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Tag No.: C0888
Based on observations and personnel interview, the facility failed to maintain readily available supplies commonly used in life-saving procedures.
The findings included:
During the facility tour on 08/19/20, the following expired (exp) supplies were observed:
*In Central Supply: -Multilumen CVC Kit, exp 10/31/19
-Three Stryker Mixing Bone Cement, exp 05/01/20
-Arthroscopy, exp 02/01/20
-Five Salem Sump, exp 01/2020
-Six Salem Sump, exp 06/2020
-Five 1/2 inch iodoform, exp 06/2020
-1/2 inch iodoform, exp 07/2020
-Three 1 inch iodoform, exp 12/2019
-Three 1 inch iodoform, exp 01/2020
*In the Operating Room (OR) hallway:
-Amnihook, exp 04/2008
-Impervious surgical gown, exp 05/2020
*In the OR:
-Four Poole with removable sheath, exp 08/2016
-Two Disposable tourniquets, exp 01/04/19
-Disposable tourniquet, exp 07/18/13
-Disposable tourniquet, exp 04/16/14
-Disposable tourniquet, exp 02/17/16
-Disposable tourniquet, exp 01/07/14
-Glidescope supplies: -LoPro S3, exp 04/06/19
-LoPro S1, exp 08/08/19
-Mac S4, exp 04/01/19
-Two Gliderite single-use stylet, exp 09/14/17
-Hemovac, exp 11/30/18
-Monopolar cable, exp 07/2016
-Three Pneumosure, exp 07/01/20
-5 mm trocar, exp 02/2020
-Four 5 mm bladeless trocar exp 03/2020
-Three closure system, exp 07/20/20
-Steridrape, exp 10/2016
-Two U-drape, exp 08/2017
-Two cystoscopy pack, exp 01/2019
-Total knee pack exp, 06/05/18
-Pedi ET Tubes size: *Three 2, exp 01/2020
*Three 2, exp 05/2019
*Two 2.5, exp 01/2020
*Two 3, exp 01/2020
*Two 3.5, exp 05/2019
*Two 4, exp 05/2019
*Four 5, exp 07/2019
*Four 7, exp 11/2018
*7.5, exp 08/2018
*Malignant Hypothermia Cart:
-Esophageal stethoscope with temperature probe, disposable exp 10/2012
-60 mL (milliliter) syringe, exp 01/2013
*Supply Closet: - One Pediatric foley 6 French, exp 07/2020
The above was confirmed in an interview with Personnel 11 during the tour.
Tag No.: C0924
Based on observations and personnel interview, the facility failed to maintain a clean and orderly environment.
The findings included:
In the anteroom, prior to entering the COVID-19 isolation rooms, observed numerous dead bugs, dirt and dust particles. Also, dead roaches were stuck to the taped entrance upon entering the COVID-19 rooms.
In the Operating Room supply area, there were dead bugs in the light fixtures.
The above findings were confirmed by Personnel 24 during the tour on 08/19/20.
Tag No.: C1110
Based on review of medical records and personnel interviews, the facility failed to ensure 1 of 4 (Patient 8) surgical records reviewed included a properly executed informed consent. Also, the facility failed to ensure the surgical orders were timed and dated for 3 of 4 surgical records reviewed (Patients 8, 9 and 10).
The findings included:
Review of the medical record for Patient 8 revealed a surgery date of 06/02/20 with a surgery time of 1846. The consent for procedure was signed, but not dated or timed. The pre- and post-procedure orders were not dated or timed by the physician.
Review of the medical record for Patient 9 revealed a surgery date of 06/02/20. The pre-op orders were not timed by the surgeon.
Review of the medical record for Patient 10 revealed a surgery date of 01/29/19. The physician pre- and post-procedure orders were not dated or timed.
The above findings were confirmed in an interview with Personnel 11 on 08/19/20.
Tag No.: C1208
Based on observation and personnel interview, the facility failed to maintain a clean and sanitary environment.
The findings included:
During the facility tours on 08/19/20, the following were observed:
Two ceiling tiles discolored in the Emergency Room (ER).
One ceiling tile discolored and swollen in the ER supply room.
Two ceiling tiles discolored in the Nursing Station.
One ceiling tile discolored and one cracked in the Operating Room (OR) hallway.
One missing ceiling tile in the Dexa Room.
In the Supply Room, where clean and sterile supplies were stored:
-Numerous electrical and computer wires were running along the side of the wall.
-Raw wood framing the air conditioning unit.
-One missing ceiling tile and multiple discolored ceiling tiles were above the supplies.
-Corrugated shipping boxes were mixed in with clean and sterile supplies.
-ACE bandages laying on the floor beneath a cart.
-The room was in disarray and there was no way to know which supplies and equipment were
clean or dirty.
The above findings were verified during the tour with Personnel 11.
The nationally accepted standards set forth by the Association for the Advancement of Medical Instrumentation (AAMI) state, "External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material; serve as generators of and reservoirs for dust." (AAMI 5T46-Section 5.2 Receiving Items).