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Based on observation, staff interview, policy and procedure review, and review of Job Description for the Staff Pharmacist, the facility failed to follow its policy and procedure to monitor for expired medication and supplies on the Emergency Department, Adult Crash Cart, Medical Surgical Unit Crash Cart, Radiology Department Crash Cart, and the Respiratory box on the Surgical department crash cart on one (1) of three (3) days of survey.

Findings Include:

Observation of Emergency Department crash cart at 2:15 p.m. on 07/25/2023 with Emergency Department Director revealed one (1) 1000 milliliter (mL) bag of 0.9% Sodium Chloride Lot number 4383981 expiration date May 2023 manufacturer Baxter, one (1) 250 milliliter (mL) bag of 0.9% Sodium Chloride Lot number V2165C expiration date June 2023 manufacturer Baxter, one (1) 500 milliliter (mL) bag of 0.9% Sodium Chloride Lot number Y387972 expiration date May 2023 manufacturer Baxter, two (2) 1000 milliliter (mL) bags of Lactated Ringers Lot number Y376440 expiration date March 2023 manufacturer Baxter.


Observation of Medical Surgical Unit crash cart at 1:30 p.m. on 07/25/2023 with Registered Nurse (RN) #2 revealed: one (1) laryngoscope expired on 12/31/2022, one (1) endotracheal tube, size three (3), lot number (#) 10000298248, expired 03/12/2022, nine (9) three (3) milliliter (ml) syringe with needle, lot #7093548, expired 03/31/2022, ten (10) 22 gauge Angio catheters, lot # 3889066, expired 10/15/2022, six (6) 20 gauge Angio catheters, lot number 3708779, expired 10/24/2021, seven (7) 18 gauge Angio catheters, lot #3847460, expired 07/01/2022, six (6) 16 gauge Angio catheters, lot #3423728, expired 06/27/2020, two (2) 20 gauge power pack needle, lot #36X835, expired 07/31/2023, one (1) central line dressing kit, lot # 2020031990, expired 10/31/2022, two (2) 1000 ml bags of sodium chloride intravenous fluid, lot #Y391252, expired 07/2023, one (1) 500 ml bag of dextrose five percent half normal saline, lot # Y386098, expired June 2023, one (1) 1000 ml, dextrose five percent in water, lot #Y359290, expired August 2022, one (1), 250 ml bag of dextrose five percent in water, lot #V21B25B, expired August 2022 and confirmed findings with RN #2.

Observation of Radiology department crash cart at 2:42 p.m. on 07/25/2023 with Director of Radiology revealed: two (2) 250 ml bag of dextrose five percent in normal saline fluid, lot # V21H26B, expired February 2023 and confirmed findings with Radiology Director #2.

Observation of the red Respiratory Box on the crash cart in the surgical department on 07/25/2023 at 11:00 a.m. with Respiratory Therapist #1 revealed Laryngoscope Handle, Lot #2017-08-01, expiration date 07/2022, quantity one (1).

During an interview with Emergency Department Director on 07/25/2023 at 2:15 p.m., it was confirmed that expired intravenous fluids were on Emergency Department crash cart and available for patient use.

During an interview with RN #2 on 07/25/2023 at 1:30 p.m., it was confirmed that expired medications and supplies were found in the crash Cart on the Medical Surgical Unit.

During an interview with Director of Radiology on 07/25/2023 at 2:42 p.m., it was confirmed that expired medication was in the Radiology Department Crash Cart.

During an interview with Respiratory Therapist #1 (RT) on 07/25/2023 at 11:00 a.m., it was confirmed an expired laryngoscope handle was in the respiratory box on the crash cart in the surgical department.

Review of the Cardinal Health, "job description" of Staff Pharmacist, revealed, " ...Ensures safe, appropriate, cost-effective medication therapies for patients according to established policies, procedures, protocols, and national guidelines ...Inspects medication areas for outdated medications ...Accepts and completes special duties to be performed on a regular basis ...crash cart inspection ...Complies with all applicable state, local, and federal regulations ...".

Review of the facility policy, "Obsolete, Damaged, or Expired Inventory" dated 02/10/2023, " ...To ensure stock that is obsolete, damaged, or expired is no longer used and removed from inventory as soon as the condition is noted ...Expired items ...Supplies stored in the warehouse and used in patient care areas that are restocked by Materials Management are repositioned in date sequence ...Expired items will be removed from stock and returned to Materials Management ...".

Review of facility policy, "Medication Administration" dated 09/15/2022, " ...All discontinued, expired, damaged and/or contaminated medications should be returned to the Pharmacy ...".

