HospitalInspections.org

Based on a review of facility documentation, facility observation, and employee interviews (EMP), it was determined that Warren General Hospital failed to ensure that the physical plant and overall hospital environment was maintained in such a manner that the safety and well being of patients were assured (A-0701); and failed to ensure that facilities, supplies, and equipment were maintained to ensure an acceptable level of safety and quality (A-0724).

Findings include:
A-0701

Review at approximately 9:00 AM on October 17, 2017, of "Patients' Rights," dated September 12, 2017, revealed, "... You have the right to: ... Receive care in a safe setting."

Review, at approximately 1:58 PM on October 24, 2017, of Policy SAF 15.6, "Eyewash Stations," revised January 21, 2013, revealed, "... Purpose: OSHA standards require that eye wash stations be available as a form of first aid in areas where the eyes of a person may be exposed to injurious corrosive or biological materials. Eye wash stations are placed throughout the laboratory in the event of a chemical or biological splash to the eyes. ... Maintenance: Eye wash stations shall be activated weekly to verify proper operation. Weekly tests will be documented on the log sheets. ..."

Review, at approximately 2:07 PM on October 24, 2017, of a policy titled, "Eyewash Stations," effective July 18, 2017, revealed, "... Policy: Emergency eyewash stations will be provided with in the work area for immediate emergency use where any person has a potential for eye injury or infection per OSHA regulations. ... Standards: 1. Eyewash stations will meet the following general requirements: ... f. Eyewash stations must be checked weekly and be flushed for at least 5 minutes to flush sedimentation and to reduce the change for microbial hazards. g. Record inspection date on a log (attachment A) ..."

Review, at approximately 3:29 PM on October 24, 2017, of Policy 102, "Admission Criteria," revised November 24, 2016, revealed, "... Procedure: ... Inpatient admission requires that the patient demonstrate all of the following symptoms: 1. A physician has conducted and [sic] examination and determined that the person has a psychiatric diagnosis or provisional psychiatric diagnosis, excluding mental retardation, substance abuse or senility, unless these conditions coexist with another psychiatric diagnosis. ... The severity of the illness presented by the person meets one or more of the following: the person poses a significant risk of harm to self or others, or to the destruction of property ..."

1. Review, at approximately 3:04 PM on October 24, 2017, of the, "Warren General Hospital Board of Directors Meeting," minutes from March 29, 2017, April 26, 2017, May 31, 2017, June 28, 2017, August 30, 2017, and September 27, 2017, did not reveal specific mention of the requirements to upgrade non-anti-ligature hardware noted within the Behavioral Health Unit. At approximately 1:20 PM on October 19, 2017, when asked where the minutes would reflect the possible expenditure associated to these upgrades, EMP5 stated that that information would be included within the capital budget, but would not necessarily be specifically identified within the Board minutes. A request was made at this point for a copy of the capital budget, indicating that the anti-ligature upgrades were included in the budget. As of October 26, 2017, this documentation was not provided.

2. Review, at approximately 3:26 PM on October 24, 2017, of the, "ECRI Institute, Behavioral Health: Patient Safety Healthcare Risk Control Self-Assessment Questionnaire," was provided. The assessment was dated August 8, 2016. Review revealed documentation that the initial assessment was by EMP39 and EMP5. Review revealed, "... Violence and Aggression ... 29. Has a risk assessment audit been conducted to assess where, how, and when violent incidents can occur, including which items in the healthcare environment are potentially dangerous in the hands of a resourceful patient determined to harm him- or herself or others?" The response by EMP39 indicated a Yes answer, with an additional comment of "FMEA when needed and debriefing." Further review revealed, "... 29.1 As part of the audit, are the following actions performed: ... c. A physical walk-through of the facility?" The response by EMP39 indicated a Yes answer. Review of the Action Plan section of the questionnaire revealed this portion to be blank.

3. Review, at approximately 3:35 PM on October 24, 2017, of a Grant Application filed by EMP39, with the Community Foundation of Warren County, revealed, "... Date of Application: 6/30/17 ... Our wing of the hospital was built in the early 1970's. Approaching 60 years of wear and tear, we have equipment needs and safety hazards which need to be addressed. During my brief tenure as nurse manager, I have identified several key safety issues related to our physical environment. A recent event highlighted the necessity to imminently address at least one of these issues. This newest need was not anticipated, and therefore is outside of our budget. ... Objective- to improve consumer safety and decrease the risk of self-harm by addressing the following key safety issues. Item 1 Replace existing door handles. Existing handles present 2 specific issues. 1.) Consumers intent on self-harm, are able to manipulate the locking mechanism to impede staff from entering. 2.) The existing handles present a "ligature" risk (hanging). ..." Further review of the application did not reveal evidence that the application had been submitted to the organization from which funds were being requested.

