled "Fentanyl" (a narcotic). The labels did not contain the name of the patient, the strength and/or dose of the drugs.

3. During an interview on 01/08/12 at 12:50 PM Staff L, Certified Registered Nurse Anesthetist (CRNA) (an advanced practice registered nurse who has acquired graduate-level education and board certification in anesthesia) stated that the syringes should not have been in the cart even though the cart was locked. The drugs should have been wasted (destroyed).

4. Further observation on 01/08/13 at 12:50 PM showed two 240 cc bottles of Omnipaque (a contrast medium used to enhance the contrast of structures or fluids within the body in medical imaging) on a table in OR #1.

5. During an interview on 01/08/13 at 12:55 PM Staff Z, Charge Nurse, stated that the Omnipaque was brought by Radiology at OR's request for a case. He stated that it should have been removed at the end of the case it was requested for and that all OR staff were responsible for it's removal.

6. During an interview on 01/09/13 at 9:00 AM, Staff U, Registered Pharmacist (Pharm.D.), Director of Pharmacy, stated that no medications, especially narcotics, should be left in the Anesthesia cart after a patient's surgical procedure.


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Based on observation, interview and record review the facility failed to remove one container of expired lemon Jell-O, and approximately 300 individual packets of thickener (used for patients with swallowing problems) from the Medical/Surgical Nourishment room refrigerator per their policy. This had the potential to affect any patient receiving these products. The facility census was 19.

Findings included:

1. Review of a patient food services facility policy titled, "Floor Stock Distribution," revised 03/01/09, showed the following:
-Food supplies are supplied to patient floors to provide nourishment to patients when regular meal service is not available;
-Strive to serve safe food and prevent food borne illness by preventing spoilage and/or contamination;
-Label and date all perishable items with expiration for appropriate disposal;
-Discard expired and unlabeled products from unit refrigerators;
-Unit refrigerators will be checked on a weekly basis for outdated products.

2. Observation on 01/08/13 at 9:50 AM, showed a box of 1.1 ounce individual packets of honey consistency thickener in the cabinet of the nourishment room. This box of thickener originally held 200 packets, and currently was approximately 2/3 full. This box of thickener expired on 01/06/13, or two days prior. Concurrent observation showed another box of nectar consistency thickener in the same cabinet. This box originally held 300 packets, and currently was approximately 2/3 full. This box of thickener expired on 12/31/12, or about eight days prior.

During an interview, concurrent with the observation above, Staff D, Director of the Medical/Surgical unit, stated that she would think the speech therapist would check this thickener for expiration dates because they use it the most. However, Staff D stated that the nurse technicians use the thickener too.

3. Observation on 01/08/13 at 9:52 AM, showed one individual serving sized container of lemon flavored Jell-O with an expiration date of 01/07/13, one day prior.

4. During an interview on 01/08/13 at 10:06 AM , Staff H, the Speech therapist, stated that food service staff checked for expiration dates on thickener.

5. During an interview on 01/08/13 at 10:16 AM, Staff F, Dietitian, stated that the dietary courier should be checking for expiration dates on all food/thickener in the nourishment room.

6. During an interview on 01/08/13 at 10:32 AM, Staff G, dietary courier, stated that food items were labeled with the date they expire, and they were typically removed from service late the day they expire. Staff G was unaware the thickener packets had an expiration date on them, so he had not been checking it. Staff G could not explain why there was a container of Jell-O that was expired in the refrigerator.

Based on observation, interview and record review the facility failed to have a Policy and Procedure in place that gave staff direction on how to indicate when intravenous (IV - a medical line placed into the vein) tubing should be replaced for nine (Patients' #3, #4, #5, #6, #7, #8, #9, #14 and #21) of nine patients observed with intravenous therapy on the Medical/Surgical (Med/Surg) Unit. This had the potential to increase the risk of infection for all patients receiving intravenous therapy in the facility. The facility census was 19.