Review of the facility policy, "Medication Administration", dated 09/15/2022, revealed: "...vii All ...expired...medication should be returned to the Pharmacy."

No policy submitted for review regarding the Respiratory Box on the Emergency Crash Cart.
During exit conference on 07/27/2023 at 1:30 p.m. with Chief Executive Office, Chief Nursing Officer, Quality Director and Administrative Assistant above findings were discussed, and no further documents submitted for review.

Based on observation, staff interview, policy and procedure review, and review of manufacturer guidelines, the facility failed to provide surgical services in a safe manner by not following safe practices for endoscope dilator reprocessing and maintaining the anesthesia cart for safe anesthesia administration on one (1) of four (4) days of survey.

Findings Include:

Observation of the locked anesthesia cart in the locked medication room in the surgery department on 07/25/2023 at 10:20 a.m. with Registered Nurse #1 (RN) revealed: Fiber Optic Laryngoscope, Lot #16L, expiration date 04/30/2022, quantity one (1); Fiber Optic Laryngoscope, Lot # 158, expiration date 05/2022, size zero (0), quantity one (1); Laryngoscope Blade, Lot #14A, expiration date 11/2021, size three (3), quantity one (1); Robutazzi Nasopharyngeal Airway, Lot # 091812, expiration date 09/2017, size 22 French (Fr.); Sevoflurane Inhalation Anesthetic, multi-dose bottle, 250 milliliters (ml), not dated when opened, Lot # S2870J01, expiration date 09/30/2025, approximate volume of liquid 125 milliliters (ml), Gastro Cuff Pilot, Lot # MMAFQ8, expiration date 05/2022, size four (4), quantity one (1); Slick Stylet, Lot #07GE30, expiration date 06/2012, size large, quantity three (3); Introducer/Bougie, Lot #MD153, use by date 11/09/2020, size Adult and Coude tip 15 French times 70 centimeters, quantity one (1); Introducer/Bougie Lot #MD035, use by date 03/24/2021, size pediatric and Coude tip 10 French times 70 centimeters, quantity one (1).

Observation of the sterile instrument room in the Surgical Department on 07/25/2023 at 11:10 a.m. with Surgical Technician #1 revealed: a small blue container with blueish liquid confirmed to be Cidex OPA (ortho-Phthalaldehyde), dated with a sticker 07/31/2023 to be changed, no thermometer present, no log available for temperature readings, container not labeled with type of solution.

Observation of the endoscope reprocessing room in the Surgical Department on 07/25/2023 at 11:20 a.m. with Surgical Technician #1 revealed: a large blue container with blueish liquid confirmed to be Cidex OPA (ortho-Phthalaldehyde) by the Surgical Technician, with sticker 07/31/2023 to be changed, no log available for testing or changing of fluids, no test strips located in the endoscopic reprocessing room, no thermometer, or temperature log for Cidex OPA (ortho-Phthalaldehyde).

During an interview with Registered Nurse (RN) #1 on 07/25/2023 at 10:30 a.m., it was confirmed that expired supplies and multi-dose medication bottle not dated when opened, were found on the locked anesthesia cart in the locked medication room in the Surgical Department.

During an interview with RN #1 on 07/25/2023 at 10:37 a.m., it was confirmed anesthesia is responsible for the anesthesia cart located in the locked medication room in the Surgical Department.

During an interview with Surgical Technician #1 on 07/25/2023 at 11:10 a.m., the Surgical Technician confirmed no available temperature log or thermometer for the Cidex OPA (ortho-Phthalaldehyde) container located in the sterile instrument room in the Surgical Department.

During an interview with Surgical Technician #1 on 07/25/2023 at 11:20 a.m., the Surgical Technician states, "I test the Cidex, but I do not document it on a log." She further confirms there is no log available for testing, changing of fluids, test strips, or thermometer present for the Cidex OPA (ortho-Phthalaldehyde) container in the endoscope reprocessing room in the Surgical Department.

Review of the facility policy, "Anesthesia Responsibilities", not dated, revealed: " ...Department: Surgical Services ...To establish the responsibility of the C.R.N.A./Nurse anesthetist caring for patients in the facility ...The C.R.N.A. will be responsible for inspecting and requesting supplies for the anesthesia cart ...".

Review of the manufacturer's guidelines and instructions for use titled, "Cidex OPA", " ...Instructions for use ...Manual Processing ...High Level Disinfectant at a minimum of 20 degrees Celsius (68 degrees Fahrenheit) ...with an immersion time of at least 12 minutes for a reuse period no to exceed 14 days ...Cidex OPA solution test strips prior to each use to determine that the concentration of ortho-phthalaldehyde is above the Minimum Effective Concentration (M.E.C.) of 3% ...record the date the solution was poured out of the original container, or log in book ...on a label affixed to the secondary container ...tested with Cidex OPA solution test strips prior to each use ...thermometer and timer be utilized to ensure that the optimum conditions are met ...".