4. Review, at approximately 2:01 PM on October 24, 2017, of a Maintenance Work Order, provided by EMP4 during the onsite survey, revealed, "... Requested By: ECC - Emergency Care Center Request for Service ... Order # 0713-0014 Request Install eyewash station in sink in decontamination room in ER ... Entered By: [EMP29] 07/13/17 1624 ..." Further review revealed that the eyewash station was installed by [EMP49] on July 18, 2017.

5. A tour of the Laboratory Department was conducted between 3:00 PM and 3:30 PM on October 16, 2017. During the tour, four eyewash stations were noted to be missing between two and three weeks of weekly preventative maintenance checks. When asked, during the observations, how frequently eyewash preventative maintenance checks were to be conducted, EMP11 confirmed that the maintenance should be conducted weekly. EMP11 additionally confirmed the missing preventative maintenance checks for the four eyewash stations.

6. During a tour of the Emergency Department, at approximately 10:30 AM on October 17, 2017, a request was made for the weekly eyewash checks. EMP16 was unable to provide the documentation of the eyewash checks. EMP5 informed survey staff that the eyewash station had been recently installed.

7. During a tour of the Dietary Department, at approximately 12:14 PM on October 18, 2017, a plumbed eyewash station was noted within the department. When asked about the eyewash preventative maintenance log for the plumbed eyewash station, EMP38 stated, "I don't think [EMP29] knew we had that [plumbed eyewash station]." EMP38 confirmed that prior to October 18, 2017, there was no documentation of preventative maintenance for the plumbed eyewash station.

8. Review, at approximately 2:05 PM on October 24, 2017, of the WaterSaver (rev. 0115 / 2015), installation, operation, and maintenance guide, provided by EMP5, during the onsite survey, revealed, "... C. Maintenance 1. Periodic cleaning of the eye wash aerators is advisable to assure proper water flow. ... 3. The Eye Safe unit, like all emergency eye wash and shower equipment, should be tested weekly. ..."

9. The Eyewash Station policy dated July 18, 2017, was provided by EMP29, at approximately 9:40 AM on October 18, 2017. EMP29 stated, "The Lab had their own policy and I wrote this one for the whole house." When asked if the policy provided would overrule the policy provided by the Lab Department, EMP29 stated, "Yes, it should."

A facility tour was conducted between 10:45 AM and 12:00 PM, on October 19, 2017, EMP5 and EMP14 were present for this tour.

10. At approximately 10:59 AM, observation of the entry door on room 3363, revealed, chips around the door handle and door latch, exposing the unfinished wood beneath.

11. At approximately 11:00 AM, observation of the entry door on room 3364, revealed, multiple chips on both sides of the door, exposing the unfinished wood beneath.

12. At approximately 11:01 AM, observation of the entry door on room 3364.1, revealed, chips in the wood, on the bottom of the door, exposing the unfinished wood beneath.

13. At approximately 11:02 AM, observation of the entry door on room 3365, revealed, chips in the wood, on the bottom of the door, exposing the unfinished wood beneath.

14. At approximately 11:03 AM, observation of the entry door on room 3365.1, revealed, chips in the wood, on the bottom of the door, exposing the unfinished wood beneath.

15. At approximately 11:04 AM, observation of the entry door on room 3366, revealed, chips in the wood and areas of splintered wood, exposing the unfinished wood beneath.

16. At approximately 11:05 AM, observation of the entry door on room 3366.1, revealed, chips in the wood and areas of splintered wood, on the sides and bottom, exposing the unfinished wood beneath.

17. At approximately 11:06 AM, observation of the entry door on room 3367, revealed, chips and areas of splintered wood, on the sides of the door, exposing the unfinished wood beneath.

18. At approximately 11:07 AM, observation of the entry door on room 3367.1, revealed, chips on the sides of the door, exposing the unfinished wood beneath.

19. At approximately 11:08 AM, observation of the entry door on room 3368, revealed, chips on the sides and bottom of the door, exposing the unfinished wood beneath.

