HospitalInspections.org

Based on observation, interview, and policy review, the provider failed to ensure:
*Outdated patient care supplies were not available and ready for patient use in three of three crash carts, one of one pediatric airway cart, and one of two ambulances.
*Outdated patient care supplies were not available and ready for patient use in three of three emergency treatment rooms, one cardiac rehab room, one of one medication rooms, and one of one nurse aide storerooms.
Findings include:

1. Observation on 5/19/25 at 2:30 p.m. in emergency department (ED) room 1 revealed:
*One crash cart, one pediatric airway cart, and three large cabinets containing patient care supplies.
*Outdated supplies included:
-Three intravenous (IV) start kits with expiration dates of 11/30/22 and 3/31/25.
-Multiple gauge needles with expiration dates ranging from 2022 through 2024.
-One fiberoptic laryngoscope with an expiration date of 7/31/24.
-One foley catheter kit with an expiration date of 8/2020.
-Endotracheal kits containing laryngoscope blades with expiration dates ranging from 2019 through 2024.
-One oxygen saturation probe with an expiration date of 2024.
-Multiple three milliliters (ml) syringes with an expiration date of 3/23.
-One lumbar puncture tray with an expiration date of 9/30/24.
-One lumen central venous catheter kit with an expiration date of 5/31/24.
-One quicktrach kit with an expiration date of 10/21/23.
-Three pairs of #6 latex gloves with an expiration date of 8/31/23.
-Two pairs of #6 ½ latex gloves with an expiration date of 4/30/24.
-Two Yankauer suction devices with expiration dates of 10/24 and 1/28/23.
-Two pediatric I-gel airways with expiration dates of 6/23 and 10/23.
-19 huggable electrodes with an expiration date of 6/24.

Interview on 5/19/25 at 2:45 p.m. with registered nurse (RN) A and RN B revealed:
*Nurses had not checked the crash carts, pediatric airway cart, or supply cabinets for expired supplies.
*Confirmed the supply chain departments were responsible for checking the supplies for items
*RNs A and B confirmed they had never been told to check for outdates in the crash carts, pediatric cart, or cabinets in the ED rooms.
*RN A had thought the supply chain staff were checking for outdated supplies monthly.

2. Observation on 5/19/25 at 3:15 p.m. in the ED triage room revealed outdated patient care supplies. Those supplies included:
*Two #18 gauge (G) IV start needles that expired on 5/31/24.
*One staple removal kit that expired on 4/30/25.
*One chest tube tray that expired on 9/30/23.
*Six huggable electrodes that expired on 6/24.
*Multiple gauge needles located on a baby warmer that expired in 2022.

3. Observation and interview on 5/19/25 at 3:40 p.m. in the medication room with RNs A and B revealed:
*Outdated supplies that included:
-Three #20 G IV needles that expired on 7/31/23.
-Two #18 G IV needles that expired on 12/31/24.
-Four statlock IV device kits with expiration dates of 1/23 and 6/24.
*RNs A and B confirmed nurses had been restocking the supplies in the medication room, but had been unaware of a process for checking for outdated supplies.

4. Observation and interview on 5/19/25 at 4:12 p.m. in ER room 2 with RNs A and B revealed:
*One crash cart containing supplies with expiration dates ranging from 2022 through 2024 included:
-Three IV start kits.
-Four #20 G IV needles.
-Four #18 G IV needles.
-Multiple sterile gloves.
-One bougie dilatator.
-One I-gel airway.
*RNs A and B confirmed the supplies had outdated and should have been discarded.
*RN A stated, "I believe there is a miscommunication between nursing and central supply on who is responsible for checking outdates [expiration dates] on patient supplies."

5. Interview on 5/20/25 at 9:15 a.m. with manager of materials management D revealed:
*The provider had been following their policy for event-related shelf life and sterile storage of supplies.
-She had thought it was acceptable to go six months to a year past the expiration date for supplies if their policy supported that practice.
-She had been unaware in that had not applied to patient care items supplied by manufacturing companies.
*She agreed expiration dates on patient care supplies set forth by the manufacturer needed to be followed and expired supplies needed to be discarded appropriately.
*She confirmed both central supply staff and nurses should have been checking for product expiration dates on the nursing units as outlined in the provider's policy.
-Central supply staff had been checking for outdated supplies monthly and when restocking supplies.
*She confirmed nurses were supposed to be checking expired supplies in the crash carts as outlined in the provider's crash cart policy.
*She confirmed the supplies found throughout the ED rooms and crash carts had expired and should have been removed.

