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Based on observation, review of policies and procedures, and staff interview, the facility failed to secure 1 of 7 portable oxygen cylinders, Volume E, found in the CICU (Critical Intensive Care Unit) Fish Bowl Room (Conference Room with glass windows facing the patient rooms). The facility reported a current census of 5 patients in the CICU at the time of the observation.

Failure to secure portable oxygen cylinders could potentially result in the cylinders falling and breaking the top. Any pressurized oxygen remaining in the cylinder could cause the top to blow off, potentially with enough pressure to go through a wall or window. Additionally, unsecured cylinders could add fuel to a fire if knocked over breaking the top.

Findings include:

1. Observation on 4/30/12 at 9:00 AM, with Staff K, CICU Nurse Manager, revealed 1 of 7 portable oxygen cylinders, Volume E , located in the CICU Fish Bowl Room was unsecured. The portable oxygen cylinder did not have a gauge on the tank.

2. Review of hospital policy titled "CICU Safety Management Plan", reviewed January 25, 2012, stated in part, ". . . Oxygen tanks used in any area of CICU shall be secured in an upright position preferably in holder or cart to assure the safe operation of the O2 without the fear of being tipped over. Empty O2 tanks shall be returned to the storage area and secured in an upright position. . . ."

3. During an interview on 4/30/10 at 9:00 AM, Staff K stated the portable oxygen cylinders should always be stored in a secured position and never left free standing. Staff K acknowledged the oxygen tank felt full. Staff K also acknowledged the nursing staff did fail to store the portable oxygen tank in a secure position.

Based on review of documents and staff interviews, the Critical Intensive Care Unit (CICU) failed to include restraints as a part of the patient's plan of care, in 3 of 3 open and 1 of 3 closed medical records, when the patient was placed in restraints. (Patient # 1, 2, 3, 4). The CICU nursing staff reported an average daily census of 5 patients.

Failure to include restraint use in the patient's plan of care could inhibit the nurses' ability to know what techniques or methods to use in assisting the patient in restraints and potentially avoid the use of restraints.

Findings include:

1. Review of hospital policy/procedure titled "Restraint and Seclusion Use", dated 12/11, stated, in part ". . . Documentation for Patients with Non-Violent or Non Self-Destructive Behavior . . . The patient's plan of care is updated every shift to reflect the use of restraints or seclusion. . . ."

2. Review of Patients' #1, 2, 3, and 4 medical records showed they lacked evidence that CICU nursing staff included restraints as a part of the patient's plan of care when they were placed in restraints.

a. Review of Patient #1's open medical record revealed the patient was placed in soft wrist restraints from 4/28/12 at 2:00 PM to 4/29/12 at 10:00 AM. The patient's plan of care failed to include restraints.

b. Review of Patient #2's open medical record revealed the patient was placed in soft wrist restraints on 4/18/12 from 2:00 PM to 5:11 PM and from 4/26/12 at 7:30 AM to 4/27/12 at 8:00 AM. The patient's plan of care failed to include restraints.

c. Review of Patient #3's open medical record revealed the patient was placed in soft wrist restraints on 4/23/12 from 2:30 AM to 8:25 AM. The patient's plan of care failed to include restraints.

d. Review of Patient #4's closed medical record revealed the patient was placed in soft wrist restraints from 4/5/12 at 6:47 PM to 4/10/12 at 9:50 AM. The patient's plan of care failed to include restraints.

3. On 4/30/12 at 11:05 AM, during medical record review and interview, Staff L, Nurse Educator CICU, confirmed the medical records for Patients' #1 and 2 lacked evidence that CICU nursing staff included restraints in the patients' plan of care.

4. On 5/1/12 at 9:30 AM, during medical record review and interview, Staff O, Nurse Manager 3 East, confirmed the medical record for Patient #3 lacked evidence that CICU nursing staff included restraints in the patient's plan of care.

5. During an interview on 5/2/12 at 7:30 AM, Staff K, Nurse Manager CICU, verified the CICU nursing staff failed to follow established hospital restraint policies/procedures documentation requirement to include restraints in the patients' plan of care.

6. On 5/3/12 at 7:10 AM, during medical record review and interview, Staff P, Quality Partner, confirmed the medical record for Patient #4 lacked evidence that CICU nursing staff included restraints in the patient's plan of care.

I. Based on review of CSA's (Contracted Service A) policies and procedures, observation, and staff interview, the facility failed to ensure the CSA staff administered the heparin infusion in accordance with the established CSA policy and procedure.

