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Based on random observation, interview, and policy review, the provider failed to ensure medical supplies stored in the emergency room (ER), the ER crash cart, and the endoscopy room/ER scrub area were not being used beyond their expirations dates. Findings include:

1. Random observation on 9/6/11 from 3:30 p.m. through 4:30 p.m. of the ER, the ER crash cart, and the endoscopy room/ER scrub area revealed the following expired medical supplies:
*In the ER:
-Seven 24-gauge intravenous (IV) catheters had expired in March 2011.
-One 20-gauge IV catheter had expired in January 2011.
-Three 18-gauge IV catheters had expired in November 2010.
-One 24-gauge IV catheter had expired in May 2010.
-One 24-gauge IV catheter had expired in September 2008.
-One 24-gauge IV catheter had expired in November 2007.
-Five adaptic dressings had expired in August 2011.
-One steri-strip benzoin tincture ampule had expired in July 2010.
-Six alcohol swabsticks had expired in December 2010.
-Six povidone-iodine swabsticks had expired in July 2010.
*In the ER crash cart:
-Five 24-gauge IV catheters had expired in March 2011.
-Two 16-gauge IV catheters had expired in April 2011.
-Five 20-gauge IV catheters had expired in May 2011.
-Five 22-gauge IV catheters had expired in August 2011.
*In the endoscopy room/ER scrub area:
-One tracheotomy tube had expired in May 2011.

Interview on 9/6/11 at 4:50 p.m. with the director of nursing (DON) confirmed the above expired medical supplies. She stated the central supply manager was responsible for checking for expired medications and supplies in those areas.

Interview on 9/8/11 at 11:15 a.m. with the DON revealed the nursing staff was responsible for checking the ER crash cart monthly for expired medications. She confirmed the nursing staff had not been checking for other expired supplies in that crash cart.

Review of the central supply policy and procedure manual reviewed July 20, 2011 revealed the responsibilities of the central supply assistant were:
*To have kept up with the unit demands for sterile supplies and equipment.
*The care and use of the supplies and equipment used in the performance of duties.

Review of the ER crash cart protocol from the endoscopy policy and procedure manual reviewed July 20, 2011 revealed:
*All crash carts should have been checked monthly by the nurses of the department.
*Monthly checks would have included the replacement of outdated supplies.
*Those monthly checks would have been recorded on the Pharmacy checklist.

Based on observation, policy review, and interview, the provider failed to ensure:
*Three of four observed opened multiple-dose vials observed in the medication room were not used after their assigned beyond use dates had been reached.
*Four of four medications in opened multiple-dose vials observed in the endoscopy room/emergency room (ER) scrub area and the ER were marked with dates when opened.
*One of two multiple-dose vials of lidocaine solution observed in the ER was not beyond the manufacturer's assigned expiration date.
Findings include:

1. Observation on 9/7/11 at 3:30 p.m. revealed four opened multiple-dose vials of insulin were stored at room temperature in the medication room. Three of the vials were opened for more than 28 days as follows:
*Novolin N, marked with an opening date of 7/26/11.
*HumaLog, marked with an opening date of 7/6/11.
*Levemir, marked with an opening date of 7/9/11.

Review of the provider's pharmacy policy and procedure reviewed on 6/7/11 revealed:
*All multiple-dose vials were to be dated when opened.
*All vials were to be removed from service after 28 days or according to the manufacturers' directions.

Review of the USP General Chapter <797> Pharmaceutical Compounding - Sterile Preparations, effective 6/1/08, revealed the beyond-use date for an opened or entered (e.g., needle-punctured) multiple-dose container with antimicrobial preservatives was 28 days, unless otherwise specified by the manufacturer.

Interview on 9/7/11 at 9:00 a.m. with the director of nursing revealed the provider's procedure was for all multiple-dose vials of medication to be removed from use 28 days after opening.

Interview on 9/7/11 at 3:30 p.m. with registered nurse B revealed she:
*Knew the multiple-dose vials of insulin were to be marked with a date when opened.
*Was not aware how long the marked vials could have remained in use.




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2. Random observation on 9/6/11 from 3:30 p.m. through 4:30 p.m. of the endoscopy room/ER scrub area and the ER revealed:
*The storage cupboard in the endoscopy room/ER scrub area had two intravenous (IV) start kits. Each IV start kit contained an open and undated 30 milliliter (ml) vial of normal saline.
*The ER had two opened and undated vials of lidocaine anesthetic. One of those two vials was 20 ml of one percent lidocaine and the other was 20 ml of two percent lidocaine. The two percent lidocaine vial also had an expiration date of May 2011.

