HospitalInspections.org

Based on observation, and staff interview, the facility did not ensure that the physical environment of the Emergency Department (ED) was maintained to ensure the safety of patients.

Findings include:

During tour of the Emergency Department (ED) on 11/15/16 at approximately 12:45 PM, in the presence of Staff C, the Director of Nursing and Staff D, the ED Clinical Nurse Manager the following findings were identified:

- The storage room used for Personal Protective Equipment was noted with a missing ceiling tile. Wires of different colors were noted hanging in the exposed ceiling of the closet.
The exposed ceiling poses a risk for contamination of clean supplies.


During interview with Staff R, Director of Security on 11/18/16 at 2:45 PM, the staff acknowledged the findings.

- The metal roof cover of the Ambulance Bay was noted with a steady stream of rainwater dripping down while patients were being brought into the ED. There was a collection of rainwater on the floor of the Ambulance Bay area. Emergency Medical Technicians were observed maneuvering stretchers with patient in them to avoid the steady stream of rainwater.
The leak in the metal roof poses a safety hazard to patient and individuals entering the ED.

- An oxygen tank with 1000 liters of oxygen was noted without a safety cage. The oxygen tank was placed in the hallway of the ambulance entrance to the ED and was accessible to unauthorized individuals.

- Wheelchairs and splints were noted strewn along the hallway of the Ambulance Entrance to the ED restricting the path of egress during an event of emergency evacuation.

Based on observation, and interview, the facility did not remove expired supplies from patient care area to ensure patients safety.


Findings include:

During tour of the Emergency Department (ED) on 11/15/16 at approximately 12:30 PM accompanied by Staff C, Director of Nursing, the following expired supplies were found in storage cabinets:

- 500-milliliter bag of 5% Dextrose and 0.9 sodium chloride with an expiration date of January 16, 2016 was found in the storage cabinet in the Fast Track section of the Emergency Department

- An opened container of 500 cc of sterile water that was not labeled with an open date or a beyond-use-date. The liquid in the container had light brownish color.

- A Thoracentesis tray and catheter with an expiration date of 9/30/16 was found on the second shelve in the storage room for Emergency Crash Carts.

During interview with Staff D, ED Clinical Nurse Manager on 11/15/16 at 1:05 PM, the staff acknowledged the findings.

Based on document review, observation, and interview, in 1 (one) of three (3) emergency code carts inspected, the facility did not implement its policy to ensure that pediatric emergency cart was equipped with a pediatric bag-valve-mask required for emergency ventilation.

The failure to have a pediatric bag-valve-mask readily available for use during emergencies may place patient at risk for harm.

Findings include:

During inspection of the Pediatric Emergency Code Cart on 11/15/16 at approximately 12:00 PM, the cart did not contain a Pediatric bag-valve-mask.

Review of the facility policy titled "Code Cart - Broselow Pediatric Emergency," last revised August 2015, stated that a Pediatric bag-valve-mask is to be placed on the outside of a Pediatric code cart.

During interview with Staff E, Registered Nurse on 11/15/2016 at 1:09 PM, staff stated that she checked the Pediatric Code Cart in the morning of 11/15/16 and confirmed that she did not observe that the Pediatric bag-valve-mask was missing from the cart.

When Staff D, Clinical Nurse Manager was advised to call for immediate delivery of the device to the unit, it took approximately 5 minutes for the bag valve device to be delivered.

This finding was confirmed with Staff D and Staff A, Assistant Vice President, who were present during the inspection.