Failure to deliver a constant infusion of heparin over the course of the patients' hemodialysis treatments could potentially clot the arterial and venous circuits, resulting in early termination of the patient's hemodialysis treatment and blood loss.

The facility reported a census of 3 acute hemodialysis patients at the time of the survey. Findings for 1 of 3 acute hemodialysis patients (Patient #1) include:

1. Review of the hospital policy titled, "ANTICOAGULATION" Policy: 7-06-04 with a Revision Date of 7-06-04 included in part "...POLICY: Heparin is the primary anticoagulant used to prevent clotting...3. Heparin is administered per physician's order. Order is to include...heparin loading dose, hourly infusion ...14. A heparin pump is used to deliver a constant infusion of heparin over the course of the hemodialysis treatment..."

2. Observation and Interview on 4/30/12 at 10:10 AM showed RN A standing next to the dialysis machine delivering the hemodialysis treatment to Patient #1. RN A pushed the plunger of an unlabeled syringe attached to the bloodline, then opened the clamp on the IV (Intravenous) line. The surveyor asked RN A what procedure RN A had just performed. RN A reported the facility did not have the correct bloodline tubing to administer the heparin infusion automatically. RN A went on to report, CSA staff administered the heparin infusion manually during the patient ' s hemodialysis treatments. RN A stated, " I push a small amount of heparin and then flush with saline every 30 minutes". Observation showed RN A documented 250 units of heparin given at 10:00 AM.

3. During an interview on 5/2/12 at 2:00 PM with the FA and the Executive Director of Medical Surgical. The CSA's FA (Facility Administrator) reported, CSA staff ordered the wrong Combi Set bloodline set and the CSA's staff used the incorrect Combi Set bloodline for approximately 6 to 8 weeks. The Executive Director of Medical Surgical reported the hospital ordered the correct bloodline set and expected the shipment within a week.



II. Based on review of the CSA policies and procedures, observation, and staff interview, the hospital failed to ensure CSA provided documented evidence of the bicarbonate concentrate mixing, rinsing/disinfecting the bicarbonate jugs and wands, and the final bicarbonate concentrate pH and conductivity testing.

Failure to document bicarbonate concentrate mixing, rinsing/disinfecting the bicarbonate jugs and wands, and the final bicarbonate concentrate pH and conductivity testing inhibits the facility's ability to determine, in the event of an adverse complication, if the complication was related to the dialysate used during the patient's hemodialysis treatment.

The facility reported a census of 3 acute hemodialysis patients at the time of the survey. Findings for 1 of 1 bicarbonate concentrate mixing procedure include:

1. Review of the facility form titled, "BICARB MIX-LOG-CONDUCTIVITY" Procedure 2-04-01A, with a Revision Date of September 2010, included in part "...Date...Time...Lot #...Expiration date on bag of bicarb ...#Bags added...Final cond...Signature of preparer...Second teammate verification..."

Review of the facility form titled, "WEEKLY BICARB CONTAINER DISINFECTION LOG" Policy 7-12-35, with a Revision Date of March 2010, included in part "...Date...Bleach...30 Minute Dwell Time...Rinse...Residual Result...Initials..."

2. An initial tour in the CSA supply room on 4/30/12 at 11:40 AM showed an open box of Powder Bicarbonate packages labeled, "RENAL PURE POWDER BICARBONATE CB-02 ROCKWELL MEDICAL TECHNOLOGIES, INC". The CSA FA reported the hospital used bicarbonate powder as the back-up to the bicarbonate premix solution. The surveyor requested the bicarbonate mixing policy and procedure, bicarbonate mixing, bicarbonate jug rinsing and disinfecting logs. The FA reported the staff would refer to the manufacturer's mixing instructions on the bicarbonate powder package. The FA stated, "I don't think we have logs for the mixing and/or the cleaning of the jugs." The FA provided no additional documentation and/or logs related to CSA staff mixing bicarbonate, and/or bicarbonate cleaning and disinfecting the bicarbonate jugs at the hospital.

3. During an interview on 5/2/12 at 2:00 PM, the FA provided bicarbonate mixing pH and conductivity testing/rinsing/disinfecting forms. According to the FA they had not implemented these forms and policy at this facility. This information would not be available to the staff should they need to mix bicarb. The FA reported staff had not mixed any bicarb at this facility up to this point.