Interview on 9/6/11 at 4:50 p.m. with the director of nursing confirmed the vials of normal saline and lidocaine anesthetic had been opened and not dated upon opening. She stated those vials of saline should have been dated when opened, and the lidocaine should have been single-use only. She also confirmed the two percent lidocaine vial had expired in May 2011. She stated the central supply manager was responsible for checking for expired medications and supplies in those areas.

Review of the central supply policy and procedure manual reviewed July 20, 2011 revealed the responsibilities of the central supply assistant were:
*To have kept up with the unit demands for sterile supplies and equipment.
*The care and use of the supplies and equipment used in the performance of duties.

Based on observation, record review, interview, and policy review, the provider failed to ensure:
*Antiseptic hand gels and hand sanitizers in the conference room, endoscopy room, endoscopy/emergency (ER) scrub room, and three of twelve patient rooms (105, 106, and 112) were not being used beyond their manufacturer's expiration dates.
*One of one employee (A) with a history of a positive reaction to the Mantoux (tuberculosis) (TB) skin test had received an annual risk assessment according to the provider's policy and procedure.
*Proper hand hygiene between glove use was performed during the observation for one of one patient's (3) wound care.
Findings include:

1. Random observation throughout the survey from 9/6/11 at 3:30 p.m. through 9/8/11 at 10:00 a.m. revealed the following hand gels and hand sanitizers had expired and were still in use:
*The conference room:
-One bottle of Isagel antiseptic hand gel on the sink with a manufacturer's printed expiration date of October 2006. That bottle also had a taped label on it that stated the bottle was refillable by the central supply department. It had been unknown if that bottle had ever been refilled.
*The endoscopy room:
-One Quik-Care hand sanitizer on the wall had an expiration date of June 2010.
-One bottle of Isagel antiseptic hand gel on a cart with biopsy jars, needles and other endoscopy supplies, had an expiration date of February 2008.
*The endoscopy/ER scrub room:
-One Quik-Care hand sanitizer on the wall had an expiration date of January 2011.
*Three of twelve patient rooms (105, 106, and 112) had expired Quik-Care hand sanitizers mounted on the walls. In room 105 the hand sanitizer expired in January 2011, room 106's expired in June 2010, and room 112's expired in December 2010.

Interview on 9/6/11 at 4:50 p.m. with the director of nursing (DON) confirmed the above hand sanitizers and hand gels in the endoscopy room and the endoscopy/ER scrub room had expired and had been in use in those areas. She stated the central supply manager was responsible for checking for expired supplies in those areas.

Interview on 9/8/11 at 10:45 a.m. with the central supply manager revealed:
*The manufacturer's printed expiration date on the Isagel antiseptic hand gel bottle from the conference room was October 2006.
*That pump bottle of Isagel could have been refilled from the larger containers of the hand gel in central supply but she had not been able to confirm that for sure.
*She agreed a new label should have been applied to that Isagel bottle if it had been refilled to establish a new expiration date.

Review of the central supply policy and procedure manual reviewed July 20, 2011 revealed the responsibilities of the central supply assistant were:
*To have kept up with the unit demands for sterile supplies and equipment.
*The care and use of the supplies and equipment used in the performance of duties.

2. Record review for one of one employee (A) with a history of a positive reaction to the TB skin test revealed employee A:
*Had a positive reaction to the TB skin test in 2006. A negative chest x-ray had been completed in 2006.
*Annual TB risk assessments had been completed in July 2007 and October 2008.
*No further documentation of annual TB risk assessments were found in employee A's record.

Interview on 9/8/11 at 9:45 a.m. confirmed the October 2008 TB risk assessment was the last annual assessment she could find for employee A. She agreed the TB risk assessments were to have been completed annually for positive TB skin test reactors.

Review of the TB Risk Assessment policy and procedure from the infection control manual reviewed July 20, 2011 revealed:
Each healthcare worker with a history of a positive reaction to the TB skin test should have been evaluated annually by a physician or a nurse.
*A record should have been maintained of the presence or absence of symptoms of Mycobacterium tuberculosis.



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3. Observation on 9/7/11 at 8:40 a.m. revealed registered nurse B replaced patient 3's dressing to her left lower leg. With gloves on she cleansed the wound with gauze saturated with sterile water. She removed the gloves and donned new gloves to apply the new dressing. She did not wash her hands after removing the first pair of gloves and donning the new gloves.

Interview on 9/8/11 at 9:15 a.m. with the DON revealed when gloves had been removed during a dressing change and new gloves had been donned the nurse should have washed her hands after removal of the gloves. She confirmed the hand hygiene policy had not been followed.

Review of the 7/20/11 hand hygiene policy revealed indications for hand hygiene included "after removal of gloves."