HospitalInspections.org

Based on document reviews, observations and interviews, the hospital failed to ensure that policies and procedures were established to assure safe and clean storage of supplies for direct patient care with the Medical Supplies Department and the Infection Control Department, for all individuals seeking care in the Emergency Department.

Findings:

On 9/18/2024 at 10:58 AM, the Inventory Control policy and procedure for the Emergency Department ("ED") was requested.

On 9/18/2024 at 3:16 PM, an email was received from the Director of Quality and Risk. He was unable to provide any such policy.

On 09/18/2024 at 8:50 AM, a tour of the emergency department was conducted with the Director of Emergency Services and Director of Quality and Risk Management. This tour revealed the following: :
Triage Room findings:
-Adhesive tape residue present on glucometer meter and glucometer kit creating a non-intact surface. Not easily sanitized
-Chair in triage has non-intact surface.
-These non-intact surfaces that could not be sanitized.
EKG machine outside Triage Room:
-Adhesive tape residue on monitory creating a non-intact surface. These non-intact surfaces that could not be sanitized.
-Supply tray had debris in bottom of tray, -
Crash Cart outside Triage Room:
-Defibrillator Monitor soiled.
ED Rm. 2:
-Computer monitor has multiple areas of adhesive tape residue on screen frame and screen.
-Computer cart wrist rest has large area missing creating a nonintact surface.
-Computer keyboard has copious amounts of debris below/between keys. Not sanitary.
-Portable cardiac monitor on wall arm has multiple areas of adhesive tape debris creating a non-intact surface.
-Wooden headboard has multiple non-intact surfaced on bottom edge of headboard creating a non-intact surface.
-Shelving above counter to right side of bed which contained patient supplies had adhesive tape residue on the edge of both shelves creating a non-intact
surface.
-These non-intact surfaces that could not be sanitized.

-Needle, empty syringe, and pre-filled flush noted on counter to right of bed. Not secured.
-2 of 2 BD BBL NS expired. One syringe expired 07/2023 and the other expired 06/2024.
-1 of 1 Hologic Swab Specimen Collector expired 04/30/2024
-1 of 2 nasal swab specimen collection item was unwrapped and amongst the sterile supplies.
-1 of 2 Culture Swab kits expired 09/30/2023.
-1 of 4 Triple Pack Povidine Iodine packages contaminated and amongst the sterile supplies.
-2 of 2 clear-top blood collection tubes expired 05/31/2024

