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Based on observations and staff interviews, the facility failed to ensure that all patient care supplies were maintained to ensure an acceptable level of safety and quality. Findings include:

1. During the observation of the obstetrics department on 3/28/11, beginning at 1:30 p.m., the surveyor noted the following outdated patient care items:
-2 Insyte Autoguard 16 gauge by 1.16 inch intravenous catheters with a manufacturer's expiration date of 10/2010.
-4 sterile single Povidone-Iodine swab sticks with the manufacturer's expiration date of 2/2011.
-9 sterile Povidone-Iodine prep pads with the manufacturer's expiration dates of 6/07 (4), 4/03 (1), 8/02 (1), 9/02 (1), 8/1998 (2).
-2 BBL Culture Swab culture tubes with the manufacturer's expiration date of 11/2010.
-4 25 gauge by 3 1/2 inch spinal needles with the manufacturer's expiration date of 9/2010.
-1 22 gauge by 1 inch Insyte Autoguard intravenous catheter with the manufacturer's expiration date of 6/2010.
-2 Becton-Dickson 4.0 milliliter purple top vacutainer tubes with the manufacturer's expiration dates of 1/2011 (1) and 2/2011 (1).
-2 Grier BioOne 5 milliliter green/yellow top Vacuette blood collection tubes with the manufacturer's expiration dates of 10/2010 (1) and 7/2009 (1).
-4 sterile Povidone-Iodine prep pads with the manufacturer's expiration dates of 3/07 (2) and 1/1998 (2).
-1 25 gauge by 3 1/2 inch spinal needle with the manufacturer's expiration date of 1/2009.

During an interview with the medical/surgical/ obstetrics nurse manager on 3/28/11 at approximately 2:30 p.m., the manager stated that the staff checked supplies for expiration dates monthly, but those items had been missed.

2. During the observation of the operating room areas on 3/28/11 beginning at approximately 3:20 p.m., the surveyor noted the following outdated patient care items:
-2 red top 7 milliliter Vacutainer blood collection tubes with the manufacturer's expiration date of 9/2010.
-1 sterile 1 inch by 36 inch foil package of Vaseline gauze with the manufacturer's expiration date of 1/2007.
-1 sterile 3 inch by 18 inch foil package of Vaseline gauze with the manufacturer's expiration date of 5/2007.

During an interview with staff member C on 3/28/11 at approximately 3:50 p.m., staff member C verified the patient care supplies identified were outdated.

3. During the observation of the intensive care unit on 3/29/11, beginning at 7:15 a.m., the surveyor noted the following outdated patient care items:
-1 Insyte Autoguard 16 gauge by 1.16 inch intravenous catheter with the manufacturer's expiration date of 10/10.
-1 Argon Dual pressure monitoring kit with the manufacturer's expiration date of 2/2011.
-1 Portex Adult lumbar puncture kit with the manufacturer's expiration date of 1/2011.

During an interview with staff member B, the director of nursing, on 3/29/11 at approximately 7:50 a.m., staff member B verified the expiration dates of the supplies.

4. During the observation of the emergency department on 3/29/11, beginning at 8:45 a.m., the surveyor noted the following outdated patient care items:
-4 Povidone-Iodine single swab sticks with the manufacturer's expiration dates of 3/2010 (1) and 11/2010 (3).
-1 Kendall Curity sterile plain packing strip, 2 inch by 5 yards, with the manufacturer's expiration date of 11/2010.
-1 open 20-milliliter bottle of Seracult developer with the manufacturer's expiration date of 12/2009.

During an interview with the staff nurse on duty in the emergency department on 3/29/11 at approximately 9:30 a.m., the nurse stated that staff check medications and supplies for expiration dates monthly, but those items had been missed.

5. During the observation of the physical therapy area on 3/31/11, beginning at 9:15 a.m., the surveyor noted the following outdated patient care items:
-15 Tegaderm 6 by 7 centimeter sterile transparent dressings with the manufacturer's expiration date of 11/2007.
-8 Tegaderm 10 by 12 centimeter sterile transparent dressings with the manufacturer's expiration dates of 9/2007 (4) and 5/2008 (4).
-7 Tegaderm 10 by 25 centimeter sterile transparent dressings with the manufacturer's expiration dates of 3/2009 (1), 7/2009 (2), and 3/2010 (4).
-2 Kendall Curasorb Calcium Alginate sterile dressings with the manufacturer's expiration date of 2/2008.
-55 Novaplus Povidone-Iodine prep pads with the manufacturer's expiration date of 4/2008.
-1 Kendall Curity sterile plain packing strip, 1/4 inch by 5 yards, with the manufacturer's expiration date of 10/2010.
-1 8-ounce bottle of Restore Wound Cleansing Spray (partially used) with the manufacturer's expiration date of 10/2008.
-1 4-ounce bottle of Gel San Antiseptic handwash with the manufacturer's expiration date of 2/2004.

