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34449


Based on observations, interviews, and document review, the facility failed to ensure disposable and/or sterile supply inventory was monitored to ensure items were not retained past the expiration date to prevent their being used in patient care.
The failure created the potential for supplies and equipment to lose both sterility and effectiveness, leading to avoidable infection or the inability to emergently treat patients timely and effectively.
FACILITY POLICY
According to facility policy, disposable sterile supplies should be routinely checked for damaged packaging and/or expiration dates.
FINDINGS
1. The facility did not identify and remove expired disposable/sterile supplies from patient care areas. The areas included the laboratory, obstetrical unit, operating room code cart, and the operating room anesthesia cart.
a) During a tour of the laboratory with the Director of Nursing (DON) and Laboratory Director on 6/24/14 at 11:38 a.m., a central port access needle with a manufacturer's expiration date of 08/2013 was found in a drawer used to store patient supplies. The Laboratory Director stated s/he did not have a specific process for routinely checking for expired supplies.
b) A tour of the facility's Labor and Delivery (LDRP) room #2 was conducted with the DON on 6/24/14 at 12:19 p.m. The following expired supplies were found: 2 neonatal resuscitation bags with manufacturer's expiration date of 01/2005; 1 neonatal resuscitation bag with manufacturer's expiration date of 08/2005; 4 umbilical cord clamps, each with one of the following manufacturer's expiration dates: 06/2005, 07/2012, 10/2006, and 02/2005; 1 skin surface temperature sensor with manufacturer's expiration date of 07/2002; and 6 heel lancet devices with manufacturer's expiration date of 5/2011. The DON stated, "we never use this room, it is just a backup." The DON stated it was the responsibility of nursing staff to stock supplies in the LDRP rooms and to dispose of expired supplies.
c) A tour of LDRP #1 on 6/24/14 at 12:40 p.m., revealed 1, 10 cc normal saline prefilled syringe with manufacturer's expiration date of 6/2010, in a drawer used to store patient supplies at the bedside.

d) On 06/25/14 at 11:15 a.m., a tour of the facility operating room was conducted with the DON and the chief Sterile Supply Technician. The following expired items, per the manufacturer's expiration dates, were found in the operating room code cart:

1 adult resuscitator expired on 7/2012;
1 end-tidal carbon dioxide detector expired on 06/2009;
1 package of pediatric electrodes expired on 11/2008;
1 package of 30 electrodes expired on 5/2008;
2 packs of defibrillator pads expired on 7/2008;
4 arterial blood sampling kits expired on 1/2010;
3 intravenous pump tubing sets, expired on 03/2009, 1/2009, and 1/2010;
1 nitroglycerin intravenous spike expired on 9/2010;
9 Autoguard devices, expired on 1/2008, 12/2008, and 1/2010;
4, 14 gauge needles expired on 3/2009;
5, 18 gauge needles expired on 5/2010;
2, 18 gauge needles expired on 12/2007;
2, 24 gauge needles expired on 3/2009;
2 spinal needles expired on 5/2009;
2 packages of povidone iodine swabs expired on 1/2008;
10 Tegaderm dressings, expired on 1/2005 and 10/2006;
4 cotton tipped applicators expired on 11/2007;
6 tongue depressors expired on 12/2010.

e) During a tour of the operating room on 6/25/14 at 11:15 a.m., the following expired items, per manufacturer's expiration dates, were found in the anesthesia cart: 1 tube of sterile surgical lubricant, expired on 03/2014; 2 endotracheal tubes originally packaged as sterile, both open with portions of the tubes exposed outside of the packaging, and 1 of these with a syringe still attached to the inflatable cuff port.

f) The DON was interviewed on 6/26/14 at 4:26 p.m. The Director stated s/he was ultimately responsible for ensuring supplies were not expired, and s/he identified two staff members and two registered nurses who shared responsibility for monitoring of expired supplies. The Director could not state when the operating room code cart and anesthesia cart were last checked for content and for expired supplies and stated that expired supplies were not being monitored through facility quality improvement activities. The DON could not locate the log that nursing staff used to keep track of supplies and to indicate the supplies that would soon expire. The DON stated s/he could not remember the last time s/he saw the log, which was kept on top of the carts. The DON could not locate the log in other areas of the operating room.

Based on observations, interviews, and document review, the facility failed to ensure that point of care blood glucose testing equipment, used in the emergency department and labor and delivery, underwent a daily test for quality control in compliance with facility policy. The facility failed to test emergency medical equipment to ensure the equipment would be functional when needed for patient use.

The failure created the potential for inaccurate measurement of and/or delays in obtaining accurate patient blood glucose results, and/or availability of emergency equipment for immediate use, resulting in inappropriate treatment or delays in diagnosis and treatment.

FACILITY POLICY

According to facility policy, point of care blood glucose testing equipment should undergo quality control testing each day of use/and or every 24 hours, or before performing tests on patients, to ensure an acceptable level of safety and quality for patient blood glucose results. According to the policy, results of testing must be recorded.

FINDINGS

1. The facility point of care blood glucose testing devices (glucometers) for use in the emergency department were not calibrated or recorded on the facility log daily. A glucometer located on the inpatient unit lacked quality control solutions and a quality control log.

a) A tour of the facility emergency department was conducted on 6/24/14 at 11:10 a.m. with the Chief Executive Officer (CEO) and Director of Nursing (DON). The point of care blood glucose testing device (glucometer) log revealed that quality control checks were not recorded on the 1st through the 9th, the 12th through the 15th, the 21st, and the 24th of June, 2014.

b) Observation of the facility's medical/surgical and labor and delivery areas was conducted on 6/24/14 at 12:00 p.m. with the DON. A glucometer with no control solution and no quality control log was found in labor and delivery (LDRP) room #1. When asked, the DON stated, "This shouldn't be back here, we usually pull (the glucometer) from the floor."

c) The Laboratory Director and DON were interviewed on 6/24/14 at 11:20 a.m. S/he stated it is common practice for staff to use the glucometers from the inpatient unit and the LDRP rooms, in addition to the glucometer stored in the emergency department. The Laboratory Director and the DON stated from review of the existing glucose monitoring logs, the facility's glucose testing policy was not being adhered to by staff.

2. The emergency suction machine and defibrillator, located on top of the emergency room code cart, were not checked to ensure they would function if needed for patient use.

a) On 06/25/14 at 11:15 a.m., observation of the operating room was conducted with the DON. An emergency suction machine and emergency defibrillator were seen on top of the operating room code cart. The DON stated the emergency equipment was tested by nursing staff on a regular basis, but s/he could not locate the log with documentation of testing dates. The DON stated s/he did not know the last time the equipment was tested to ensure it was functional as s/he could not locate the equipment testing log.

b) On 06/26/14 at 4:26 p.m., an interview was conducted with the DON who stated nursing staff could not produce the expired supply/emergency equipment testing log for the emergency room code cart. The DON stated without the documented log, s/he could not be certain the equipment was being tested on a regular basis as s/he could not expect nursing staff to remember when the equipment was being tested. The DON stated s/he was unaware the testing was not being documented, that the log was missing from the top of the cart, and that it was his/her responsibility to ensure the testing was being conducted and documented. The DON stated the log also contained information about supplies/expired supplies found in the emergency room code cart.