4. During an interview on 5/3/12 at 8:45 AM, the CSA's Area Biomed Supervisor reviewed the bicarbonate mixing and conductivity log, and the rinsing/disinfection of the bicarbonate jugs forms provided to the surveyor. The CSA's Area Biomed Supervisor acknowledged the forms had not been implemented at this facility.


III. Based on document review, observation and staff interview, the hospital failed to ensure CSA staff had a system in place that provided documented evidence of the exact dialysate used during the dialysis process.

Failure to ensure dialysis staff documented the exact additive, amount of additive, and additive lot number inhibits the facility's ability to determine if an adverse complication related to the dialysate used during the patient's hemodialysis treatment.

The facility reported a census of 3 acute hemodialysis patients at the time of the survey. Findings for review of 1 of 1 additive procedure included:

1. Observation and Interview on 4/30/12 at 9:40 AM showed RN (Registered Nurse) A at Patient #1's bedside. Further observation showed 1 gallon jug labeled, "Renal Pure Liquid Acid 1K+(potassium) 2Ca+(calcium) that displayed an additional label stating, "...25 grams POTASSIUM CHLORIDE have been added to increase this concentrate From: 1K+mEq (milliequivalent)/Liter To: 3 K+mEkq/Liter Added By: RN A Date: 4/30/12 Time: 0730..." RN A reported the hospital supplied 1K+ liquid acid and RN A followed the physicians order by adding potassium chloride and attached the label that indicated the amount of potassium chloride added. RN A reported documenting the dialysate concentration on the Patient's treatment flowsheet. However, review of Patient #1's document titled, "Acute Hemodialysis Treatment Assessment/Flow Sheet" dated 4/30/12, failed to show the K+ liquid acid beginning concentration, an exact amount of potassium that RN A added, or the potassium lot #. RN A stated, " We just write what was ordered by the Dr on the treatment sheet. We mix the K+ to what the Dr ordered."

2. Observation and Interview on 5/1/12 at 7:55 AM showed the FA (Facility Administrator) pouring 1 package labeled, "Dialysate Additive Calcium Chloride 6.3 grams" into a 1 gallon jug labeled "Renal Pure Liquid Acid 1K+(potassium) 2Ca+(calcium) that displayed an additional label stating, "...25 grams POTASSIUM CHLORIDE have been added to increase this concentrate From: 1K+mEq/Liter To: 3 K+mEkq/Liter Added By: FA Date: 5/1/12 Time: 0730..." Further observation showed the FA placed an additional label that stated, "12.6 grams CALCIUM CHLORIDE have been added to increase this concentrate From: 2 Ca+mEq /Liter To: 3 Ca+mEq/Liter...Added By: FA Date: 5/1/12 Time: 0750..." The surveyor questioned the FA in regards to staff documenting the mixing of additives K+ and Ca+ for the patient's hemodialysis treatments. The FA stated, "We document the final concentration on the patient's flowsheet."

3. During an interview on 5/3/12 at 8:45 AM with the CSA's Area Biomed Supervisor, the FA and the Executive Director of Medical Surgical, the CSA Area Biomed Supervisor acknowledged the facility did not have a system in place that provided documented evidence of the exact dialysate used during the dialysis process.

I. Based on document review, observation and staff interview, the Cardiac Cath Lab staff failed to follow the Cardiac Cath Lab policy to ensure all clean items are secured in a clean storage room. The concern is for one of two storage areas in the Cardiac Cath lab. The Cardiac Cath Lab staff reported approximately 6 cardiac procedures per day.

Failure to separate soiled and clean supplies could potentially result in contamination of the clean items and thus the spread of infection.

Findings include:

1. Review of the policy, "Cardiac Cath lab infection Prevention and control Policy", revision 2/2/12 revealed in part, "...Separate areas will be maintained as "clean and dirty...Equipment and supplies will be stored in clean areas only...".

2. An observation, during initial tour of the Cath Lab, on 5/2/2012 at 10:06 AM, revealed a storage room that contained a hopper, commode and dirty sharp's containers. This storage area, also contained, clean items used during cardiac procedure performed in the Cath Lab. Clean items stored next to the hopper included new suction tubing, suction canisters, suction canister lids, Foley catheter trays, intravenous pressure bags, new red bags and clean sharp canisters.

3. During an interview on 5/2/12 at 10:15 AM, Staff M, Registered Nurse (RN) Cath Lab manager, stated, "I didn't know these clean items were in this room". RN M, acknowledged the hopper would be used to clean dirty items and stated the "clean items should be stored in the clean storage room".