20. At approximately 11:09 AM, observation of the entry door on room 3368.1, revealed, chips on the sides of the door, exposing the unfinished wood beneath.

21. At approximately 11:10 AM, observation of the entry door on room 3393, revealed, chips on the bottom of the door, exposing the unfinished wood beneath.

22. At approximately 11:11 AM, observation of the entry door on room 3394, revealed, chips on the bottom of the door, exposing the unfinished wood beneath.

23. At approximately 11:12 AM, observation of the Fire Exit door, revealed, four ¼ inch chips located around the push bar; one chip approximately five inches above the metal plate, on the bottom of the door and five inches in from the left side of the door, facing the hallway, exposing the unfinished wood beneath.

24. At approximately 11:13 AM, observation of the by swing door in the hallway, located by room 3392, revealed, chips on sides and splintered areas, exposing the unfinished wood beneath.

25. At approximately 11:14 AM, observation of the entry door on room 3392, revealed, chips on the bottom of the door and a splinter area approximately 1 ½ inches long approximately 2 ½ feet up from the ground and in the center of the door, exposing the unfinished wood beneath.

26. At approximately 11:15 AM, observation of the entry door on room 3391, revealed, chips on the bottom of the door, exposing the unfinished wood beneath.

27. At approximately 11:16 AM, observation of the entry door on room 3390, revealed, chips on the sides and ten small holes on door hinge side and five small holes on the top, facing the hallway, exposing the unfinished wood beneath.

28. At approximately 11:17 AM, observation of the entry door on room 3369, revealed, chipped areas and large areas of splintered wood, exposing the unfinished wood beneath.

29. At approximately 11:18 AM, observation of the entry door on room 3370.1, revealed, chips on the bottom and around the door handle, exposing the unfinished wood beneath.

30. At approximately 11:19 AM, observation of the entry door on room 3370, revealed, chipped and splintered areas on the bottom and around the door handle, exposing the unfinished wood beneath.

31. At approximately 11:20 AM, observation of the entry door on room 3371, revealed, multiple chipped areas throughout all sides of the door, exposing the unfinished wood beneath.

32. At approximately 11:21 AM, observation of the entry door on room 3371.1, revealed, multiple chipped areas, on the bottom of the door and around the door handle, exposing the unfinished wood beneath.

33. At approximately 11:22 AM, observation of the entry door on room 3389, revealed, multiple chipped areas, on the bottom of the door and around the door handle, exposing the unfinished wood beneath.

34. At approximately 11:23 AM, observation of the entry door on room 3372.1, revealed, multiple chipped and splintered areas, on the bottom of the door and around the door handle, exposing the unfinished wood beneath.

35. At approximately 11:24 AM, observation of the entry door on room 3372, revealed, no entry door was present on room 3372 during this tour.

36. At approximately 11:25 AM, observation of the entry door on room 3373, revealed, large splintered and chipped areas, on hinge and door handle side of the door; smaller chipped areas on the bottom of the door, exposing the unfinished wood beneath.

37. At approximately 11:26 AM, observation of the entry door on room 3373.1, revealed, multiple chipped areas and a splintered area, approximately one inch in length and approximately two feet up from the bottom, exposing the unfinished wood beneath.

38. At approximately 11:30 AM, observation of the entry door on room 3388, revealed, multiple chipped areas, above the middle metal plate, exposing the unfinished wood beneath.

39. At approximately 11:34 AM, observation of the entry door on room 3374A, revealed, multiple chipped areas, exposing the unfinished wood beneath.

40. At approximately 11:38 AM, observation of the entry door on room 3374B, revealed, multiple chipped and splintered areas with varying sizes, exposing the unfinished wood beneath.

41. During an interview on October 19, 2017, at approximately 12:16 PM, EMP5 confirmed all of the above listed findings regarding the doors within the behavioral health unit.

42. At approximately 10:37 AM on October 19, 2017, EMP5 confirmed that the facility admits patients with suicidal ideations to the facility's behavioral health department.

43. At approximately 1:49 PM on October 19, 2017, EMP2 stated that he/she was not aware of anti-ligature concerns on the behavioral health unit that were identified in April 2017. At approximately 2:40 PM, EMP2 added, "If I had been aware in April of the seriousness, I wouldn't have waited a week. ... I don't know if EMP39 didn't relay the seriousness. ..."