6. Observation and interview on 5/20/25 at 10:15 a.m. in two of two ambulances with director of ambulance E revealed:
*Outdated supplies in one ambulance included:
-Three #22 G IV needles with an expiration date of 2024.
-Four #20 G IV needles with an expiration date of 4/26/25.
-Eight endotracheal tubes with an expiration date of 2024.
*He confirmed he had been responsible for checking for outdated supplies monthly.
*He confirmed the intubation supplies had been purchased as a kit and had not been checked for expiration dates.
*He agreed staff should have been checking all patient care supplies for expiration monthly.

7. Observation on 5/20/25 at 1:45 p.m. in the nurse aide storeroom located by the nurses' station revealed:
*Outdated supplies included:
-Five staple removal trays with an expiration date of 9/25/23.
-Two staple removal trays with an expiration date of 3/4/25.



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8. Observation and interview on 5/21/25 at 10:45 a.m. in the cardiac rehabilitation room with RN K revealed:
*In the crash cart drawer there were three sealed packages of five electrodes each that expired on 11/12/23.
*She was not sure who monitored the crash cart for expired supplies.
*She agreed there should be a checklist for the supplies in the crash cart to ensure that nothing had expired.
*She confirmed the supplies should have been removed from the cart and replaced.

9. Interview on 5/21/25 at 10:00 a.m. with director of nursing (DON) C revealed she:
*Had thought the supply chain staff had been responsible for checking the crash carts for outdated supplies.
*Stated, "This is on me. I did not communicate with nursing staff that they were responsible for checking the crash carts for outdated supplies."
*Confirmed staff should have been discarding supplies that had expired as dated on the packaging per the manufacturer.
*Would have expected nurses to check for expired supplies prior to patient use.
*Would have expected staff to ensure outdated supplies were removed prior to restocking.

Review of the provider's January 2023 Emergency Crash Cart Protocol and Defibrillator Checks policy revealed:
*"All crash carts will be checked monthly by the Pharmacy Department to check medications for outdates.
*Nursing will check for outdated supplies.
*Central supply will be notified of any nonpharmacy outdates for replacement purposes.
*After each use, the supplies must be checked and replenished.
*Nursing should replenish supplies after wiping off the crash cart."

Review of the provider's April 2024 Event-Related Shelf Life & Sterile Storage policy revealed:
*"Sterility of items will be event-related, but some commercially processed items will also be date-related.
*These dates are monitored by CSR and the department and the items discarded when the date is reached.
*An hourglass is sometimes used in manufacturing to mean expiration."

Review of the provider's March 2025 Sterile Supplies policy revealed:
*"It is the responsibility of the Central Supply Services and nursing when available in down time to check routinely for outdated supplies in the nursing units, exam rooms, and [the] emergency room.
*Central Supply supplies are monitored for outdated supplies every month, those which are outdated or soon to be outdated before next check will be re-processed or destroyed.
*In a department where CSR does not check outdates, it will be the responsibility of the Department Head to monitor outdates."

Review of the provider's March 2025 Supplies (Ordering/Stocking) policy revealed:
*"Nursing Unit Supplies:
-CSR and Nursing when able is responsible to check daily for adequate supplies in ER, Triage, ICU, Exam Room and Nurses Aid Storeroom.
-Product outdates will be checked monthly and removed as appropriate."

