HospitalInspections.org

Based on a review of facility documentation, observation and employee interviews (EMP), it was determined that the facility failed to ensure that outdated medications were not made available for patient use in the Pre-Operative and Radiology areas.

Findings include:

On December 6, 2016, at approximately 2:13 PM, a review of Policy # PH 13.0 "Distressed Drugs," revised October 2013, revealed, "SCOPE: This policy applies to all distressed drugs. POLICY: Medications which are outdated, visibly deteriorated, unlabeled or inadequately labeled, recalled, discontinued, or obsolete shall be disposed of in compliance with applicable State and Federal laws and regulations. ... ."
1. On December 6, 2016, at 11:30 AM, a tour of the Radiology Department revealed a box of 100 ml Sodium Chloride, with an expiration date of November 2016.

EMP2, present at the time, stated, "I guess I didn't check that at the end of the month."

2. On December 6, 2016, at approximately 11:45 AM, inspection of the Pre-Op/PACU crash cart revealed the following expired medications: Sodium Bicarbonate 8.4% solution (four units) expired November 2016; Naloxone injection 0.4 mg/ml (four units) expired November 2016; Potassium Chloride 40 mEq (one unit) expired December 1, 2016; Furosemide 40 mg/ml (two units) expired December 1, 2016; Digoxin injection 500 mcg/2 ml (one amp) expired November 2016.

On December 6, 2016, at 11:54 AM, EMP3 confirmed the expired medications located in the Pre-Op/PACU crash cart.

3. On December 6, 2016, at approximately 11:58 AM, inspection of the Pre-Op/PACU medication refrigerator revealed an opened/uncapped vial of Tuberculin Purified Protein Derivative. A sticker placed on the bottle revealed, "Do not use after 11/30/16."

EMP3, present during the observation, confirmed the verbiage on the sticker stating, "It does [say do not use after 11/30/16]."

4. On December 6, 2016, at approximately 12:05 PM, an inspection of the Pre-Op/PACU medication cupboard revealed two boxes of Tobramycin & Dexamethasone ointment with an expiration date of November 2016.

EMP3, present during the observation, confirmed the expired Tobramycin & Dexamethasone ointment, stating, "I see."

5. On December 6, 2016, at approximately 12:16 PM, inspection of the Pre-Op/PACU pediatric crash cart revealed Lidocaine 2% HCL injection (four units) that expired on December 1, 2016, and Epinephrine 1:10,000 0.1 mg/ml that expired November 2016.

EMP3, present during the observation, confirmed the expired Lidocaine and Epinephrine stating, "We have a system in place. It's very frustrating."

Based on a review of facility documentation, observation and employee interview (EMP), it was determined that the facility failed to ensure a safe and sanitary environment for one of one ice machines, located in the Pre-Operative/PACU area.

Findings include:

On December 6, 2016, at approximately 2:13 PM, a review of Policy # (No Number Identified), original date November 2012, revealed, "TITLE: Ice Machine Cleaning RESPONSIBLE DEPARTMENT: Environmental Care ... PURPOSE: Cleaning and sanitizing ice machine. ... POLICY: Follow manufacturer recommended cleaning and sanitizing every six months for efficient operation. ..."

1. On December 6, 2016, at 12:26 PM, inspection of the ice bin located in Pre-Op/PACU, revealed an accumulation of a pink substance in the rear of the bin. At the time of discovery, the substance was able to be wiped away with a 4x4 leaving an accumulation of the substance on the 4x4.

On December 6, 2016, at 12:27 PM, EMP3 confirmed the findings stating, "It's cleaned twice a year."

Based on a facility documentation, observation and employee interviews (EMP), it was determined that the facility failed to ensure that outdated and/or improperly stored supplies were disposed of per facility policy and manufacturer expiration date for culture containers and laryngeal mask airways (LMA).

Findings include:

Review of Policy# MM 11.0 "Rotation of Supplies to Avoid Outdates," revised October 2009, revealed, "PURPOSE: Monitor all products on a routine basis to ensure that all materials having an expiration date are properly rotated for next use and if not used remove from circulation at least one month prior to expiring. ... POLICY: It is the policy of Edgewood Surgical Hospital to use inventory in the most efficient manner and to provide product that is not expired to the end user. Also, to ensure that product expiration or near expiration is not utilized for patient care. ... ."

1. A tour of Operating Room #2 (OR#2) on December 7, 2016, at 1:05 PM, at the Lawrence County Surgery Center of Edgewood Surgical Hospital (LCSC) revealed two specimen containers containing buffered solution. Review of the containers revealed expiration dates of June 2013 and April 2015. The tour of OR2 further revealed two LMAs with expiration dates of May 2014 and July of 2016.

2. A tour of Operating Room #1 (OR#1) on December 7, 2016, at 1:10 PM, at LCSC revealed two LMAs with expiration dates of May 2014 and July of 2016.

3. Examination of the PACU crash cart located at the LCSC, on December 7, 2016, at 1:20 PM revealed an LMA with an expiration date of September 2016.

4. On December 7, 2016, at approximately 1:25 PM, EMP5, present for the observations in OR#1, OR#2 and of the PACU crash cart, confirmed the expired LMAs and specimen containers.