44. Review, at approximately 6:00 PM on October 19, 2017, of a Behavioral Health Action Plan, with a print date of October 18, 2017, revealed, "... 4. all bathrooms continue to have ligature risks due to unmitigated handrails ... [due date] 9/30/17 ... initial work order request entered April 2017 ... 5. men's bathroom, 368 br [bathroom], geri bathroom, QR [quiet room] bathroom and tub room all have ligature risk - shower handles ... [due date] 9/30/17 ... cost to replace tentatively approved through capital budget ..."

45. Review, at approximately 6:10 PM on October 19, 2017, of the, "Warren General Hospital - EOC Rounds Checklist," from April 6, 2017, for the Behavioral Health Area, revealed, "... Quiet Room bathroom looks dirty, shower looks dirty, NOT LIGATURE SAFE ..."

A tour of the Behavioral Health Unit was conducted from approximately 10:45 AM to 12:00 PM on October 19, 2017.

46. Tour of the Behavioral Health Unit revealed non-ligature safe door hinges in the following rooms: 361-bathroom, 360-bathroom, 364-bathroom, 365-bathroom, 364 closet, 365 closet, 3366.1, 366 closet, 3367.1, 3368.1, 368 closet, 367 closet, 3393, 3370.1, 3371.1, 3372.1, 3373.1, 3377, 3376, 3362.1, hallway partition doors, and soiled utility room.

47. Tour of the Behavioral Health Unit revealed non-ligature safe sink faucets in the following rooms: 361-bathroom, 360-bathroom, 364-bathroom, 3365.1, 3366.1, 3367.1, 3368.1, 3370.1, 3389-bathtub, 3372.1, 3373.1, 3376, and 3362.1.

48. Tour of the Behavioral Health Unit revealed non-ligature safe door handles in the following rooms: 361-bathroom and entry doors, common detox shower door, 360-bathroom and entry doors, 364 bathroom, 3365.1, 3366.1, 364, 365, 366, 3367.1, 3368.1, 3393, 3394, 3392, hallway partition doors, 3391, 3390, 3369, Quiet Room entry and bathroom doors, 3370.1, 370, 371, 3389, 3388, 3372.1, 3373.1, 373, 3374A, 3374C, 3377, 3376, 3362.1, 3375, 3384, 3387, and 3385.

49. Tour of the Behavioral Health Unit revealed non-ligature safe closet door handles in the following rooms: 361, 360, 364, 365, 366, 367, 370, 371, 372, and 373.

50. Tour of the Behavioral Health Unit revealed non-ligature safe shower handles in the following rooms: common detox shower room, 3368.1, 3393, 3392, Quiet Room bathroom, 3389, and 3376.

51. Tour of the Behavioral Health Unit revealed non-ligature safe grab bars in the following rooms: common detox shower room, 360-bathroom, 3368.1, 3393, 3392, Quiet Room bathroom, 3370.1, 3371.1, 3389, 3372.1, 3373.1, and 3376.

52. Tour of the Behavioral Health Unit revealed non-ligature safe plumbing in the following rooms: 361-bathroom, 360-bathroom, 364-bathroom, 3365.1, 3366.1, 3367.1, 3368.1, 3393, Quiet Room, 3370.1, 3371.1, 3389, 3372.1, 3373.1, 3376, 3362.1, and soiled utility room.

53. Tour of the Behavioral Health Unit revealed non-ligature safe handwashing handles in the following rooms: 361-bathroom, 360-bathroom, 364-bathroom, 3365.1, 3366.1, 3367.1, 3368.1, Quiet Room bathroom, 3370.1, 3371.1, 3372.1, 3373.1, 3376, and 3362.1.

54. Tour of the Behavioral Health Unit revealed non-ligature safe toilet paper holders in the following rooms: 361-bathroom, 360-bathroom, 364-bathroom, 3365.1, 3366.1, 3367.1, 3368.1, Quiet Room bathroom, 3370.1, 3371.1, 3372.1, 3373.1, and 3376.

55. Tour of the Behavioral Health Unit revealed non-ligature safe towel racks in the bathrooms for rooms 361 and 360.

56. Tour of the Behavioral Health Unit revealed non-ligature safe dresser handles in the following rooms: 361, 364, 365, 366, 367, 368, 370, 371, 372, and 373.

