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Based on review of facility documents, observations, and employee interviews (EMP), it was determined the facility failed to ensure preventative maintenance (PM) was completed on the eye wash station in the Surgical Department, the eye wash station in the Emergency Department, and the eye wash station in the Laboratory Department.

Findings include:

Review on November 21, 2019, at 2:15 PM of the facility's policy "Eye Wash Station," revision dated June 2014, revealed " ... Definition: Emergency eye wash stations [sic] is for the purpose of quick drenching or flushing of the eyes exposed to potentially injurious materials. ... B. Maintaining the System: 1. Weekly checks of the eyewash station will be completed by the department utilizing the following steps ..."

1. A tour of the Surgical Department on November 21, 2019, beginning at 9:39 AM revealed an eye wash station. Three weeks of weekly preventative maintenance checks were missing. EMP1 confirmed the maintenance was to be completed weekly. EMP1 confirmed the missing preventative maintenance checks for the eye wash station in the Surgical Department.

2. A tour of the Emergency Department on November 21, 2019, beginning at 1:25 PM revealed a wall mounted sign posted adjacent to the eye wash station. The sign read " ... Test All Equipment Weekly." EMP2 and EMP15 were asked to provide the documentation of the weekly eye wash station. EMP2 and EMP15 confirmed documentation was not available.

3. A tour of the Laboratory Department on November 21, 2019, beginning at 2:00 PM revealed an eye wash station. Documentation of the weekly checks was requested. EMP16 stated the Maintenance Department was now in charge of doing the weekly checks.

On November 21, 2019, at 2:30 PM, EMP1 presented to the conference room and confirmed the eye wash station preventative maintenance checks were not completed by the Maintenance Department after October 28, 2019, in the Surgical Department, Emergency Department, or the Laboratory Department.

Based on review of facility documents, observations, and employee interviews (EMP), it was determined the facility failed to ensure expired hospital supplies were discarded and not available for patient use.

Findings Include:

Review on November 25, 2019, at 1:35 PM of the facility policy "Expiration Date Guidelines," dated May 2019, revealed "Definition: Expiration date is the last date a medication, hospital product or supplies can be used. Objective: 1. To ensure that all hospital employees are informed of the facility's 'Expiration Date Guidelines.' 2. To manage expired medications and hospital supplies in a manner that promotes patient safety. ... Information: 1. Expiration date is the last date a product is to be used. ... Policy: 1. All hospital medications and supplies will expire the last day of the month specified unless a specific date is stated on the product. ..."

On November 21, 2019, the following expired hospital supplies were observed:

1. At 9:00 AM in the Respiratory Supply Closet, there were 13 aerosol drain bags with an expiration date of 3/2019.

EMP1 and EMP6 confirmed the expiration date of 3/2019 on the 13 aerosol drain bags at the time of the observation.

2. At 9:11 AM in the Clean Utility Room on the Medical/Surgical Unit, there were three Para Pak ZN PVA Fixative with an expiration date of 9/2019, and three Para Pak 10% Buffered Neutral Formalin with an expiration date of 9/2019.

EMP1 confirmed the expired hospital supplies in the Clean Utility Room on the Medical/Surgical Unit at the time of observation.

3. At 9:29 AM in a patient room in the Intensive Care Unit (ICU), there was a 5-in-1 Bubble Connecter with an expiration date of 8/2019.

EMP1 confirmed the expired 5-in-1 Bubble Connector in the patient room in the ICU at the time of observation.