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II. Based on observation, staff interview, and document review, the radiology department's administrative staff failed to develop, and implement, a policy consistent with the manufacturer's directions for testing 1 of 1 disinfection solution, (Cidex OPA) prior to each use, in the ultrasound examination room. Radiology Manager N stated the hospital's radiology staff performed an average of 2 transvaginal ultrasound examinations per day.

Failure to develop and implement a policy consistent with the manufacturer's directions for testing the disinfecting solution prior to each use could potentially result in the radiology staff using a disinfectant that lacked a sufficient concentration of the active ingredient to kill all microorganisms on the transvaginal probe, potentially resulting in the spread of an infection between patients.

Findings include:

1. Observations during a tour of the radiology department on 5/2/12 at 2:15 PM revealed 1 of 1 transvaginal ultrasound probe soaking in a disinfecting solution.

2. During an interview at the time of the tour, Radiology Manager N stated the ultrasound technicians soaked in Cidex OPA solution to disinfect the transvaginal probes between patients. Radiology Manager N also stated the ultrasound technicians only tested the Cidex OPA solution to determine the concentration of the active ingredient once per day, even if the ultrasound technicians used the disinfecting solution on the probes on multiple patients per day.

3. Review of the radiology department's Cidex test log from 2/6/12 to 5/2/12 revealed the ultrasound technicians only tested the Cidex OPA once per day. Further review of the Cidex test log revealed 15 days where the ultrasound technicians used the solution multiple times per day, and only tested the Cidex OPA solution prior to the first use of the day. The Cidex test log did not show the ultrasound technicians tested the solution prior to each use.

4. Review of the policy "CIDEX OPA MONITORING", not dated, revealed in part, "On days the product will be used, a test strip must be used to check effectiveness of the Cidex OPA."

5. Review of the manufacturer's directions for the Cidex OPA Solution Test Strips, not dated, revealed in part, "... [the] CIDEX OPA solution [must] be tested before each usage with the CIDEX OPA Solution test strips in order to guard against dilution, which may lower the [active ingredient] level of the solution below its [minimum effective concentration] ..."

6. During an interview at the time of the tour, Radiology Manager N acknowledged the manufacturer's directions required the ultrasound technicians to test the Cidex OPA solution prior to each use, and the hospital's policy did not follow the manufacturer's directions to test the Cidex OPA solution prior to each use.


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III. Based on review of CSA policies and procedures, CDC (Centers for Disease Control) MMWR (Morbidity and Mortality Weekly Reports) Recommendations and Reports, observations, and staff interviews, the facility staff failed to ensure a designated clean sink used for hand washing met the needs of the staff.

Failure to ensure the CSA staff had a designated clean sink could potentially discourage staff to wash their hands according to CSA policy and procedures and CDC recommendations.

The facility staff reported a census of 3 acute hemodialysis patients at the time of the survey. Findings for observation on 3 of 3 patient treatment days (4/30/12, 5/1/12 and 5/3/12) include:

1. Review of the CDC MMWR Recommendations and Reports, titled "Recommendation for Preventing Transmission of Infections Among ... Hemodialysis Patients", dated April 27, 2001, included in part, "...A sufficient number of sinks with warm water and soap should be available to facilitate hand washing..."

2. Review of the hospital policy titled, "INFECTION CONTROL IN THE HOSPITAL DIALYSIS SETTING" Policy: 7-03-01 with a Revision date of March 2011, included in part "... 26. Sinks should be easily accessible and readily available in the treatment area...Hand washing sinks should be dedicated only for hand washing purposes and remain clean. Avoid placing, cleaning or draining used items in hand washing sinks. Used or contaminated items should be handled in designated utility sinks. Soap and a supply of paper towels protected from contamination must be available at each sink..."

3. During a tour of the hospital on 4/30/12 at 10:00 AM, the Executive Director of Medical Surgical referred to room number 395 as the "Patient Treatment Room" and CSA (Contract Service A) provided hemodialysis treatments for 2 patients at a time. Further observation showed RN (Registered Nurse) A monitored the patient receiving a hemodialysis treatment. RN A showed the surveyor the portable RO (Reverse Osmosis) machine that was located in the bathroom which showed 2 hoses connected to the sink's faucet. RN A reported staff used the only sink available in the patient treatment room to deliver the acute patients' hemodialysis treatments. Further observation showed the nearest sink available for clean procedures, such as hand washing is at the nurses' station approximately 30 feet away from the patient treatment room. The surveyor questioned RN A where staff would perform a clean procedure such as hand washing, RN A stated, "I don't know because I can't leave the patient".