57. Tour of the Behavioral Health Unit revealed a non-ligature safe clothing bar in Room 361 closet.

58. Tour of the Behavioral Health Unit revealed a non-ligature safe shower curtain rod in the common detox shower.

59. Tour of the Behavioral Health Unit revealed non-bi-swing doors in the following rooms: 3393, Quiet Room, 3370.1, 3371.1, 3377, 3376, 3362.1, soiled utility room.

60. Tour of the Behavioral Health Unit revealed non-tamper resistant vents in the following rooms: Telephone Room, 364, 365, 366, 367, 3368.1, 3367.1, 3366.1, 3365.1, 3364.1, 368, 3368.1, 3392, Quiet Room, 370, 3370.1, 3371.1, 371, 389, 3372.1, 372, 373, 3373.1, Common Room, Laundry, 3377, 3376, 3362.1, and soiled utility.

61. Tour of the Behavioral Health Unit revealed non-tamper resistant outlet covers in the following rooms: 364, 365, 366, 367, hallways, 3368.1, 3367.1, 3366.1, 3365.1, 3364.1, 368, 3392, Quiet Room, 370, 371, 3370.1, 3371.1, 3389, 372, 3372.1, 373, 3373.1, Common Room, 3377, 3376, 3362.1, and soiled utility.

62. Tour of the Behavioral Health Unit revealed non-ligature safe above bed lighting in the following rooms: 364, 365, 366, 367, 368, 370, 371, 372, and 373.

63. Tour of the Behavioral Health Unit revealed non-ligature safe bed rails in the following rooms: 364, 365, 366, 367, 368, Quiet Room, 370, 371, 372, and 373.

64. Tour of the Behavioral Health Unit revealed non-ligature safe arm rests on the lounge chairs in the following rooms: 364, 365, 366, 367, 368, outside the Quiet Room, 372, 3377, and 3376.

65. Tour of the Behavioral Health Unit revealed non-ligature safe door swing arms on the door to room 3394, quiet room door, door to room 3376, door to the soiled utility room, and on the hallway partition doors.

66. Tour of the Behavioral Health Unit revealed non-ligature safe hardware on the partition wall in the common room, cupboard and refrigerator door handles in the common room, and cupboard handles in the soiled utility room.


Review, at approximately 2:12 PM on October 24, 2017, of the, "Statement of the Patient's Rights & Responsibilities," Patient Care Policy 101.03 Appendix A, revised September 12, 2017, revealed, "... You have the right to: ... Privacy concerning your own medical care. ..."

1. During a tour of the Behavioral Health Unit, between 10:05 AM and 12:15 PM on October 19, 2017, it was noted that Room 372 did not have a door at the entry to the room.

Review, at approximately 3:25 PM on October 26, 2017, of MR5 revealed that the patient had been admitted at approximately 12:15 AM on October 17, 2017.

2. At approximately 11:45 AM on October 19, 2017, EMP5 and EMP14, present for the unit tour, confirmed there was a patient currently assigned to Room 372, lacking an entry door.

3. At approximately 11:48 AM on October 19, 2017, a staff nurse, present at the time, stated, "We could move [PT8] to another room right now. ..."

4. Review, at approximately 3:28 PM on October 26, 2017, of MR9, revealed that the door to Room 372 had been removed by PT9 on September 20, 2017, at approximately 9:10 PM. EMP5 confirmed the date of the door removal at approximately 5:15 PM on October 19, 2017.


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A-0724

Review, at approximately 10:00 AM on October 19, 2017, of, "Materials Management: Materials Management Supervisor," revised April 2006, revealed, "... Essential Job Duties: ... 4. Establishes with COO purchasing/inventory policies and procedures, goals, budgets, including the development and maintenance of a perpetual computerized inventory and cost system; ... 7. Oversees inventory management and distribution of all supplies, equipment and materials; 8. Ensures efficient functioning of supply room operations. ... Standards of Behavior: ... Maintains all State and Federal regulatory requirements. ..."

Review, at approximately 9:55 AM on October 19, 2017, of, "Materials Management: Materials Management Technician," revised November August 7, 1996, revealed, "... Essential Job Duties: ... 12. Checks dates on supplies, disposes and refill as needed; 13. Cleans and straightens supply carts, storeroom shelf, restocks and rotates as needed. ... Professional Requirements: ... Maintains all State and Federal regulatory requirements. ..."