During an interview on 3/31/11, beginning at 10:15 a.m. with staff member M, the staff member stated that all care supplies came from the hospital storeroom. The staff in the physical therapy department did not check the dressing supplies for expiration dates after they were received.

Based on observations and staff interviews, the facility failed to ensure that outdated or otherwise unusable drugs were not available for patient use. Findings include:

1. During the observation of the obstetrics department on 3/28/11, beginning at 1:30 p.m., the surveyor noted the following outdated or medications:
-4 foil packets of double antibiotic ointment with the manufacturer's expiration date of 8/2009.
-2 single dose 50 milliliter vials of 0.9% normal saline with the manufacturer's expiration date of 1 March 2011.

During an interview with staff member H on 3/28/11 at approximately 2:00 p.m., staff member H verified the expired medications noted by the surveyor.

2. During the observation of the intensive care area on 3/29/11 beginning at 7:15 a.m., the surveyor noted the following outdated medications:
-2 open multidose vials of Humulin R insulin. The bottles were not marked with the date that they were opened.* **

During interviews with staff member B and the staff nurse on duty in the intensive care area on 3/29/11 at 7:50 a.m., both staff members verified that there was no date or label on the bottles to document when they had been opened.

3. During the observation of the emergency department on 3/29/11 beginning at 8:30 a.m., the surveyor noted the following outdated medications:
-1 open partially used 120-milliliter bottle of gastrografin solution, with approximately 20 milliliters remaining in the bottle. The bottle was not labeled with the date when it was opened. ***
-1 10-milliliter single dose container of Milk of Magnesia solution with the manufacturer's expiration date of 1/2011.

During an interview with the staff nurse on duty in the emergency department on 3/29/11 at approximately 9:00 a.m., the nurse stated that emergency room staff were responsible for checking expiration dates for medications and supplies, but had missed those items.




* According to Aventis Pharmaceuticals "Opened vials, whether or not refrigerated, must be used within 28 days. They must be discarded if not used within 28 days. If refrigeration is not possible, the open vial in use can be kept unrefrigerated for up to 28 days away from direct heat and light, as long as the temperature is not greater than 86 degrees F (30 degrees Celsius)." *

In accordance with recommendations by the International Committee for Harmonization (ICH) and the Committee for Proprietary Medicinal Products (CPMP), Eli Lilly and Company suggests disposal of an in use insulin vial after 28 days. The ICH/CPMP mandates this time limit providing the following rationale: "the storage time following initial use or reconstitution/dilution should be as short as possible, as risk of microbial contamination can never be fully eliminated." **

*Aventis Pharmaceuticals, July 22, 2004; 300 Somerset Corporate Boulevard, PO Box 6977; Bridgewater, New Jersey 08807

**Eli Lilly and Co. June 7, 2001; Eli Lilly and Company, Lilly Corporate Center,

***
The bottle should be securely closed after each withdrawal and the contents discarded within 72 hours of first opening the bottle.

http://home.intekom.com/pharm/schering/gastgraf.html

Based on observation and staff interviews, the facility failed to have air gaps in place to prevent sewage backup in three of three identified kitchen drains. Findings include:

On 3/29/11 at 8:30 a.m., the surveyor toured the kitchen with the dietary manager, staff member N. Staff member N said that the 3-compartment sink was used for thawing meat. She also said that the adjacent sink and counter area were used for daily salad preparation. The surveyor noted that there were no air gaps for the three compartment sink, salad preparation sink, or for the dish machine.

On 3/29/11 at 8:55 a.m., the facility engineer, staff member E, confirmed that there were no air gaps.

Based on document review and staff interview, the facility failed to maintain a list of all services furnished under arrangements or agreements. The list describes the nature and scope of the services provided. Findings include:

During the initial interview with the facility management team on 3/28/11 beginning at 11:10 a.m., the surveyor reviewed the information request provided to the facility. The facility administrator read the request for a current list of contracts, with scope and nature of the contract. The administrator stated that he did not have a current list of the contracts, but could create one for the survey team.

At the end of survey exit meeting on 3/31/11 at 11:15 a.m., the survey team had not received a complete list of contracts for the facility. A partial list had been provided by the facility engineer that included shredding, recycling, snow plowing, floor mats, laundry, medical waste, diesel fuel, and freight elevator maintenance. The list provided did not address services that included food services, radiological services, or other direct patient care services.

Based on document review and staff interview, the facility failed to maintain a current roster listing each practitioner's specific surgical privileges available in the surgical suite and area/location where the scheduling of surgical procedures was done. Findings include:

During the review of the operating rooms and surgery area on 3/28/11 beginning at approximately 3:00 p.m., the surveyor asked to see the current surgical privileges book for the operating room. The operating room manager, staff member C, went to her office to retrieve the book. The binder brought to the surveyor included the roster of the medical staff of the facility and was labeled "expires 12/31/2009". The binder did not include the current surgical privileges granted to each individual surgeon. When asked about the date and current surgical privileges for providers, staff member C acknowledged that the manual was not current.