Review of the facility policy, "Ortho-Phthalaldehyde (OPA), not dated, revealed: " ...an Ortho-Phthalaldehyde monitoring test strip will be used prior to each use ...results will be maintained in a daily log ...endoscopy dilators are sanitized using OPA only ...".

During exit conference on 07/27/2023 at 1:30 p.m. with the Chief Executive Officer, the Chief Nursing Officer, the Administrative Assistant, and the Director of Quality, survey findings were discussed, and no further documentation was submitted for review.

Based on observation, staff interviews, and policy/procedure review the facility failed to follow its policy and procedures to remove expired supplies from stock available for patient use in the Materials Management supply area on one (1) of (4) days of survey.

Findings Include:

Observation of Materials Management supply area on 07/27/2023 at 10:07 a.m. with Purchasing Assistant revealed 27-gauge precision needles 100 per box, six (6) boxes, Lot number 8047626, expiration date 06/30/2023, three (3) millimeter (mL) Luer lock tip syringes 200 per box, two (2) boxes, Lot number 8119664, expiration date 04/30/2023.

During an interview with Purchasing Assistant on 07/27/2023 at 10:20 a.m., it was confirmed that expired needles and syringes were expired and in stock in Materials Management area to be distributed for patient use.

Review of facility policy, "Obsolete, Damaged, or Expired Inventory", dated 02/10/2023, revealed, "...Materials Management staff will perform an expiration check of the warehouse...Materials Management will check...labeled items...once monthly ...will expire...it will be removed from stock."

During exit conference on 07/27/2023 1:30 p.m. with Chief Executive Officer, Chief Nursing Officer, Quality Director, and Administrative Assistant, survey findings were discussed, and no further documentation was submitted for review.

Based on observation, staff interviews, and facility policy and procedure review the facility's leadership failed to ensure systems were in place for tracking expired medications, expired supplies and ensure safe practices for endoscope dilator reprocessing were followed on two (2) of two (2) days of survey.

Findings Include:

Cross Refer to C-1206/485.640(a)(2) for the facility's failure to remove expired supplies from the Material Management Supply.

Cross Refer to C-0884/485.618(b) for the facility's failure to ensure expired equipment, supplies and medication were not available for treating emergency cases on the Emergency Department Adult Crash Cart, Medical Surgical Unit Crash Cart, Radiology Department Crash Cart, and the Respiratory box on the Surgical department Crash Cart.

Cross Refer to C-1140 Condition/485.639 for the facility's failure to provide surgical services in a safe manner by following safe practices for endoscope dilator reprocessing.

Based on medical record review, staff interview, and review of facility policy, the facility failed to have an admission order for two (2) of nine (9) medical records reviewed on one (1) of three (3) days of survey; Patient #3 and Patient #4.

Findings Include:

Review of the medical record of Patient #3 confirms there is no documented evidence of an order for Patient #3 to be admitted to the Swing Bed Unit.

Review of the medical record of Patient #4 confirms there is no documented evidence of an order for Patient #4 to be admitted to the Medical Surgical Unit for Observation status.

During an interview with Registered Nurse #2 on 07/26/2023 at 3:49 p.m. it was confirmed, there is not an admission order for Patient #3 or Patient #4 to be admitted to the facility.

During an interview with Director of Health Information Management on 07/27/2023 at 11:00 a.m. it was confirmed, there is not an admission order for Patient #3 or Patient #4 to be admitted to the facility.

During an interview with Director of Case Management on 07/27/2023 at 12:22 p.m. it was confirmed, there is not an admission order for Patient #3 or Patient #4 to be admitted to the facility.

Review of the facility policy, "Utilization/Discharge Planning/Case Management Plan" dated 02/19/2023, " ...To ensure that the continuum of care for patients admitted ...and compliant with all third-party payer guidelines and regulations ...The major focus is on: Appropriateness of admission status and medical necessity ...Pre-Certification ...".

Review of the facility policy, "Admission Policy" dated 04/30/2023, " ...Patient admission or change in status (Swing bed) ...Admitting medical orders are written by the Hospitalist or Admitting Provider and include Order to admit to the unit ...Patients who are changed to swing bed status will be discharged as an acute inpatient and re-admitted as a swing bed patient ...".

During exit conference on 07/27/2023 at 1:30 p.m. with Chief Executive Office, Chief Nursing Officer, Quality Director and Administrative Assistant above findings were discussed, and no further documents submitted for review.