Patient nutrition station with hand hygiene sink located next to staff working station:
-Opened bottle of ginger ale and Pepsi sitting out on counter.
-Otoscope/Ophthalmoscope handles present in battery pack plugged into electrical outlet charging.
-Bin located to the right of the ophthalmoscope contained:
-2 of 2 opened packages of otoscope caps/cones
-1 of 1 black marker
-5 of 5 soiled ophthalmoscope heads
-2 of 2 soiled otoscope heads
-1 of 1 Panoptix ophthalmic instrument which is soiled.
-1-Bottom of bin which contained the ophthalmoscope/otoscope heads had a layer of debris and was not sanitary.
Ambulance Entrance/Port:
-Water damage noted to ceiling at ambulance entrance.
ED Rm. 7/Critical Care Room:
-Pediatric Crash cart tip drawer has adhesive tape debris creating a non-intact surface.
-Adhesive tape debris stuck to floor in front of the Pedi Crash Cart creating a non-intact surface.
-These non-intact surfaces that could not be sanitized.
-Needle Decompression Box:
-2 of 2 20-cc Syringes both expired 11/30/2023
-2 of 2 3-way Hi-Flow Stopcocks expired on 7/22/2022
-4 of 4 14G x 2-inch needles expired on 09/30/2023
-ED Rm 7 Computer stand:
-Work surface on stand contains debris.
-Computer keyboard has missing keys and debris under keys.
-Computer monitor has multiple areas of adhesive tape debris creating a non-intact surface.
-These non-intact surfaces that could not be sanitized.
-ED Rm 7 Adult Crash cart:
-Top of cart has debris and not sanitary.
-ED Rm 7 Intubation Box:
-2 of 2 Arterial line sets expired 09/1/2024
-7 of 7 Nellcor Pediatric Calorimetric CO2 detectors expired 9/12/2024
-ED Rm 7 Glucometer Kit on countertop:
-One section of the interior of box has debris in the bottom.
-Outside of box is soiled and had adhesive tape residue creating a non-intact surface.
-These non-intact surfaces that could not be sanitized.
-ED Rm. 7-Electric Razor handle:
-Razor head receiver is soiled and pieces of hair is present.
Suture Cart:
-1 of 2 multiuse bottles of Bupivicaine vials and not labeled appropriately.
-1 of 1 multiuse bottles of Lidocaine 1% vials opened and not labeled appropriately.
-1 of 1 multiuse bottles of Xylocaine 1% vials opened and not labeled appropriately.
-1 of 1 multiuse bottles of Lidocaine 2% vials opened and not labeled appropriately.
-1 of 45 5-0 Prolene suture packs expired 07/31/2024
-7 of 12 6-0 Prolene suture packs expired 9/30/2023
-6 of 27 5-0 Vicryl suture packs expired 9/30/2023
-1 of 15 4-0 Vicryl suture packs expired 11/30/2023
-1 of 20 5-0 Vicryl suture packs expired 01/31/2024
Ear, Nose, and Throat Cart:
-1 of 1 Box of red tube-like adapters to apply to Xylocaine spray for application was soiled and contaminated.
-1 of 1 Box of Katz extractors soiled and contaminated.
-1 of 1 Sterile McGill Forceps expired 07/31/2023
Area where registration/tech/pharmacy tech stations located:
-Damaged/broken ceiling tiles.
Medication Room:
-Counter where medication is prepared is soiled with multiple areas of white dried matter.

All above findings were confirmed by the Director of Emergency Services and Director of Quality and Risk Management at the time of discovery.

Based on document reviews and interviews, the hospital failed to ensure that Emergency Department policies were reviewed and updated for thirteen (13) of seventeen (17) policies reviewed.

Findings:

This is a repeat deficiency from the previous survey completed in July 2024.

The Director of Quality and Risk and the Corporate Compliance Officer stated they use a software that prompts the facility to review policies and procedures every three (3) years.

On 09/18/2024 and 9/19/2024, Emergency Department ("ED") policies were reviewed with the Director of Quality and Risk.

The following policies have not met the hospital expectation for policy review:
- Violence: Physical Assault, last approved on 09/2018, next to be reviewed by 08/2021;
- Safe Haven for Abandoned Infants Dropped Off at Hospital, last approved on 02/2012, next to be reviewed by 01/2015;
- Capacity Management Plan Code Purple (Surge Capacity), last approved on 06/2011, next to be reviewed by 05/2014;
- Controlled Medications and Pyxis Access, last approved on 10/2018, next to be reviewed by 09/2021;
- Domestic Violence, last approved on 12/2019, next to be reviewed by 12/2022;
- Emergent Care & Wells ERgent Care Procedural & Deep Sedation Policy, last approved 12//2019, next t be reviewed by 12/2022;
- Legal Claim of Evidence, last approved on 01/2020, next to be reviewed by 01/2023;
- Restrictions of Procedures Performed, last approved on 10/2019, next to be reviewed by 10/2022;
- Review of Lab/Radiology Reports last approved on 01/2020, next to be reviewed by 01/2023;
- Triage Guidelines, last approved on 11/2018, next to be reviewed by 10/2021;
- Blood Alcohol Samples : Consent and Drawing, last approved on 07/2019, next to be reviewed by 06/2022;
- Dispensing of Medication: Emergency Department, last approved on 09/2021, next to be reviewed by 08/2024; and
- Care of the Patient with Suicidal/Homicidal Ideation, last approved on 05/2018, next to be reviewed by 04/2021.

The above findings were confirmed at the time of the review with the Director of Quality and Risk.