4. Observation on 5/1/12 at 8:00 AM the patient treatment room showed the portable RO machine hoses connected to the bathroom sink's faucet. The surveyor questioned the FA (Facility Administrator) in regards to the availability of a "clean sink" for hand washing procedures in accordance with the CDC Recommendations and the CSA policy. The FA agreed, however, continued to run the portable RO machine connected to the only available sink in the patient treatment room.

5. During an interview on 5/1/12 at 9:15 AM with the CSA Area Biomed Supervisor, the Biomed Technician, the Executive Director of Medical Surgical, the Biomed Technician reported the staff reported the facility stopped connecting the portable RO machine to the shower after the CSA staff notified the Biomed Technician of pressure problems during the patient ' s hemodialysis treatment. The CSA Area Biomed Supervisor acknowledged the facility follows the CDC's Recommendations and verified the facility Infection Control policy and procedure. The CSA Area Biomed Supervisor stated, "There used to be a box that was used to tap in at the sink. We will get this fixed"

6. During an interview on 5/1/12 at 2:30 PM the FA reported the CSA Area Biomed Supervisor corrected the pressure problem with the shower in the "Treatment Room". The FA stated, "The sink is now a designated clean sink".

7. Observation on 5/3/12 at 10:48 AM in the patient treatment room showed 2 patients receiving hemodialysis treatments. The dialysis machine next to the patient in bed #2 alarmed, RN B reported the dialysis machine temperature raised to 38.5 degrees Fahrenheit 30 minutes after RN B initiated the patient in bed #2's hemodialysis treatment and the patient complained about feeling ill. Further observation showed the portable RO machine hoses connected to the shower and a designated clean sink in accordance with the CDC recommendations and the CSA policy and procedures. However, the CSA Area Biomed Supervisor stated, "We can either run 2 patients and not have a sink available or run 1 patient and use the shower." The Executive Director of Medical Surgical presented a letter to the surveyor in regards to the hospital plan to run 1 patient at a time.


IV. Based on review of the CDC (Centers for Disease Control and Prevention) MMWR (Morbidity and Mortality Weekly Report) Recommendations and Reports, CSA policies and procedures, observation, and staff interview, the hospital failed to ensure CSA staff provided the clear separation of clean areas or supplies from contaminated or potentially contaminated areas and items in the patient treatment area.

Failure to separate clearly clean supplies from contaminated areas or items could potentially result in contamination of these clean supplies, which could in turn potentially result in the transmission of infectious agents or substances to objects, medical equipment, environmental surfaces, and to patients, staff, and/or visitors. Clean supplies stored or handled in the same area or in an area adjacent to a contaminated area, such as an area where blood samples are handled, could potentially result in the clean supplies becoming contaminated and then serve as a vehicle of transmission of infectious agents to objects such as medical equipment or environmental surfaces, patients, staff and/or visitors.

The facility staff reported a census of 3 acute hemodialysis patients at the time of the survey. Findings for observation on 2 of 3 patient treatment days (4/30/12 and 5/3/12) include:

1. The CDC MMWR Recommendations and Reports titled "Recommendations for Preventing Transmission of Infections among Chronic Hemodialysis Patients," dated 4/27/01, included in part, "... During the process of hemodialysis, exposure to blood and potentially contaminated items can be routinely anticipated... Additional measures to prevent contamination of clean or sterile items include... not handling or storing contaminated (i.e., used) supplies, equipment, blood samples, or biohazard containers in areas where... clean (i.e., unused) equipment and supplies are handled..."

2. Review of the facility policy titled, "INFECTION CONTROL IN THE HOSPITAL DIALYSIS SETTING" Policy: 7-03-01 with a Revision date of March 2011, included in part "... 29. If a common supply cart is used to store clean supplies in the hospital dialysis setting, this cart is to remain in a designated area at a sufficient distance from patient stations to avoid contamination with blood...Only teammates with clean hands may remove items from the supply cart... Clean areas should be clearly designated for preparation, handling, and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled..."

Review of the facility policy titled, "HAND WASHING" Policy: 7-03-02 with a Revision Date of March 2011, included in part "...3. Hands will be washed...prior to gloving, after removing gloves, between patients...before touching... supply carts..."

