HospitalInspections.org

Based on observation and interview, the facility failed to ensure expired medical supplies were not available for patient use in one of two ultrasound rooms.

The findings included:

Observation on 4/27/15 at 11:30 AM, in Building B radiology department ultrasound room #1, revealed two hypodermic needle kits with an expiration date of 5/2012 and four hypodermic needle kits with an expiration date of 5/2013, stored in a supply cabinet.

Interview with the Director of Quality Management at 11:35 AM, outside the ultrasound room, confirmed the hypodermic needle kits were expired and available for patient use.

Based on review of the facility's Plan of Correction (POC), with a correction date of 3/27/15, and interview, the facility failed to maintain a data collection tool for monitoring intravenous (IV) sites, as described in the POC, for one (Building A) of two facilities.

The findings included:

Review of the facility's POC for the Validation survey conducted on 3/4/15, revealed the facility alleged compliance with the Conditions of Participation at CFR 482.42 on 3/27/15. Further review of the POC revealed, "...The ICP [Infection Control Preventionist] and Nursing Supervisors will montior monthly for compliance to [facility] policy via a data collection tool and report to the Quality director, who will review the data and then report to the [Quality Committee]...We have added duration of IV [intravenous] sites to the monitoring tool to ensure that the policy is being followed..."

Interview with the Director of Quality Management on 4/27/15 at 10:45 AM, in the conference room, revealed the facility had not maintained an IV Catheter Maintenance Data Collection Tool. Continued interview confirmed the data tool had not been implemented because the facility supervisors had not been in-serviced on how to collect the data and the "...[Chief Nursing Officer] will be in-servicing the supervisors in May..."