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Based on observation, interview, and record review, the hospital was found to be out of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital.

Findings include:

Please refer to Life Safety Code inspection tags: K-0011, K-0012, K-0018, K-0027, K-0029, K-0033, K-0043, K-0048, K-0050, K-0051, K-0052, K-0062, K-0067, and K-0147.

Based on observation, interview and document review, the hospital failed to ensure the integrity of sterile supplies stored in 2 of 3 airway carts and 1 of 3 central line carts in the emergency department (ED).

Findings include:

On 12/2/14, during the ED tour from 9:00 a.m. until 10:30 a.m. the supply carts and airway carts in ED rooms #14 and #16 were observed to have the following outdated sterile supplies:

ED room #14 airway cart:
-One endotracheal tube (ET) 6 millimeter (mm) (catheter inserted into the trachea to establish and maintain a patent airway) - label indicated the product sterility was outdated and the product was labeled "expired 9/2014".
-Three Yank suction catheters (a rigid hollow tube with a curved end used for oral suctioning) - labeled as "expired 7/2013", and another one was labeled "expired 12/2013".

ED room #16 airway cart:
-Two ET tubes 6 mm - one labeled "expired 10/2014", and the other "expired 6/2010".
-Three ET tubes 5.5 mm - one which expired 12/2010, one labeled "expired 11/2009", and the other "expired 10/2009".
-Three ET tubes 8.5 - each labeled "expired 12/2010".
-One specimen trap 40 cubic centimeters (cm) (plastic trap connected to a suction catheter used to collect sputum samples) - labeled "expired 1/2012".
-One Yank suction catheter - labeled "expired 1/2014".

ED room #16 central line supply cart:
-Two trocar catheters (a sharp pointed tube used to pierce the skin and puncture the wall of a body cavity) size 20 French (F) (system for the sizing of tubes used in ET intubation) - one labeled "expired 12/2012", the other "expired 3/2012".
-One trocar catheter size 36 F- labeled "expired 9/2013".
-One trocar catheter size 16 F - labeled "expired 12/2011".
-One trocar catheter size 32 F - labeled "expired 5/2013".

On 12/2/14, at 10:35 a.m. the ED patient care manager (PCM) verified the sterility outdates on the packages of the noted supplies, and confirmed they should be sterilized again. The PCM stated the ED did not have a process for checking the sterility outdates in the supply carts. She stated the emergency medical technicians (EMTs) restock the carts, however are "obviously not checking for expired supplies." The PCM confirmed the chances of using the airway and central line supplies in the ED rooms was high.

A policy related to monitoring for outdated "expired" sterile supplies was requested, but was not provided.

Based on interview and document review, the hospital failed to ensure that 4 of 4 direct care staff hired since the most recent Validation survey, received training related to the hospital's organ procurement program.

The findings include:

On 12/4/14, at 8:30 a.m. employee records were review for compliance with organ procurement education requirements. The following employees who had been hired since the previous Validation survey had not received training related to organ procurement:

Physical therapist (PT)-A's personnel record identified a hire date of 2/13/12. There was no evidence of the employee having received initial education in the area of organ procurement.

Registered Nurse (RN)-A's (who specialized in mental health) personnel record identified a hire date of 10/12/11. There was no evidence of the employee having received initial education in the area of organ procurement.

A mental health assistant (MHA)-C's personnel record identified a hire date of 10/17/11. There was no evidence of the employee having received initial education in the area of organ procurement.

MHA-D's personnel record identified a hire date of 4/5/10. There was no evidence of the employee having received initial education in the area of organ procurement.

In an interview on 12/4/14, at 10:25 a.m. with the Quality and Safety manager, she confirmed the only personnel who had been educated in the area of organ procurement/donation were nurses. The Quality and Safety manager further acknowledged the hospital did not have a policy which stipulated what other professional staff were to receive education related to the organ procurement program.