3. Observation on 4/30/12 at 11:58 AM showed RN (Registered Nurse) A wearing a gown and face shield, placed a stethoscope on Patient #1's chest, touched Patient 1's clothing and then without sanitizing hands, removed 2 alcohol prep pads from the clean supply cart.

4. Observation on 5/3/12 at 10:40 AM showed a supply cart that measured approximately 6 feet in height by 5 feet wide by 2 feet in depth, which held clean unused care supplies, located approximately 2 feet from the foot of the patient's hospital bed. The supply cart held patient care supplies including boxes of gloves, facial masks, and protective barriers used for the patient dialysis treatments, syringes, tape, alcohol prep pads, and gauze. The distance between the supply cart and the foot of the patient's hospital bed did not ensure the clear separation of clean areas or supplies from contaminated areas to prevent contamination of the clean supplies from potentially infectious materials/substances. Contamination of the supplies could potentially result in the transmission of infectious agents from the supplies to the dialysis patients resulting in patient illness or adverse patient outcomes.

5. Observation on 5/3/12 at 11:10 AM showed RN B touched Patient #3's arm, picked up Patient #3's potentially contaminated medical chart (transported with Patient #3 from the medical floor), and without washing or sanitizing hands obtained an emesis basin from the clean supply cart.

6. During an interview on 5/3/12 at 11:30 AM the Executive Director of Medical Surgical acknowledged the above findings. The Executive Director of Medical Surgical stated, "I saw that it could be a problem".


V. Based on review of the facility policies and procedures, CDC (Centers for Disease Control and Prevention) MMWR (Morbidity and Mortality Report) Recommendations and Reports, observation, and staff interview, the hospital failed to ensure the medication preparation area was clearly separated from contaminated or potentially contaminated areas and/or items in the patient treatment area.

Failure to separate medication preparation and/or supplies at a sufficient distance from contaminated areas or items could potentially result in contamination of these clean areas and supplies and transmission of infectious agents to objects such as medical equipment or environmental surfaces, patients, staff and/or visitors.

The facility staff reported a census of 3 acute hemodialysis patients at the time of the survey. Findings for observation on 1 of 3 patient treatment days (4/30/12) include:

1. Review of the CDC MMWR Recommendations and Reports titled, "RECOMMENDED INFECTION CONTROL PRACTICES FOR HEMODIALYSIS UNITS" No. RR-5 with a date of 2001 included in part, "...Clean areas should be clearly designated for the preparation, handling, and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to where used equipment or blood samples are handled..."

2. Review of the facility policy titled, "MEDICATION POLICY" Policy: 7-06-01 with a Revision Date of March 2012, included in part "...13. An aseptic environment...should be used when preparing medications..."

3. Observation on 4/30/12 at 11:20 AM in the patient treatment room showed Patient #1's bedside table contained papers, 1 writing pen, 3 gauze packages, 2 syringes, 2 medicine vials labeled, "Epogen" and "Heparin". Further observation showed RN A placed Patient #1's potentially contaminated medical chart (transported with Patient #1 from the medical floor) next to 2 medicine vials labeled, "Epogen" and "Heparin" on Patient #1's bedside table. RN A picked up 1 syringe from Patient 1's bedside table and withdrew fluid from the vial labeled, "Epogen". The distance between the medication preparation area and the supplies did not show a clear separation that provided a clean and separate area to prepare the dialysis medications.

4. During an interview on 4/30/12 at 11:45 AM RN A reported the facility stored patient medications on the medical floors. RN A reported obtaining Patient #1's medication from the medical floor and preparing Patient #1's medication at the bedside in the CSA patient treatment room. When asked about a designated medication preparation area in the patient treatment room. RN A stated, "No we just do it at the bedside".

5. Observation on 5/3/11 at 11:10 AM showed RN B standing at Patient #3's bedside table, picked up a vial labeled, "Zofran", withdrew fluid into 1 syringe. Further observation showed the Patient #3's bedside table contained 2 gauze pads, 4 alcohol prep pads, a writing pen, 2 syringes and 1 medicine vial labeled, "Heparin". The distance between the medication preparation area and the supplies did not show a clear separation that provided a clean and separate area to prepare the dialysis medications.

6. During an interview on 5/3/12 at 11:30 AM, the Executive Director of Medical Surgical acknowledged the findings. The Executive Director of Medical Surgical reported the hospital used a bedside bar code system for medication preparation and administration; however, the hospital would evaluate the dialysis medication preparation procedure.