Review, at approximately 1:40 PM on October 24, 2017, of a Memorandum provided by EMP3, revealed, "... TO: File From: [EMP3] Date: 10/19/17 Subject: Expired Supplies - Procedure Materials Management Technicians (specifically Distribution Clerks) check the Nursing carts daily throughout the Hospital, except for weekends, to replenish medical supplies from the Storeroom inventory. As they are checking these medical supplies, they check expiration dates. Items are removed on their expiration dates. Expired items are given to the Nurse Educator. In the Storeroom, Materials Management personnel rotate stock and check expiration dates weekly."

A tour of the Maternal Child Health Unit [MCH] was conducted between 12:05 PM and 1:00 PM on October 17, 2017. EMP5 and EMP14 were present for this tour.

1. At approximately 12:10 PM, a Lo-Pro Oral/Nasal Tracheal Tube Cuffed with a labeled expiration date of "3/2016," was identified in the MCH Operating Room.

EMP5 provided confirmation of this finding at the time of observation.

2. At approximately 12:10 PM, there were three Size 3 Laryngeal Mask's with expiration dates of "7/24/2014," "9/28/12," and "8/28/2010," identified in the MCH Operating Room.

EMP5 provided confirmation of the findings at the time of observation.

3. At approximately 12:10 PM, there were three Size 4 Laryngeal Mask's with expiration dates of "5/28/2016," "12/28/2009," and "9/28/2012," and this package was also unsealed, identified in the MCH Operating Room.

EMP5 provided confirmation of the findings at the time of observation.

4. At approximately 12:11 PM, one Size 5 Laryngeal Mask, with a labeled expiration date of "11/28/2015," was identified in the MCH Operating Room.

EMP5 provided confirmation of this finding at the time of observation.

5. At approximately 12:11 PM, there were two Lo-Pro Trach Cuffed with labeled expiration dates of "7/2017," and "2/2/2012," and the package was open, with a 10 cc syringe attached, identified in the MCH Operating Room.

EMP5 provided confirmation of this findings at the time of observation.

6. At approximately 12:11 PM, a suction yankauer was open with no date on the package, was identified in the MCH Operating Room.

EMP5 provided confirmation of this finding at the time of observation.

7. At approximately 12:12 PM, a 10 cc syringe with no packaging, was identified in the MCH Operating Room.

EMP5 provided confirmation of this finding at the time of observation.

8. At approximately 12:12 PM, there were tongue depressors with labeled expiration dates of: one expired "5/2005," three expired "10/2006," one expired "6/2007," one expired "3/2013," four expired "4/2016," four expired "6/2016," twelve expired "10/2016," and two were open with no packaging or dates, identified in the MCH Operating Room.

EMP5 provided confirmation of the findings at the time of observation.

9. At approximately 12:13 PM, a Medi Vac Tubing Connecter with a labeled expiration date of "7/3/2016," was identified in the MCH Operating Room.

EMP5 provided confirmation of this finding at the time of observation.

10. At approximately 12:13 PM, there were 22G IV Catheters with labeled expiration dates of: one expired "6/2017," and three expired "3/2017," in the MCH Operating Room.

EMP5 provided confirmation of the findings at the time of observation.

11. At approximately 12:14 PM, a 25G IV Catheter with a labeled expiration date of "8/2011," was identified in the MCH Operating Room.

EMP5 provided confirmation of this finding at the time of observation.

12. At approximately 12:14 PM, an 18G IV Catheter with a labeled expiration date of "9/2015," was identified in the MCH Operating Room.

EMP5 provided confirmation of this finding at the time of observation.

13. At approximately 12:14 PM, there were 26G IV Catheters with labeled expiration dates of: one expired "10/2014," and one expired "1/2015," identified in the MCH Operating Room.

EMP5 provided confirmation of the findings at the time of observation.

14. At approximately 12:14 PM, there were 20cc syringes with labeled expiration dates of: one expired "5/2014," and one expired "1/2015," identified in the MCH Operating Room.

EMP5 provided confirmation of the findings at the time of observation.

15. At approximately 12:15 PM, a 17G Minimum Cannula with a labeled expiration date of "9/2017," was identified in the MCH Operating Room.

EMP5 provided confirmation of this finding at the time of observation.

16. At approximately 12:15 PM, there were two Endotracheal Tube Introducers with labeled expiration dates of: "11/2011," and "3/2010," identified in the MCH Operating Room.

