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Based on observation, record review and interview, the hospital failed to ensure crash cart ambu bags were not expired for one (Emergency Department Bay 2 crash cart) of three crash carts.

This failed practice has the likelihood to result in the compromised delivery of oxygen to patients in cardiac or respiratory arrest.

Review of a document titled "TISH MM Stocking of Distribution" read in part, "Expiration of Supplies: The supplies that have reached the expiration date on the package, or a date within 30 days of the expiration, will be removed from the department."

Finding

During a tour of the Emergency Department on 04/21/21 at approximately 1:10 PM, an adult ambu bag with an expiration date of 02/27/21 (53 days past expiration) was observed hanging on the Bay 2 crash cart.

On 04/21/21 at 1:13 PM, Staff B reviewed the ambu bag and stated the expired ambu bag could malfunction during a code.

Based on observation, record review and interview, the hospital failed to ensure patient care products were not stored on the floor for one (Medical Surgical supply room) of two supply rooms.

This failed practice has the likelihood to place patients at risk of receiving care with the use of products having compromised structural or sanitary integrity.

Review of a document titled "TISH MM Stocking of Distribution" read in part, "All clean and sterile supplies/equipment are stored in an environment free of...contamination...Products supplied to patient care and support departments should be stored in such a manner to protect them from damage. Will be stored on clean, dry, and dust free shelves...Will be stored at least 8 to 10 inches above the floor."

Finding

During a tour of the Medical Surgical supply room on 04/21/21 at approximately 12:15 PM, one package of blue pads, two packages of large adult briefs, 1 box of surgical hoods, 1 box of surgical caps, and one box of N95 masks with an open lid were observed stored on the floor.

On 04/21/21 at 12:17 PM, Staff B observed Medical Surgical supply room and stated the supplies on the floor were at risk of contamination and were a risk of infection to patients.

Based on observation, record review and interview, the hospital failed to ensure sanitizer solution test strips were not expired for one (AutoChlor) of three containers of test strips.

This failed practice has the likelihood to place patients, staff and visitors at risk of infection.

Review of a document titled "TISH FNS Maintaining a Sanitary Environment Policy" read in part, "The hospital contracts with Autochlor for cleaning chemicals to include...sanitizer solutions...The sanitizer cleaning bucket will be processed through the dishwasher before each use and filled with fresh sanitizer solution. Solution will be checked by use of test strips provided by the vendor."

Finding

During a tour of the Kitchen on 04/21/21 at approximately 1:40 PM, on the dishwasher was observed a container of AutoChlor test strips Lot #100118 with an expiration date of 01/2021 (3 months past expiration).

On 04/21/21 at approximately 1:45 PM, Staff D reviewed the container of test strips and stated the following:
1. The test strips in the container were last used on 04/21/21 just before lunch and should not have been.
2. The test strips were used to check if the sanitizer solution would be effective in cleaning the surfaces they wipe down.