HospitalInspections.org

Based on policy review, observation and staff interview it was determined the facility failed to ensure drugs and biologicals are managed in a safe and appropriate manner. This failure places all patients and staff at risk for injury or death.

Findings include:

1. Facility policy, "Medication Storage #3300," last revised 07/2019 states: "Medications shall be stored according to the provisions of the USP/NF and/or the specifications of the manufacturer so that their integrity, stability, and effectiveness are maintained."

2. Facility policy, "Unit Inspection #7005," last reviewed 07/2020 states: "Drugs shall not be kept in stock after the expiration date on the label and no contaminated or deteriorated drugs shall be available for use."

3. Observation of the Frozen Section Cart on 05/10/2021 revealed an accessible expired bottle of Regent solution. The container's label showed an expiration date of 10/20/2020.

4. Observation of the Frozen Section Cart on 05/10/2021 revealed an accessible expired bottle of Regent solution. The container's label showed an expiration date of 10/20/2020.

5. Observation of the Frozen Section Cart on 05/10/2021 revealed an accessible expired bottle of Cytology spray. The container's label showed an expiration date of 12/20/2019.

6. Observation of the Frozen Section Cart on 05/10/2021 revealed an accessible expired bottle of Tissue Freeze. The container's label showed an expiration date of 01/2018.

7. Observation of the Frozen Section Cart on 05/10/2021 revealed an accessible expired bottle of Tissue Freeze. The container's label showed an expiration date of 01/2018.

8. Observation of the Frozen Section Cart on 05/10/2021 revealed an accessible expired bottle of Harris Hematoxylin. The container's label showed an expiration date of 08/2020.

9. Observation of the Frozen Section Cart on 05/10/2021 revealed an accessible expired bottle of Histoprep Xylene. The container's label showed as expiration date of 02/2021.

10. During an interview with the Corporate Compliance and Risk Management Director on 05/10/2021 at 1:00 p.m., she concurred it is her expectation and facility policy for all supplies and stock be frequently inspected regarding expiration dates.

Based on observation and staff interview it was determined the hospital failed to ensure nursing staff performed proper hand hygiene while performing patient care. This failure has the potential to transmit infections to a patient receiving care at the hospital.

Findings include:

1. A tour of the medical surgical floor was conducted on 5/11/21 at approximately 9:30 a.m. During the tour it was witnessed that Registered Nurse (RN) #1 came out of a patient's room with gloves on, walked down to the clean linen room, came back carrying clean linen, went back into the room at 9:32 a.m. wearing the same gloves and no hand hygiene performed. She walked back out of the room at 9:33 a.m. with the same gloves on and no hand hygiene performed, went back to the clean linen room, returned with the same gloves on, went back into the patient's room at 9:34 a.m. and no hand hygiene performed.

2. An interview was conducted with the Corporate Director of Compliance and Risk Management on 5/11/21 at approximately 9:35 a.m. She concurred that RN #1 did not follow the hospital's expectation for performing hand hygiene.