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Based on observation and interview, the facility failed to establish and implement a procedure for ensuring expired supplies in the surgical crash cart and supply storage were replaced prior to the expiration date. This deficient practice had the potential to affect any surgical patient requiring the use of these supplies. Findings include:

During an observation and interview on 7/18/23 at 8:04 a.m., three Echelon Flex 60mm (millimeter) staplers with an outdate of 6/30/23 were located on a shelf in the surgical supply room. Staff member L said the supplies were checked regularly and those items must have been missed.

During an observation and interview on 7/18/23 at 8:27 a.m., staff member L said the pharmacy was responsible for checking the crash carts for outdated medication and supplies.

The following items were found outdated in the surgical crash cart:

Sterile gloves: Size 6 1/2 with an outdate of 4/28/22, three pairs,
Size 7 with an outdate of 7/28/22, three pairs,
Size 8 with an outdate of 4/28/22, four pairs, and
Size 8 1/2 with and outdate of 4/28/22, five pairs.

Sterile gauze 2X2 with an outdate of 12/2/16, five packages.

Tegaderm dressings: 4X4 size with an outdate of 12/2018, three each and
Large size with an outdate of 12/2016, two each.

During an interview on 7/18/23 at 9:38 a.m., staff member L said the pharmacy was responsible for the monitoring of outdated medication on the crash cart. Staff member L was not aware the department was responsible for maintaining supplies and checking for outdates.

During an interview on 7/18/23 at 1:50 p.m., staff member G said pharmacists monitored the medications in the crash carts monthly. He said nursing is responsible for managing the supplies in the crash carts.

Based on observation, interview, and record review, the facility failed to follow their established policies and procedures to ensure the periodic maintenance on a Hologic DXA scan (bone density machine) was completed on a yearly basis. This deficient practice had the potential to affect the validity of the Hologic DXA scan test results for patients. Finding include:

Review of the facility's policy and procedure titled, Quality Control of Medical Imaging Equipment, last revised 11/22, showed:

- "PURPOSE: To establish guidelines for testing all Medical Imaging equipment at regular intervals to assure proper function and safety related to patients and personnel.
- POLICY: All x-ray producing and non-radiation producing equipment in the Medical Imaging department will be serviced by the contracted service provider at least annually, if not more often as per the service contract specifications. ..."

During an observation on 7/18/23 at 10:46 a.m., a Hologic DXA scan machine was included in the radiology department inventory.

During an interview on 7/18/23 at 10:50 a.m., staff member F stated periodic maintenance on the radiology equipment was completed on a yearly basis. She stated the Hologic DXA was last serviced in 2020 but would contact the servicing company to acquire a copy of the latest maintenance documentation.

During an interview on 7/18/23 at 2:00 p.m., staff member F stated the Hologic DXA scan machine had not received periodic maintenance since 2020. She stated the machine was no longer supported by Hologic and she needed to call to have the service provided by a third-party company, which had not been completed.

Review of a facility produced spreadsheet of all the radiology department medical equipment, received 7/20/23 at 7:30 a.m., showed the Hologic Discovery W's last date of service was 3/6/20.