Based on observation, interview, equipment logs review, policy review, and manufacturer's instruction for use (IFU) review, the provider failed to ensure:
*The temperature of one of one fluid warmer machines located in the medication room had been monitored daily.
*One of one Medivators Advantage Plus endoscope reprocessor machine's (disinfects endoscopes) water and air filters had been changed every six months per the manufacturer's IFU.
Findings include:

1. Observation and interview on 5/19/25 at 3:40 p.m. with registered nurse A in the medication room revealed:
*One fluid warmer contained three bags of lactated ringers solution.
*No temperature readings had been recorded for May 4, 10, 11, 17, and 18 on the temperature log.
*She stated the pharmacy staff was responsible for documenting the temperatures of the fluid warmer.
*She had never been told to record the temperatures on the fluid warmer when pharmacy staff were not on-site.

Interview on 5/20/25 at 3:10 p.m. with pharmacist coordinator J and pharmacy technician O revealed:
*Confirmed pharmacy staff were responsible for monitoring and documenting the temperatures of the fluid warmers when pharmacy staff were on-site.
*Pharmacy technician O stated, "Depends on who is working if the nurses will monitor the warmer when we are not here."
*Pharmacist coordinator J confirmed there had not been formal communication to the nursing staff about documenting the temperatures of the fluid warmers when pharmacy staff were unavailable.
*Both agreed the temperatures of the fluid warmer should have been monitored and documented daily.

Interview on 5/21/25 at 10:00 a.m. with director of nursing C revealed:
*The fluid warmer temperatures had been monitored by pharmacy staff.
*She was unaware the fluid warmers needed to be checked on the weekends or when the pharmacy staff had been unavailable.
*She stated nursing staff could have assisted in documenting fluid warmer temperatures daily.

Review of the provider's May 2025 Bulk IV Fluid Warmers policy revealed:
*"All bulk IV bag fluid warmers are to have a visible thermometer.
*The temperature of the warmer is monitored daily by pharmacy and/or nursing staff if pharmacy is unavailable."

2. Observation and interview on 5/20/25 at 8:35 a.m. with manager of materials management D in the endoscope reprocessing decontamination room revealed:
*Three air filters on the wall had dates listed on each filter that read 6/24/24.
*She
-Confirmed maintenance was responsible for documenting the water and air filter logs.
-Did not have the maintenance log for the filter changes in the decontamination room to reference.
-Was unsure if maintenance kept a separate log of the filter change dates.
-Would reach out to the director of maintenance to the confirm air and water filter changes of the Medivators Advantage Plus endoscope reprocessor.

Interview on 5/20/25 at 1:30 p.m. with manager of materials management D of the reprocessor's air and water filter logs revealed:
*Documentation of the air filter changes had been completed in July 2024 by maintenance.
-The reprocessor's left and right air filters should have been changed every six months per the manufacturer's IFU.
*Documentation of the water filter changes had been completed in July 2024.
-The water filters (1 micron, 0.4 micron, and 0.1 micron) should have been changed every six months per the manufacturer's IFU.
*She was unaware of when the manufacturer had changed the time frame for the air and water filters, as she thought it had been every year.

Interview on 5/20/25 at 1:55 p.m. with director of plant operations F revealed:
*He was unaware the reprocessor's air and water filters needed to be changed every six months per the manufacturer's IFU.
*He confirmed maintenance had been changing the filters yearly, and that was last completed in June 2024.
*He agreed the air and water filters should have been changed every six months according to the manufacturer's IFU.

Review of the Medivators 2020 Advantage Plus Endoscope Reprocessor Manufacturer's IFU revealed:
*"The Advantage Plus Reprocessor has four air filters. Each filter should be replaced every 6 months.
*Water filters should be replaced at a minimum of every 6 months for the 1.0 micron and 0.4 micron filters.
*0.1 micron minimum replacement schedule is 6 months."

Based on observation, interview, and policy review, the provider failed to ensure two of two syringes that had contained the medication Cimzia (medication used to treat inflammatory conditions) had been labeled with the medication name, strength, expiration date or time for one of one patient (28).
Finding include:

1. Observation on 5/20/25 at 2:23 p.m. in treatment room 155 with registered nurse (RN) H and patient 28 revealed:
*RN H:
-Entered the room with two unlabeled syringes containing a clear solution that had been prepared in the medication room.
-Had two empty vials of Cimzia 200 milligrams (mg)/1 milliliters (ml).
-Laid the syringes down on the bedside table.
-Verified the identity of patient 28.
-Scanned each vial of Cimzia into the computerized medication record.
-Administered each of the unlabeled syringes of solution separately into patient 28's abdomen.

