HospitalInspections.org

Based on facility tour, review of facility documentation, and staff interviews (EMP), it was determined the facility failed to follow its own established policy of ensuring daily defibrillator checks were performed each shift within the pre-operative and post-operative areas.

Findings include:

Review of facility documentation, "Patient Rights", on March 28, 2022, revealed "...A patient has a right to considerate and respectful care, by competent personnel, provided in a safe environment, free from all forms of abuse, neglect, harassment and/or exploitation...A patient has the right to expect emergency procedures to be implemented without unnecessary delay....".

Review of facility policy, policy number 21.0, last updated January 2022, "Check of Emergency Equipment", on March 28, 2022, at approximately 1:10 PM revealed, "Procedure...B. Defibrillator 1. The defibrillator check shall be performed in accordance with the manufacturer's directions at the beginning of each shift. 2. Documentation of defibrillator check shall include the following: a. Date machine was checked. b. Name of the person doing the check. c. Time, date and name of person notified to service, repair or replace the equipment in the event of inadequate performance....".

1. Tour of facility on March 17, 2022, at approximately 2:30 PM revealed a crash cart clip board including a "shift inspection crash cart check sheet" with the last entries dated "3/16...shift inspection...1,2,3...". There was no entry for equipment shift checks for the defibrillator for March 17, 2022. Further review of defibrillator printer paper indicated printed date of last check "March 13, 22".

Interviews with EMP1 and EMP4, present during the onsite tour, confirmed the above findings.

Based on a review of facility documentation, observation and employee interviews (EMP), it was determined that the facility failed to ensure that outdated medications were discarded and were not available for patient use in the Pre-Operative and Post-operative areas.

Findings include:

Review on March 23, 2022, at 11:00 AM, of a facility policy, "Policy#IP MM2.2 ... Guidelines for Single and Multi-dose vials and syringes/expired drugs" dated January 18, 2022, revealed, "... vials that have reached their expiration date, as well as vials suspected of being contaminated ... or changed in any way, or if the vial has not been stored according to the manufacturer's recommendations, MUST be discarded. ..."

1. On March 17, 2022, at approximatley 2:20 PM, a tour of the Pre-Operative and Post-Operative areas revealed a vial of Ropivacaine 1%, with an expiration date of August 2021, a vial of Lidocaine with an expiration date of November 2021, and 21 vials of Sensorcaine all with expiration dates of March 2021.

EMP1, present at the time of the tour confirmed the expired medication.