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Based on observation, record review and interview, the CAH failed to ensure emergency medications kept in a crash cart were appropriate for use for 1 of 2 crash carts inspected. This failed practice has the potential to result in ineffective treatment for any patients in the hospital with a cardiac emergency.

Findings:

The surveyor reviewed a policy titled "Crash Cart Checks", which read in part:

"Pharmacy should check all drugs on the emergency cart at the beginning of each month. Expired drugs should be replaced by Pharmacy."

During a tour of the facility on 07/29/21 at 11:30 AM, the surveyor inspected a crash cart in the surgical area. The crash cart contained 6 boxes of epinephrine 1mg/10ml with an expiration date of 07/01/21. Staff E verified the medications were expired and reported the consulting pharmacist should be responsible for checking the cart and removing expired medications.

During an interview on 07/29/21 at 1:40 PM, the surveyor asked Staff C about the expired medications in the crash cart. Staff C reported it is the duty of the Drug Room Supervisor to check the crash carts on a monthly basis and remove or add medications as needed.

Based on observation and interview, the CAH failed to ensure equipment that would impact patient care was maintained per policy. This failed practice has the potential to cause adverse health outcomes for all patients admitted to the hospital who might use the equipment.

Findings:

The surveyor reviewed a policy titled "Preventative Maintenance", which read in part:

"...the Maintenance Dept. carries out a proactive, systematic preventative maintenance (PM) program..."

"Each piece of equipment or feature of the infrastructure, building or grounds needing PM, is listed in the Equipment List of the program."

"All systems and equipment within the hospital are included in this program except for vending machines; most bio-medical-electrical patient equipment such as x-ray machines, c-scan, and anesthesia machines; and all sterilizers and the scope washer."

The surveyor reviewed a policy titled "Electrical Devices in the Hospital", which read in part:

"All hospital electrical devices will be examined, prior to use, to assure safety complaince."

1. Portable Ventilator

During a tour of the facility on 07/28/21 at 10:30 AM, in a room identified as "Respiratory Therapy", the surveyor noted an unmarked black case with an electrical device. Staff B informed the surveyor the device was a portable ventilator. The device had no stickers or documentation of inspection and/or maintenance. The surveyor requested documentation of inspection and/or maintenance of this device, none was provided.

During an interview on 07/29/21, Staff B reported the device was donated and he/she would check if the device was included in the Equipment List.

During an interview on 07/29/21, Staff D reported the device was not included in the equipment list, had not been inspected, and had been the responsibility of a former employee.

2. Ice Machine

During a tour of the facility on 07/28/21 at 2:30 PM, the surveyor asked Staff F to describe the cleaning procedure for the ice machine in the kitchen. Staff F reported Maintenance cleaned the ice machine but did not know the details and could not provide documentation of it's inspection or cleaning.

During an interview on 07/29/21, Staff D informed the surveyor that Maintenance personnel had not cleaned the ice machine and did not know how often it should be cleaned and what agents it should be cleaned with. Staff D also stated the machine had been in use approximately 3 months, and did not think it was the responsibility of Maintenance personnel to clean it.

During an interview on 07/29/21, Staff G reported it is the responsibility of the Maintenance Department to clean the machine because of "sharp objects". The surveyor requested any policies/procedures related to the ice machine and any documentation of cleaning/maintenance. None was provided.

Based on observation and interview, the CAH failed to ensure signage declaring patient rights under EMTALA were conspicuously posted in the ED. This failed practice has the potential to deter patients seeking emergency care and result in adverse health outcomes.

Findings:

During a tour of the facility on 07/28/21 at 10:30, the surveyor examined the Emergency Department and 2 emergency entrances (1 for EMS and 1 for walk-in patients) and did not find any signs notifying patients of their rights under EMTALA. Staff A verified no signs were posted in the Emergency Department or treatment rooms.