HospitalInspections.org

Based upon direct observation on 3/19/12 the facility failed to maintain facilities in safe operating condition as evidenced by:

1. At approximately 11:05 AM, during a tour of the laoratory and review of the documentation that logged dates for emergency eyewash inspections, it was noted that the eyewash was not being checked weekly as required by hospital policy. The only recorded eyewash inspection dates since January 1, 2012 were: 1/9, 1/16, 2/6, 2/20, and 2/27. Stagnant water in the eyewash unit could harbor harmful bacteria/amoeba that can cause eye infections leading to blindness for anyone using the eyewash.

2. The footpedal controls for the handwashing sink in the TB isolation room ante room were not functioning properly on the day of the survey (3/19/12 at approximately 2:30 PM). It was difficult to activate the water flow and only the cold water supply could be activated. Without a proper operating hand wash sink, staff will not be able to effectively wash their hands.

3. The toilet room serving the isolation room was missing the required safety garb bar. This was observed during the facility tour at approximatley 2:30 PM on 3/19/12.

4. At approximately 10:10 AM, an unsecured compressed gas cylinder (CO2) was identified in the boiler room.

5. At approximately 1:30 PM, an unsecured compressed gas cylinder was identified in the tank closet in the surgical suite. Unsecured cylinders are at risk of falling over and rupturing, causing both release of the contents and great risk for physical harm from the resulting cylinder projectile to anyone in the vicinity.

Based on observation and interview the facility failed to ensure that patient supplies were kept orderly within expiration dates. Findings include:
During the initial tour of the operating room on 3/19/12 at approximately 1100 it was found that two packages of laryngeal mask airway device (LMA) size 4 expired 2/28/12.
During the initial tour of the emergency room on 3/20/12 at approximately 0900 the following supplies were found to be expired:
1. Three LMA devices size 1 expired 1/28/12, size 2 expired 12/28/11 and size 2.5 expired 2/28/12
2. Three 18 gauge intraosseous infusion needles with one expiring in 1/99 and two expiring in 3/99
3. Three 16 gauge intraosseous infusion needles with one expiring in 11/98, one in 1/99 and one expiring in 3/99
4. Five 24 gauge intravenous (IV) angiocaths with an expiration date of 8/08
5. Five 22 gauge IV's with an expiration date of 4/10
6. Four 20 gauge IV's with an expiration date of 7/09
7. Five 18 gauge IV's with an expiration date of 10/09
8. Three urine collection kits with an expiration date of 1/31/11
Emergency Room Crash Cart:
1. Four LMA devices size 3 and 4 with an expiration date of 2/28/12, size 4 expired 1/08 and size 5 expired 4/08
2. Five 18 gauge Monoject injections, 4 that expired 10/11 and 1 that expired 5/11
3. Four 22 gauge Monoject injections, 3 that expired 1/12 and 1 that expired 2/10

These were all confirmed by Staff A at the time of the above findings.

Based upon direct observation and interview on 3/19/12 with the maintenance director the facility failed to maintain equipment in safe operating condition as evidenced by:

1. At approximately 12:10 PM, during an inspection of the roof, the two air handling units serving patient care areas had large air gaps ( 2 ft x 2 ft) where air was bypassing the final filter. It was confirmed by the maintenance director that one of the two final filter boxes was actually missing. The same problem was found in both air handling units. Since the outside air only passed through the prefilters, this could adversely affect all inpatients and staff working in patient care areas.

2. At approximately 12:30 PM, during an inspection of the roof, it was determined that four exhaust fans were not operational. Two of the exhaust fans had been electrically disconnected due to a renovation project involving two patient rooms.

Based on observation, interview and policy and procedure review the facility failed to follow their policy in regards to the disposition of outdated, mislabeled and unusable drugs so as to be not available for patient use. Findings include:
During the initial tour of the OR on 3/19/12 at approximately 1100 the following was found:
Supply Cupboard:
1. One 20 milliliter (ml) bottle of 1% Lidocaine with no open or expiration date
2. One 20 ml bottle of 2% Xylocaine with no open or expiration date
3. One 20 ml bottle of 2% Xylocaine opened on 1/23/12 and would have expired 28 days later on 2/20/12
4. One 10 ml single dose bottle of .25% Marcaine had an open date on label and placed back in cupboard for re-use
Certified Registered Nurse Anesthetist box and cart:
1. Six 10 ml bottles of .9 Sodium Chloride that expired on 3/1/12
2. One 10 ml bottle of Anectine with no open or expiration date
3. One 10 ml bottle of .9 Sodium Chloride with no open or expiration date
4. One 20 ml bottle of 2% Xylocaine with no open or expiration date

These were confirmed by Staff B at the time of the observation and finding.
During policy and procedure review on 3/20/12 at approximately 1300 it was found in the policy titled, "Vials and Ampules of Injectable Medications" states under section II, "The date opened and the initials of the first person to use the vial are recorded on multidose vials", under section III it states, "Ampules and single-use vials (containing no preservative) are discarded immediately after use".