Findings included:

1. Review of a facility policy titled, "Maintaining IV Infusion" revised 06/12, showed for staff to replace IV tubing, including IVPB (IV piggy back-a secondary line), every 96-hours, or as needed.

The policy failed to address labeling of the IV tubing, so the nurses would know when the IV tubing was changed last.

2. Observation on 01/08/13 at 8:54 AM, showed Patient #5 had a bag of Heparin (medication to alleviate blood clots) with the associated tubing hanging from an IV pole. Staff failed to label the IV tubing with the date and time of initial placement.

3. Observation on 01/08/13 at 9:50 AM, showed Patient #4 had a bag of Levaquin (an antibiotic), with the associated tubing hanging from an IV pole. The IV tubing line had not been labeled with the date and time of initial placement. Staff I, Registered Nurse (RN), removed the IV tubing and replaced it with new IV tubing before administering the IV medication. Staff failed to label the IV tubing with the date and time of initial placement.

During an interview on 01/08/13 at 10:15 AM, Staff I, RN, stated she changed the IV tubing because it wasn't labeled with the date and time of initial placement and didn't know how long the IV tubing had been there.

4. Observation on 01/08/13 at 12:15 PM, showed Patient #3 had a bag of continuous infusion of Sodium Chloride (treatment for depletion of the body's necessary balance of sodium, potassium and chloride) with the associated tubing hanging from an IV pole. Staff failed to label the IV tubing with the date and time of initial placement.

5. Observation on 01/08/13 at 12:27 PM, showed Patient #21 had a bag of IV medication with the associated tubing hanging from an IV pole. Staff failed to label the IV tubing with the date and time of initial placement.

6. Observation on 01/08/13 at 12:35 PM, showed Patient #6 had a bag of IV medication with the associated tubing hanging from an IV pole. Staff failed to label the IV tubing with the date and time of initial placement..

7. Observation on 01/08/13 at 1:00 PM, showed Patient #8 had a bag of antibiotic, Zyvox, with the associated tubing hanging from an IV pole. Staff failed to label the IV tubing with the date and time of initial placement..

8. Observation on 01/08/13 at 1:06 PM, showed Patient #9 had a bag of Sodium Chloride, with the associated tubing hanging from an IV pole. Staff failed to label the IV tubing with the date and time of initial placement.

9. Observation on 01/08/13 at 1:12 PM, showed Patient #7 had two bags of IV solution, with the associated tubings hanging from an IV pole. Staff failed to label the IV tubing with the date and time of initial placement.

10. During a concurrent interview on 01/08/13 at 1:15 PM, Staff I, RN, stated she did not know what procedure the IV Policy stated for IV tubing but that it should always be labeled with the date and time of initial placement. Staff D, RN, Director of Med/Surg, stated that the IV Policy should state the procedure for IV tubing lines to be labeled with the date, time and nurses initials at the time of placement. Staff D was not sure if the IV Policy stated to change the IV tubing lines every 72-hours or every 96-hours.

11. Observation on 01/08/13 at 3:10 PM, showed Patient #14 had an IV bag of Potassium Chloride solution, with the associated tubing hanging from an IV pole. The IV tubing had a piece of tape on it that said, "Change Thursday." Staff failed to label the IV tubing with the date and time of initial placement, so the 96-hour policy could be followed by subsequent staff. During an interview at the time of the observation, Staff M, RN, stated that she was not sure who labeled Patient #14's IV tubing, but she always labeled the tubings with her initials, the date and time of initial placement.

12. During an interview on 01/09/13 at 1:54 PM, Staff O, the Chief Nursing Officer (CNO) stated that she would expect her nursing staff to label the IV tubing. The CNO stated that she thought the policy stated the IV tubing should be changed every 72-hours, so she would review/revise the policy as appropriate.