EMP5 provided confirmation of the findings at the time of observation.

17. At approximately 12:15 PM, oxygen tubing was found to be open with no packaging present in the MCH Operating Room.

EMP5 provided confirmation of this finding at the time of observation.

18. At approximately 12:16 PM, a small adult anesthesia mask with a labeled expiration date of "1/2017," was identified in the MCH Operating Room.

EMP5 provided confirmation of the findings at the time of observation.

19. At approximately 12:16 PM, there were six Povidone Iodine Prep Pads with labeled expiration dates of "5/2015," identified in the MCH Operating Room.

EMP5 provided confirmation of the findings at the time of observation.

20. At approximately 12:16 PM, there were lab tubes with labeled expiration dates of: light blue- "9/2014," and magenta- "5/2014," identified in the MCH Operating Room.

EMP5 provided confirmation of the findings at the time of observation.

21. At approximately 12:16 PM, a 20cc syringe with a red-capped needle attached was found with no packaging or expiration date, in the MCH Operating Room.

EMP5 provided confirmation of the findings at the time of observation.

22. At approximately 12:17 PM, a cotton-tipped applicator with a labeled expiration date of "3/2016," was identified in the MCH Operating Room.

EMP5 provided confirmation of this finding at the time of observation.

23. At approximately 12:17 PM, a 3-way StopCock with a labeled expiration date of "12/2011," was identified in the MCH Operating Room.

EMP5 provided confirmation of this finding at the time of observation.

24. At approximately 12:17 PM, a Povidone-Iodine Prep Pad with a labeled expiration date of "4/2011," was identified in the MCH Operating Room.

EMP5 provided confirmation of this finding at the time of observation.

25. At approximately 12:18 PM, a 3-way Stopcock with a labeled expiration date of "1/2012," was identified in the MCH Operating Room.

EMP5 provided confirmation of this finding at the time of observation.

26. At approximately 12:18 PM, there were two 16G IV Catheters with labeled expiration dates of "9/2015," identified in the MCH Operating Room.

EMP5 provided confirmation of the findings at the time of observation.

27. At approximately 12:18 PM, there were two 22G Spinal Needles with labeled expiration dates of "1/2011," identified in the MCH Operating Room.

EMP5 provided confirmation of the findings at the time of observation.

28. At approximately 12:18 PM, there were Combined Spinal and Epidural Needle Sets with labeled expiration dates of: 17G- "2/2016," and 25G- "4/2012," identified in the MCH Operating Room.

EMP5 provided confirmation of the findings at the time of observation.

29. At approximately 12:19 PM, there were size 8 ½ sterile latex gloves with labeled expiration dates of: two expired "10/2011," one expired "11/2013," one expired "8/2015," and one expired "2/2016," identified in the MCH Operating Room.

EMP5 provided confirmation of the findings at the time of observation.

30. At approximately 12:19 PM, an IV Catheter Connector with a labeled expiration date of "8/2011," was identified in the MCH Operating Room.

EMP5 provided confirmation of the findings at the time of observation.

31. At approximately 12:19 PM, there were three ammonia capsules, with no expiration dates, taped to the anesthesia cart, identified in the MCH Operating Room.

EMP5 provided confirmation of the findings at the time of observation and could not provide documentation on the dates of expiration for all 3 ammonia capsules.

32. At approximately 12:20 PM, an open container of Betadine, with no open date on the bottle, was identified in the MCH Operating Room.

EMP5 provided confirmation of this finding at the time of observation.

33. During a tour of the operating room contained on the Maternal Child Health Unit, at approximately 12:20 PM on October 17, 2017, a tongue depressor was found in a drawer, with gauze and tape wrapped around it. When asked what the item was for, EMP14 stated, "I'm guessing it used to be a bite block, years ago."

A tour of the Imaging Department was conducted between 2:30 PM and 3:00 PM on October 17, 2017. EMP5 and EMP13 were present for this tour.

34. At approximately 2:35 PM, there were five 60 cc syringes with labeled expiration dates of "4/2017," identified in the Cardiac Stress Test Room.

EMP5 provided confirmation of the findings at the time of observation.

35. At approximately 2:35 PM, there were 22G IV Catheters with labeled expiration dates of: one expired "3/2017," one expired "11/2009," one expired "2/2013," and one expired "1/2016," identified in the Cardiac Stress Test Room.

EMP