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Based on observation, interview and review of policy and procedure the facility failed to ensure required storage and labeling of 1 intravenous solution after removal of the external over wrap.

Findings include:

On 04/24/18, during a tour of the facility, one unwrapped and undated 100 milliliter(ml) bag of Sodium Chloride Injection was found in the surgery center intravenous (IV) solution storage bin.

On 04/24/18, the Surgical Services Nurse Manager confirmed the unwrapped and undated IV bag. The Manager explained it is hospital policy to label the IV bag with a date when it is removed from the plastic wrap prior to placing in the storage bin.

Review of the "IV Over Wrap" policy, dated 05/23/11, indicated a "use by" date is written on the bag when the IV is removed from the protective over wrap. The policy revealed 100 ml bags expire 30 days after removal from the protective outer wrap.

Based on observation, interview and review of policy and procedure the facility failed to ensure annual sterilization training for 3 of 4 surgery equipment processors.

Findings include:

On 04/25/18 a tour of the surgical area and observation of the surgical sterilization process was conducted.

On 04/25/18 the Lead Processor Technician (Employee #32) acknowledged completion of annual sterile processing training at a conference 09/2017. Employee #32 reported the surgery equipment processors receive training on new equipment; however, no annual training on the sterilization process is provided.

On 04/25/18 the Surgical Services Nurse Manager (Employee #38) confirmed no formal annual training process is provided for three of four surgery equipment processors (Employees #33, #34 and #35).

The facility did not have a policy and procedure that addressed the annual training requirement for sterile processing technicians.

Based on observation, review of manufacturer's instructions, review of laboratory records, and interview with the laboratory manager, the laboratory failed to ensure that glucose quality control materials and stool transport media were not expired, appropriate temperatures were maintained for the laboratory incubator and correct quality control ranges were entered in the Abbott Precision Xceed Pro glucose testing system to evaluate quality control results.

Findings include:

1. Medisense glucose quality controls, lot #17485A, which expired in December 2017 were available for use in the glucometer case in the Emergency Room nurses' station. The laboratory manager confirmed the finding during the on-site survey on 4/24/18 at approximately 3:30 PM.

2. Total Fix stool transport media, LOT #5514-00, which expired in February 2018 was available for use in the hospital laboratory. The laboratory manager confirmed the finding during the on-site survey on 4/24/18 at approximately 3:00 PM.

3. Review of the temperature records from February through April 2018 for the incubator in the laboratory draw station revealed four records above the acceptable range of 33-37 degrees Celsius with no corrective actions taken and documented. This incubator was used to store plated urine cultures before transport to the reference laboratory for testing. The laboratory manager confirmed the finding during the on-site survey on 4/24/18 at approximately 4:30 PM.

4. Review of the manufacturer's instructions and the Abbott Precision Xceed Pro glucose records revealed that an incorrect acceptable range had been entered into the system for the low control. The manufacturer's acceptable range was 30-60 and the laboratory entered 30-80. Although the test strip lot # 4E435H was not yet in use at the time of the survey, the laboratory did not have a system in place to detect this error before placing the new lot number in service. The laboratory manager confirmed the finding during the on-site survey on 4/24/18 at approximately 5:00 PM.