HospitalInspections.org

Based on observations during a facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.

Findings include:

Refer to Life Safety Code violations.

Based on observation and interview with administrative staff, it was determined the facility failed to ensure that all medical supplies available for patient use in the Emergency Room (ER) and in the Laboratory Department were not expired. This had the potential to affect all patients.

Findings include:

Observations were conducted in the Laboratory (Lab) Department on 6/27/11 at 11:00 AM. The surveyor and Employee Identifier (EI) # 3, the Lab Director, observed the following expired supplies:

Outpatient Collection Area:
Green Top Lab Tubes times (x) 1 tray expired (exp) 3/11
Arterial blood sampling kit x 2 exp 4/11
Culture Swab x 1 exp 1/11
BacT/Alert x 6 exp 4/30/11

Observations were conducted in the Emergency Room (ER) on 6/27/11 at 12:40 PM. The surveyor and EI # 2, the ER Nurse Manager observed the following expired supplies:

ER#3 bed area:
Normal Saline (NS) 0.9% 1000 Cubic Centimeter (cc) open dated 12/24/10
NS 0.9% 1000 cc open dated 12/31/09
NS 0.9% 1000 cc open: not dated
Foley Catheter (FC) Tray 18Fr-5cc exp 7/08

During an interview with EI #2 on 6/27/11 at 12:50 PM, he confirmed that NS bottles should be dated when opened and stated, " they are only good for 30 days after opening " .

Further observations were conducted in the Emergency Room (ER) on 6/28/11 at 2:20 PM. The surveyor and EI # 1, the Director of Nursing, observed the following expired supplies:

ER # 1 bed area:
Iodoform Packing Strip x 1 exp 5/11
Plain Packing Strip x 1 exp 10/09
Culture Swab x 1 exp 12/07
Culture Swab x 1 exp 12/08
Culture Swab x 1 exp 9/09
Culture Swab x 3 exp 10/06
Culture Swab x 2 exp 5/11
Urinary Drainage Bag x 1 exp 5/10
SafeLine Intravenous Set x 1 exp 12/10
FC 26 Fr-30cc x 1 exp 7/08
2 way FC 22Fr-5cc x 2 exp 3/11
Multi-Lumen Central Venous Catheterization Kit x 1 exp 4/11
Pediatric/Infant Lumbar Puncture Tray x 3 exp 11/08
Green Top Lab Tubes x 1 tray exp 3/11
Tracheal Tube 7.5 x 1 exp 7/09
LMA-Classic Size 1 ? x 1 exp 12/06
LMA-Classic Size 3 x 1 exp 11/06