HospitalInspections.org

Based on Policy and Procedure review, direct observation during tours, and staff interviews the hospital failed to ensure an acceptable level of safety and quality by failing to discard outdated products in 3 of 5 units toured.
The findings included:
1. Policy and Procedure review of Policy Reference # 275, Version 8, "Multi-dose Containers Expiration Date after Their Initial Use" revealed "...At the time of initial entry into a sterile multi-dose container, the newly assigned date of expiration of the container should be recorded on the side of the container or with a provided label. The expiration date will be calculated by adding 28 days to the date of the initial entry, but this date may not exceed the manufacturer's labeled expiration date....Medication should not be used after the expiration date. ..."
Observation during tour of Unit B, on 05/20/2015 at 1015, revealed a medication refrigerator containing one 10 mililiter vial of Novolin Insulin dated as opened on 10/26/2014. Review did not reveal a newly assigned expiration date.
Interview with Director # 1 on 05/20/2015 at 1030 revealed the expiration date should have been recorded on the vial when it was opened, and the vial should have been discarded and unavailable for patient care use 28 days after it was opened.
2. Observation during tour of Unit C, on 05/20/2015 at 1115, revealed a medication refrigerator containing two 100 milligram vials of Fosphenytoin Sodium (treats epilepsy, seizures) with expiration dates of 03/2015.
Interview with Director # 2 confirmed the expired medication should have been discarded and unavailable for patient care use.
3. Policy and procedure review of Policy "Supply Integrity and Expiration Dates", Reference # 2950 Version # 1, computer dated 06/17/2014, revealed "...Disposable items will be inspected prior to use for the expiration date and will be considered outdated if the expiration date shown on the package (if any) has exceeded. ..."
Observation during tour of Unit A on 05/19/2015 revealed a supply room containing eight boxes, each with four 2-ounce bottles (32 total bottles) of Similac Advance Complete Nutrition Formula, with a "use by" date of 05/01/2015. Further review revealed one box of six Enfamil bottles, also with a use by date of 05/01/2015.
Interview on 05/19/2015 with NM # 1 confirmed the outdated formula should have been discarded and unavailable for patient care use.

Based on Infection Control job description, policy and procedure review, medical record review, and staff interviews the infection control officer failed to ensure compliance with the hosptial's Infection Control policy by failing to ensure a patient with a positive communicable disease culture was placed in contact precautions for 1 of 4 sampled patients identified with positive cultures. (#3)
The findings included:
Review of the Position Description for the Director of Infection Prevention, last date reviewed 11/01/2011, revealed "...EMPLOYMENT RESPONSIBILITIES....Monitors existing and potential infections through surveillance. Assumes the lead role in developing/implementing processes for surveillance of and reduction of infection risks related to MDRO (multi-drug resistant organisms)... ."
Review of Hospital Policy "Screening/Management of Patients with Methicillin Resistant Staphylococcus Aureus (MRSA), Referent # 527 Version # 9, no printed date, revealed "...Routine screening will facilitate early identification of patients colonized with MRSA....Patients that are identified as high-risk for MRSA colonization will be tested for MRSA....If the test is positive, the patient will be placed on Contact Precautions while in the hospital...."
Closed medical record review of the patient #3 revealed an 85 year old male admitted on 12/09/2014 for acute/chronic anemia (low red blood cell count), chronic kidney failure (condition of the kidneys decreasing in function), intermittent episodes of chest pain, and dyspnea (shortness of breath). Patient was discharged on 12/14/2014. Medical record review of Patient (Pt) #3 revealed patient was screened for MRSA on 12/09/2014 at 2320. Review of laboratory results revealed a positive result was obtained from the laboratory on 12/10/2014 at 0310. Record review failed to reveal the patient was placed on contact precautions.
Interview with RN #1 on 05/20/2015 at 1110 revealed positive MRSA lab results were obtained from the lab at 0310 on 12/10/2014. Further interview revealed nurse's documentation did not include new positive MRSA results. Further interview revealed comunication to oncoming shift did not include positive MRSA results. Further interview revealed pt #3 was never placed on contact isolation during hospital stay.
Interview with Infection Preventionist (IP) # 1 on 05/20/2015 at 1325 revealed she receives a computer report daily which is pulled from nursing documentation when they document a patient being placed on isolation. Because of the computer system, interview revealed, IP # 1 does not receive a direct report of MRSA laboratory results. Once a month, IP # 1 stated, she could manually put a date range into the computer and pull each individual MRSA lab result and "...I can then reference that against the daily list and can look for trends... ."
Interview with Infection Preventionist (IP) # 1 on 05/21/2015 at 1015 revealed Pt # 3 was not on the IP (Infection Prevention) Log for MRSA because current surveillance pulls from nursing documentation and the patient was not documented on contact precautions. Interview revealed a monthly summary was pulled, but did not pick up Pt # 3 because she pulled a random sample, not the entire month. Interview confirmed IP # 1 could not be sure that other patients needing isolation had not been missed. Continued interview confirmed there was "...a gap in the system right now...", but that a solution was coming.