Interview on 5/20/25 at 2:30 p.m. with RN H and RN G revealed:
*Medications were labeled only if multiple different medications were drawn up at the same time.
*Their practice had not been to label syringes if drawing up a single medication, or if drawing up the same medication into multiple syringes.
*Confirmed medications were drawn up in the medication room and walked to the patient's room for administration.
*RN H and RN G confirmed they had not been aware a single medication or the same medication drawn up into multiple syringes needed to be labeled.

Interview on 5/21/25 at 10:00 a.m. with director of nursing C revealed:
*All medications required a label for proper identification.
*Syringes containing medication should have been labeled with the medication name, strength, expiration date and time per the provider's policy.

Review of the provider's June 2024 Medication Administration policy revealed:
*"Medications are prepared, administered, labeled and recorded by personnel licensed to administer medications.
*All medications that is not immediately administered must be labeled. Any medications that are transferred from the original packaging to another container must be labeled with:
-Medication or solution name,
-Strength,
-Amount of medication (if not apparent from the container),
-Diluent name and volume,
-Expiration date or time.
*Immediately discard any mislabeled products."

Based on observation, interview, policy review, and manufacturer's instructions for use (IFU) review, the provider failed follow standard infection prevention practices by not having ensured one of one observed glucometer had been cleaned and disinfected properly prior to patient use.
Findings include:

1. Observation and interview on 5/19/25 at 4:00 p.m. with registered nurse (RN) A and RN B revealed:
*One glucometer that was docked and ready for patient use had a visible blood smear on top of the machine.
*RNs A and B confirmed there was visible blood on the glucometer and it had not been cleaned properly prior to it being placed in the docking station.
*RN A confirmed the procedure for cleaning the glucometer was to use a PDI disinfectant wipe after each patient use.
*RN A removed the blood glucometer and used a PDI wipe to disinfect it.

Interview on 5/21/25 at 10:00 a.m. with director of nursing (DON) C revealed:
*Glucometer machines should have been cleaned with a PDI disinfectant wipe between each patient use.
*Staff should have inspected the glucometer prior to placing it in the docking station to ensure it was appropriately cleaned.

Review of the provider's December 2024 NOVA Biomedical StatStrip Glucometer Hospital Meter policy revealed:
*"Cleaning the meter:
-The meter should never be immersed in any cleaning agent.
-Always apply the cleaning agent to a soft cloth to wipe the meter surface.
-The cloth should be damp NOT dripping.
-Make sure that no solution is allowed to enter the strip port or the docking port."

Review of the provider's November 2024 Equipment Cleaning policy revealed:
*"For the safety and comfort of patients, all reusable "noncritical" patient care items will be cleaned, disinfected, and maintained in a safe manner between patient use.
*Patient equipment will be disinfected immediately following patient use when the item has been contaminated with blood or other potentially infectious material (OPIM) or is visibly soiled.
*All reusable patient care equipment removed from a patient room/procedure room is disinfected before use or another patient.
*Disinfection recommendations:
-Between each patient use (anything that touches a patient)-Some examples:
-Glucose Meters."

Review of the 2024 StatStrip Glucose Meter instructions for use manual revealed:
*"The StatStrip Glucose Hospital Meters should be cleaned and disinfected after each patient use to minimize the risk of transmission of blood-borne pathogens between patient and healthcare professionals.
*1. Clean the Meter.
-Remove a fresh germicidal wipe from the canister.
-Wipe the external surface of the meter thoroughly with a fresh germicidal disinfecting
bleach wipe.
2. Disinfect the Meter.
-Using a new, fresh germicidal bleach wipe, thoroughly wipe the surface of the meter (top,
bottom, left, and right sides) a minimum of 3 times horizontally followed by 3 times vertically avoiding the bar code scanner and electrical connector.
-Gently wipe the surface area of the test strip port making sure that no fluid enters the port."

