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Based on observation and staff interview, the facility failed to ensure that outdated drugs were not available for patient use on two (2) of two (2) days of survey.

Findings Include:

Observation on 06/30/2021 at 10:37 a.m. of Adult Crash Cart in the Emergency Department revealed two (2) vials of "Lasix 20 milligrams" expired 5/2021, five (5) Vials of "Verapamil 5mg/2ml" expired 2/2021, and one (1) multidose of "Nitroglycerine" tablets expired 8/2020.

Observation on 06/30/2021 at 11:30 a.m. of East Wing Crash Cart revealed five (5) vials of "Verapamil 5 milligrams" expired 2/2021.

Interview with ER RN #1 on 06/30/2021 at 10:42 a.m. revealed that Pharmacy is responsible for monitoring/maintaining the medications on the crash cart.

During Exit Conference on 06/30/2021 at 4:15 p.m. survey findings were discussed and no further documentation was submitted for review.

Based on observation and staff interview, the facility failed to ensure that equipment and supplies needed for life-saving procedures were monitored and maintained on two (2) of two(2) days of survey.

Findings Include:

Observation on 06/30/2021 at 10:28 a.m. of supply carts in the Emergency Department revealed two (2) Emergency Chricothyrotomy Kits expired date 2/2021, two (2) Endotrachial tubes (Size 7.0) were opened.

Observation on 06/30/2021 at 10:32 a.m. of the Pediatric Crash Cart revealed three (3) pediatric endotracheal tubes expired 8/2020, one (1) pediatric intravenous start kit expired 9/2019, two (2) pediatric oral airways expired 4/2020, one (1) Neonatal Endotracheal Tube grip expired 11/2019, and (2) pediatric Nasogastric tubes expired 4/2020.

Observation on 06/30/2021 at 10:37 a.m. of the Adult Crash Cart revealed two (2) infusion sets expired 4/2021, three (3) 10 milliliter syringes of normal saline expired 5/2021, six (6) 24 gauge needles expired 11/2020, one (1) regulator intravenous extension expired 4/2020, one (1) central line kit expired 4 2020, one (1) in and out specimen catheter expired 3/2021, one male catheter kit expired 8/2020, and one (1) carbon dioxide detector expired 3/2021.

Observation on 06/30/2021 at 10:45 a.m. of Accu Chek Glucose Monitoring System revealed that both high and low controls were expired as of 5/2021.

Interview with Emergency Room (ER) Registered Nurse (RN) #1 on 06/30/2021 at 10:42 a.m. confirmed that the ER nurses are responsible for monitoring expiration dates on all supplies.

Based on staff interview and policy review, the facility failed to have current policies and procedures with documented reviews and approval by the governing board bi-annally for five(5) of 15 policy and procedure manuals reviewed on two (2) of two (2) days of survey.

Findings Include:

Review of facility's "Behavioral Health Services Policy and Procedure" manual revealed no documented evidence of review or revision since 2013.

Review of facility's "Patient and Family Advocate Policy and Procedure" manual revealed no documented evidence of review or revision since 2007.

Review of facility's "Admissions Policy and Procedure" manual revealed no documented evidence of review or revision since 2017.

Review of facility's "Senior Care Unit Policy and Procedure" manual revealed no documented evidence of review or revision since 2012.

Review of facility's "Discharge Planning Case Management Policy and Procedure" manual revealed no documented evidence of review or revision since 2007.

During an interview on 06/30/2021 at 2:45 p.m., the Director of Nursing (DON) confirmed no documented evidence of review or revision of the above mentioned policy and procedure manuals and confirmed the facility has no policy for the review and revision of policies and procedures.