HospitalInspections.org

19647


Based on observation and interview, the facility failed to ensure that medications and patient care supplies, commonly used in life-saving procedures were monitored for expiration dates and were readily available in the event of an emergency resulting in the potential of using outdated supplies with potential for ineffective treatment results for patients requiring emergency interventions. In addition, the facility failed to ensure that medications and patient care supplies were kept secured so as to ensure they would be readily available for patient procedures resulting in the potential of not having the needed medications and patient harm. Findings include:

On 8/4/15 at 1650 during a tour of the obstetrical unit (OB) a review of the emergency cart revealed three medications, available for use that were beyond the manufacturers expiration date: (2) syringes labeled Phenylephrine 100 mcg (micrograms) per ml (milliliters) IV (intravenous) with a manufacturers expiration date of 7/16/15 and (1) syringe labeled ephedrine 10 mg/ml with a manufacturers expiration date of 7/19/15. On 8/4/15 at 1700 an interview with staff B regarding the discovery revealed when asked how often the emergency carts are checked, she said, "The pharmacy checks them monthly, but obviously, they missed these, I will have them check into this."

On 8/4/15 at 1655 during a tour of the obstetrical unit (OB) a review of the emergency cart revealed three patient care supplies, available for use that were beyond the manufacturers expiration date: a sterile package labeled "BD Anesthesia Spinal Tray" with a manufacturers expiration date of 6/2015 and (2) ET (endotracheal tube), used for emergency intubation labeled "King LLT D215" with manufacturers expiration date of 6/2015, and 7/2015. On 8/4/15 at 1700 an interview with staff B regarding the discovery revealed when asked how often the emergency carts are checked for outdated supplies, she said, "The nurses check them monthly, but obviously, they missed these."

On 08/04/2015 at 1430 during tour and observation of the OR Phase I recovery with the maintenance supervisor (staff D) observed that the drawers of the Anesthesia nerve block cart were left unlocked. This was also confirmed by the OR manager (staff I).

Based on observation and interview the facility failed to maintain room cleanliness resulting in the potential for soiled and damaged product as well as acquisition of a hospital acquired infection for all patients. Findings include:

On 08/04/2015 at 1020 during tour and observation of the laboratory blood draw area with the maintenance supervisor (staff D) there were vacutainers stored on the countertop within 3 feet of the sink without benefit of a splash guard or other mechanism to prevent water during staff handwashing to splash and contaminate the clean supplies.

On 08/04/2015 at 1030 during tour and observation of the laboratory storage area with the maintenance supervisor (staff D) observed an accumulation of dust on the flat tops of equipment.

On 08/04/2015 at 1038 during tour and observation of the laboratory blood bank area with the maintenance supervisor (staff D) observed an accumulation of dust on top of the blood bank refrigerator.

On 08/04/2015 at 1150 during tour and observation of the emergency department with the maintenance supervisor (staff D) observed an accumulation of dust on top of the Olympic blanket warmer.

On 08/04/2015 at 1520 during tour and observation of the Pharmacy with the maintenance supervisor (staff D) observed an accumulation of dust on the top shelves where pharmacy product was kept.

Based upon on-site observation and document review on 8/6/2015 by Life Safety Code (LSC) surveyors, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the K-tags specified below on the CMS-2567 dated 8/6/15 for Life Safety Code.
K-0025
K-0029
K-0048

Based on document review and interview the facility failed to document dental evaluations for three (#7, #8, #11) of five swing bed patients evaluated in the sample, resulting in the potential for unidentified and unmet dental needs for patients in swing beds. Findings include:

On 8/5/15 at 1300 during record review for patient #7, revealed in the history and physical (H & P) an assessment of the EENT (eyes ears nose and throat) revealed, "Mouth throat clear...does wear dentures." On 8/5/15 at 1305 an interview with staff B when asked if a dentist is available for evaluating patients in swing beds she replied, "we don't have a dentist come in for swing bed patients."

On 8/5/15 at 1315 during record review for patient #8, revealed in the history and physical (H & P) an assessment of the EENT (eyes ears nose and throat) revealed "unremarkable......mucous membranes moist." On 8/5/15 at 1400 during an interview with patient #8 revealed the patient was missing teeth on the top and on the bottom gums. When asked if she has any problems with chewing, she said, "Oh I used to have a partial, but I lost it one of the times I was throwing up...I am having trouble chewing food..." On 8/5/15 at 1700 during an interview with staff B, when asked if patient # 8's dental issues were addressed during her stay she said, "It doesn't look like it."

On 8/6/15 at 1115 during record review for patient #11 revealed no dental or EENT assessment documented for the patient. This was confirmed at time of discovery on 8/6/15 at 1115 by staff X.