HospitalInspections.org

Based on observation and interview the facility failed to ensure that there were no potential sources of infection in 3 of 3 trauma rooms the clean linen room, and the nourishment room.


Findings included:
Trauma Room 1:
Dark red stain in the shape of a drop was observed on the counter near the sink along with a rusted examiner stool seat.


Trauma Room 2:
There were 2 blue chairs with set covers that were torn, leaving an open source for bacteria and an increased risk for spread of infections. Dirt/rust and a piece of pipe were observed in the cabinet under the sink.


Clean Linen Room:
Exposed linen (the "cover" flap was not being used) leading to an increased risk for spread of infections.


Nourishment Room:
The patient food refrigerator was found to be dirty, with several expired foods from 12/2022 and it was leaking water into the bottom shelve where staff had placed surgical towels to absorb the water.


The ED Director confirmed the findings in an interview on January 30, 2023.

Based on observation during a tour of the facility, the facility failed to ensure that all equipment was inspected in accordance with manufacturer's instructions and regulations.


Findings included:
A tour was conducted of the Emergency Department (ED) with the ED Director on January 30, 2023, at 1422 beginning in the ED lobby. There are 26 total patient rooms in the ED. Of those, only 4 were inspected as the others were in use. None of the facility's otoscopes had a biomedical sticker with a "last inspected" date on them. A request for the biomedical record of inspection was made to the Emergency Room Director and Chief Nursing Officer. The two Administrators reached out to their Biomedical Director. The Biomedical Director stated, "It is in our policy that we do not have to inspect our otoscopes."


The Chief Nursing Officer, was interviewed on the morning of February 1, 2023 and was asked if they had a copy of the policy regarding inspection of your otoscopes.
Chief Nursing Officer: "I will get with [the Biomedical Director] and get back to you."


On the morning of February 1, 2023, provided a copy of the facility policy regarding the inspection of equipment. The Policy was reviewed together with the Chief Nursing Officer. The policy stated, in part, on page 3, " ...Equipment that scores between 6 to 10 points on the criteria evaluation system and pose little or no risk to patients. These devices may be unscheduled from the management program but remain on the clinical equipment inventory; however regulatory requirements may dictate a minimum service level."


The Chief Nursing Officer was asked if he could see here [indicated the bottom of page 3 of the facility's policy] that their policy stated that regulatory requirements may dictate a minimum service.


Chief Nursing Officer: "Yes, but our policy says that we can use an outside equipment management company, and they [the equipment management company] said we don't need the otoscopes inspected."


The Chief Nursing Officer was asked if they were following the manufacturer's instructions and if they had them available for review.


Chief Nursing Officer: "Let me check with [the Biomedical Director]."


The Chief Nursing Officer and the Biomedical Director were able to produce the manufacturer's instructions, which stated in part, that the otoscopes should be " ...routinely maintained."

Based on a observation and interview of the Emergency Department on January 30, 2023, the facility failed to ensure that practices and process were in place to prevent and control infections in the Emergency Department (ED) Supply room, ED patient treatment rooms, and ED patient refrigerator for infection control by having expired supplies in all 3 trauma rooms and the supply room.


Findings included:


There were expired supplies found in all 3 Trauma rooms of the ED as follows:
1-Arterial Blood Sampler - expired 12/17/2022
1-Arterial Blood Sampler - expired 12/04/2022
1-Pneumothorax Kit, size 8 fr, - expired 11/30/2022
1-Tracheotomy Inducer Kit, size 8fr. - expired 07/31/2022
1-Pediatric Two-lumen Central Venous Catheterization kit, size 4 fr. - expired 02/08/2022
1-Pediatric Two-lumen Central Venous Catheterization kit, size 4 fr. - expired 02/28/2022
1-6mm Shiley cuffed with inner cannula - expired 09/25/2020
1-5mm Shiley - expired 05/11/2021
1-unopened bottle of Iodaform packing strip - expired 11/2022


There were expired supplies found in the supply room as follows:
1-Cook Chest Drain (Heimlich) Valve - expired 11/25/2022
1-Cook Chest Drain (Heimlich) Valve - expired 11/12/2022
1-Cook Chest Drain (Heimlich) Valve - expired 10/07/2020
1-8fr. Central Line Procedure Tray - expired 11/18/2021
1-Trocar Catheter Kit, size 28fr. - expired 02/27/2022
1-Cricothyrotomy Catheter Set - expired 10/14/2022
1-General Purpose Probe Cover - expired 12/11/2022
1-Unit Bio-Flex Arterial/Venous Catheters, size 10fr. - expired 08/28/2022
1-Petroleum Gauze Tube Foil - expired 12/31/2021
1-Swab culture tube - expired 05/12/2021
1-Gripper Plus Safety Needle, 22g - expired 02/2020


The Emergency Room Director confirmed of all the above-mentioned expired supplies.

Based on observation and interview the facility failed to post a copy of the hospital's license in the Emergency Department lobby.


Findings included:
A tour was conducted of the Emergency Department (ED) with ED Director on January 30, 2023, at 1422 beginning in the ED lobby. On the afternoon of January 30, 2023, the Medical Staff/Risk Manager, the Performance Improvement Director, and the Chief Nursing Officer were interviewed following the tour of the Emergency Department. No copy of the facility license was found in the ED lobby. The administrative staff were notified and asked to present a copy of both. The Medical Staff/Risk Manager, the Performance Improvement Director, and the Chief Nursing Officer nodded in agreement.


The Medical Staff/Risk Manager, the Performance Improvement Director, and the Chief Nursing Officer confirmed of all the above-mentioned finding.