HospitalInspections.org

Based on observation, interview and record review the hospital failed to keep equipment readily available for treating emergencies because the oxygen tank on the emergency cart kept in the newborn nursery was empty.

Findings Include:

During a tour of the nursery on 08/29/17 at 12:40 p.m. accompanied by the Chief Nursing Officer, observation and inspection of the emergency cart revealed the oxygen tank on the emergency cart was empty.

In an interview on 08/29/17 at 12:55 p.m. in front of the emergency cart, the Chief Nursing Officer confirmed the above findings and stated, "We have wall oxygen available."

Review of the emergency cart checklist with the Chief Nursing Officer at the time of inspection of the oxygen tank revealed that the oxygen tank was not listed on the checklist.

Review of the hospital policy entitled, "Emergency Crash Carts," with a revised date of 03-15-17 on 08/30/17 at 3:45 p.m. in the conference room revealed the following in part:

"After the emergency crash cart has been used, the ... shall be responsible for replacing all used instruments on the cart, cleared all of disposable items."

"The defibrillator, oxygen tank and back board shall be cleaned, O2 refilled, and placed back on the cart."

Based on observation, interview and record review the hospital failed meet the requirement because it failed to keep medications in a safe place to prevent unauthorized access because medications were stored in an unlocked drawer underneath the radiant warmer in labor and delivery.

Findings Include:

During a tour of the labor and delivery room 1 on 08/29/17 at 2 p.m. accompanied by the Chief Nursing Officer observation revealed that the following medications were stored in a drawer without a lock underneath the radiant warmer accessible to the patient and visitors:

1 Abboject Pediatric 8.4% Sodium Bicarbonate 10 meq 10 ml
10 Tubes of Erythromycin Ophthalmic Ointment 0.5% 1 g
5 Ampules of Vitamin K 1 mg/0.5 ml
7 Single Dose Vials of Naloxone 0.4 mg/ml

In an interview on 08/29/17 at 2:10 p.m. in front of the radiant warmer, the Chief Nursing Officer confirmed the above findings.

Review of the hospital policy entitled, "Medication Storage," with a revised date of 6/2016 on 08/30/17 at 1:00 p.m. in the conference room revealed in part: "Medications will either be locked or under constant supervision."

Based on observation, interview and record review the hospital failed to meet the requirement because it failed to identify areas for potential transmission of infections because uncovered laryngoscope blades, opened umbilical cord clamp clippers, opened oxygen masks, and rolls of tape with dusty debris were available for patient use.

Findings Include:

During a tour of the nursery on 08/29/17 at 12:40 p.m. accompanied by the Chief Nursing Officer, observation and inspection revealed the following:

The emergency cart drawers contained the following available for patient use:

Drawer 1: 2 rolls of 1 inch tape with dusty debris, 2 umbilical cord clamp clippers one of which was an Argyle that were out of the original packaging and 1 pair of unsterile and uncovered forceps.

Drawer 4: 2 rolls of 1 inch tape with dusty debris.

Drawer 5: 2 oxygen masks that were out of the original packaging and not covered by any type of wrapper.

In an interview on 08/29/17 at 1250 p.m. in front of the emergency cart, the Chief Nursing Officer confirmed the above findings.

During an inspection of a plastic case at the newborn nursery nurses station on 08/29/17 at 1:05 p.m. in the presence of the Chief Nursing Officer, observation revealed that the case contained uncovered laryngoscope blades.

In an interview on 08/29/17 at 1:05 p.m. at the newborn nurses station nurses station, the Chief Nursing Officer confirmed the above findings.

On 08/30/17 at 7:30 a.m., review of website product information for the Argyle Umbilical Cord Clamp Clipper revealed it is "disposable, individually packaged, non-sterile," and "By using a new clipper for each infant, the potential for cross-contamination is significantly reduced."

During a tour of the medical-surgical floor on 08/30/17 at 2:30 p.m. accompanied by the Chief Nursing Officer observation and inspection of the emergency crash cart at the nurses station revealed that a plastic case on the cart contained uncovered five laryngoscope blades.

In an interview on 08/30/17 at 2:30 p.m. at the medical surgical floor nurses station, the Chief Nursing Officer confirmed the above findings.