13. During an interview on 01/09/13 at 3:00 PM, Staff V, RN, Infection Control Officer, Employee Health Nurse, stated that the IV tubing lines should be labeled with the date, time and nurses initials at the time of initial placement and changed every 72-hours. She stated that she was not aware that the policy stated 96-hours and gave no direction to staff on procedure.








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Based on observation, interview and record review the facility failed to follow the Policy and Procedure for hand hygiene as it pertained to glove use for three patients (#3, #4, and #5) of three patients observed and two staff (Y and P) of three dietary staff observed. This had the potential to increase the risk of infection for all patients in the facility. The facility census was 19.

Findings included:

1. Record review of the facility's policy titled, "Hand Hygiene Policy" revised 06/10, showed the following direction for facility staff:
- Hand hygiene is to be performed by all healthcare personnel throughout the facility following the guidelines outlined by the Centers for Disease Control [and Prevention] (CDC) and the World health Organization.
- Hand hygiene should be performed after removing gloves;
- After any contact with inanimate objects in the immediate vicinity of the patient;
- Using gloves does not replace the need for hand hygiene after removing the gloves.

2. Observation on 01/08/13 at 8:10 AM showed Staff I, Registered Nurse (RN), in Patient #5's room for medication administration. Staff I assessed the patient by touching the bare skin on his chest, wrist and feet but did not perform hand hygiene after the assessment. She typed on the computer keyboard and then donned gloves. She emptied the patient's bedside urinal, removed the gloves but pulled back the privacy curtain before performing hand hygiene.

3. Observation on 01/08/13 at 8:54 AM showed Staff I, RN, entered Patient #3's room for medication administration but did not perform hand hygiene. She typed on the computer keyboard and then performed hand hygiene and again typed on the computer keyboard. She removed the oral medications from the packaging and dropped a pill on the patient's side table and picked it up with bare hands and put it into the paper cup with the other medications before giving it to the patient to swallow. Staff I then donned gloves without performing hand hygiene, typed on the computer keyboard, gave the Patient an injection, removed the gloves, typed on the computer keyboard and then performed hand hygiene.

4. Observation on 01/08/13 at 9:45 AM showed Staff I, RN, entered Patient #4's room for medication administration. She touched the patient's clothes and bedding, bare skin, Intravenous (IV-within the vein) port site and feet. Staff I then administered a saline flush (administered to keep the line to the vein open) through the IV port but did not perform hand hygiene or donn gloves. Staff I then prepared a bag of IV medication and connected it to the IV port but did not donn gloves and did not perform hand hygiene until she left the room.

5. During an interview on 01/08/13 at 3:00 PM, Staff I stated that she was nervous and didn't realize she hadn't performed hand hygiene appropriately.

6. Observation on 01/09/13 at 9:45 AM showed Staff Y, Dietary, entered the kitchen from the front line (where staff and visitors are served food) and removed her right hand glove. She proceeded to touch the food preparation counter with her ungloved hand. She did not perform hand hygiene.

7. Observation on 01/09/13 at 9:50 AM showed Staff P, Dietary, removed her gloves and lifted the trash can lid; disposed of trash and then donned gloves. She did not perform hand hygiene between removing the gloves, touched the dirty trash can lid and re-gloved.

8. During an interview on 01/09/13 at 9:55 AM, Staff R, Interim Director of Dietary, stated that hand hygiene was expected and required of all employees.

9. During an interview on 01/09/13 at 9:59 AM, Staff F, Dietitian, stated that she observed the staff removed their gloves, lifted the trash lid and donned gloves without performing hand hygiene. She stated that hand hygiene should be done between glove changes.

10. During an interview on 01/09/13 at 3:00 PM, Staff V, RN, Infection Control Officer, Employee Health Nurse, stated that staff were monitored and in-serviced on proper hand hygiene. She stated that employees are supposed to perform hand hygiene before and after donning gloves and after touching inanimate objects which are what the CDC Guidelines recommended.



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