HospitalInspections.org

Based on observation of 4 high/low glucometer control solutions during a tour of the facility the facility failed to ensure the glucometer control solutions were within the 90 day time frame since the vials were opened and/or the manufacturers identified expiration date. The findings include:

During a tour of the facility behavioral health unit (BHU) with the Director of Quality on 3/14/16 at 9:30 AM glucometer test strips and glucose control solutions were examined. Upon examination it was identified that 2 high and low glucometer controls (total of 4 vials) had a manufacturer expiration dated of January 2016 and March 2016. In addition the marked date on the vials indicating when the glucosec ontrols were opened was dated 10/22/14. The glucose control vials were immediately discarded and replaced.

The facility Blood Glucose Monitoring Equipment Quality Control Testing policy indicated quality control testing is performed to ensure the blood glucose equipment maintains proper monitoring control function. The policy further indicated the nurse will, when opening a new vial; write the discard date on the control solution label. Manufacturers recommendations indicated the controls should be discarded 90 days after the date the glucose controls were opened.

Based on a tour of the hospital, the facility failed to ensure that the psychiatric living dorms and wings/units were maintained in such a manner as to promote the safety and well-being of patients.

On 03/15/16 at 11:00 AM and various times throughout the day, while touring the Behavioral Health Unit with the Director of Facilities, the following was observed
a. The Behavioral Health Unit had numerous patient rooms and patient spaces were a patient would be unsupervised that lacked security / tamper resistant fasteners on door hinges, electrical recepticals, and light switches to protect the safety of psychiatric patients.
b. The facility bathrooms and sleeping rooms had sprinkler heads that were not designed to a psychiatric/ institutional standard
c. The facility lacked an audit tool for patient room window stops and on the day of survey patient rooms 152 & 154 had windows stops that were removed and the windows would open fully failing to provide a safe environment i.e a patient could elope from the facility.