Based on record review, social service consultant reports review, interview, and policy review, the provider failed to ensure Case Manager/Social Services (CM/SS) Assessments (used to develop individualized discharge plans) were completed for four of four sampled swingbed patients (7, 8, 9, and 10). Findings include:

1. Review of patients 7, 8, 9, and 10's electronic medical records (EMR) revealed:
*There was no documentation to support a CM/SS Assessment had been completed for patients 7, 8, 9, and 10.
-Information from the CM/SS Assessment was used to develop an individualized discharge plan for each patient.
*That assessment would have included discharge-related information such as:
-If the patient had a primary care physician.
-The patient's social/living circumstances.
-Their post-discharge goal/treatment preferences.
-Their anticipated discharge location.
-The supports/resources the patient used prior to admission and the supports/resources the patient needed after discharge. -Transportation needs.
-Durable medical equipment (DME) the patient used prior to admission and the DME the patient needed after discharge.
-The patient's ability/inability to pay for prescribed medications.
-Their insurance information.

Interview on 5/20/25 at 3:38 p.m. with director of nursing (DON) C regarding the completion of a CM/SS Assessment revealed:
*She stated licensed clinical social worker (LCSW) consultant P had informed her an initial CM/SS Assessment did not need to be completed.
-Other social service documentation including discharge planning notes and care conference notes were completed "at least weekly."

Telephone interview on 5/21/25 at 11:00 a.m. with LCSW consultant P revealed:
*He consulted with DON C by telephone and he reviewed patients' EMRs off-site.
*His consultant reports were forwarded to chief executive officer (CEO) I and DON C upon completion.
*A part of his consultation was the review of sampled swing bed patients' EMRs for expected social service documentation.
-That included completion of a CM/SS Assessment and CM/SS Discharge Planning notes.

Continued interview and review of LCSW consultant P's 6/12/24, 9/18/24, 12/10/24, and 3/20/25 consultant reports regarding the above social service documentation revealed:
*CM/SS Discharge Planning notes were completed for the residents he had reviewed, but there was no documentation to support a CM/SS Assessments had been completed for those residents.
-The 6/12/24 consultation documentation indicated: "I think it would be beneficial for staff to complete the Social Service Assessment Swing Bed form [a form comparable to the CM/SS Assessment] on each admission."
*The 9/18/24 consultation documentation indicated: "I did not find use of either the CM/SS Assessment [or the] Social Service Assessment Swing bed forms. I still think it would be beneficial for staff to at least complete the Social Service Assessment Swing bed Form on each admission."
*The 12/10/24 consultation documentation indicated: "I did not find use of the Social Service Assessment Swing Bed form." "...I still think it would be beneficial for staff to complete this brief assessment with each swingbed admission."
*The 3/20/25 consultation documentation indicated: "Some (but not all) charts contained CM/SS Assessment entry." "My recommendation is for staff to complete this assessment for each swing bed admission."

Interview on 5/21/25 at 1:30 p.m. with CEO I regarding LCSW consultant P's above quarterly consultation reports revealed:
*She confirmed DON C was LCSW consultant P's primary contact for social service consultations. It was DON C's responsibility to have reviewed the consultation reports and addressed the consultant's recommendations with the staff and/or consultant as needed.
*She had not known LCSW consultant P had repeatedly identified the same concerns regarding social service documentation. That pattern was indicative of a system failure that should have been brought to her attention for remediation.
*Information obtained from the CM/SS Initial Discharge Assessment was used to direct a patient's discharge plan.
*The CM/SS Initial Discharge Assessment referred to in the provider's policies was the same assessment LCSW consultant P had referred to as the CM/SS Assessment.
-The expectations for completion of the CM/SS Initial Discharge Assessment had not been followed according to the provider's policy.

Review of the provider's revised January 2020 Discharge Planning-Acute & Swing Bed policy revealed:
*Patient Assessment:
-"The admitting nurse will complete the CM/SS Initial Discharge Assessment."

Review of the provider's revised May 2021 Swingbed Utilization Review Plan policy revealed:
*V. Procedure for Discharge Planning:
-"A. Planning is initiated on the CM/SS Initial Discharge Assessment on admission."