HospitalInspections.org

Based on observations, interview, and review of facility policy and procedures, the hospital failed to ensure a calibrated thermometer was available to ensure temperatures in accordance with manufacturer's recommendations for storage of supplies and expired supplies in the patient care areas.

The findings are:

Observations on 06/07/23 at 9:45 AM of the triage area revealed (16) HCG pregnancy test cassettes expired 4/30/23. During an interview on 06/07/23 at 9:46 AM, Registered Nurse (RN) 5 verified the findings. Observations on 06/07/23 at 10:00 AM of the respiratory storage room in the emergency department (ED) revealed (1) Air life tracheostomy cleaning tray expired 08/20/22 and wall unit hand sanitizer expired 07/21. During an interview on 06/07/23 at 10:02 AM, Registered Nurse (RN) 5 verified the findings.

Observations on 06/07/23 at 10:21 AM of the Emergency Department trauma bag revealed (2) 22 gauge 1.00 inch (in) closed IV (intravenous) catheter system expired 01/31/22, (2) 20 gauge 1.00 in closed IV catheter system expired 12/31/21, (2) 18 gauge 1.00 in closed IV catheter system expired 10/31/21, (1) 24 gauge 1.00 in closed IV catheter system expired 09/30/21, (2) adult colorimeter CO 2 detectors expired 11/16/22 and (2) sterile IV start kits expired 11/24/21. During an interview on 06/07/23 at 10:25 AM, RN 5 verified the findings.

Observations on 06/07/23 at 10:31 AM of the ED supply/storage room revealed a thermometer on the wall with a sticker on it denoting re-calibration due on 05/23, (2) electrical panel boxes, and (1) electrical power box all with electrical cabling in the room with a metal rolling cart in front of the electrical box. The temperature reading on the thermometer was 78 degrees Fahrenheit (F). Further observation revealed climate-controlled supplies which showed "Store at controlled room temperature 68 degrees F (Fahrenheit) to 77 degrees F/20 degrees C (Celsius) to 25 degrees C". The climate-controlled supplies were (3) 8 fr (French) catheter drainage trays, (2) Arrow 8 fr 16 cm Pneumothorax kits, (2) Arrow vessel 20 ga (gauge) catheterization trays, (3) pressure injectable Arrowg +ard four lumen CVC trays, and (7) Baxter sterile water bottles for irrigation 1000 ml (milliliters).

During an interview on 06/07/23 from 11:30 AM to 12:02 PM, the Vice President of Support Services stated, "Storage of the ED would not be monitored. Rooms that are not monitored are set up on monthly checks and some units verify annually. That room is not checked regularly. Clean supply rooms are not checked monthly and if a problem arises, nursing is supposed to call to facilities if a problem. I ' m sure the supplies do have a certain temperature on them. We follow Ashrae guidelines and/or local authorities." During an interview on 06/07/23 from 12:21 PM to 12:40 PM, the Facilities Manager stated, "We go off of our policy to determine if a room needs to be monitored. The ED storage room is classified as a clean holding room. There is no requirement for temperature or humidity monitoring. Don ' t know why we have a thermometer in there. I think nursing asked for one, and it was put in. The electrical panels are checked periodically at least quarterly following Joint Commission guidelines".

During an interview on 06/07/23 from 12:21 PM to 12:40 PM, the Director of Facilities stated, "We do surveys quarterly as a best practice. We make sure those rooms (supply rooms) are secure. There should not be anything within 3 feet of the panels. Typically, in storage rooms, we don ' t have anything in those rooms (like electrical boxes). We have an infrared testing that is completed annually. Thermal scanning of the panel to ensure no electrical issues".


During an interview on 06/07/23 at 12:53 PM to 1:07 PM with Supply Manager stated, "My team oversees the ordering of supplies, make sure they get it, check outdates, and rotate supplies as needed. We stock the ED storage room. The ED doesn ' t have any climate-controlled rooms. We don ' t have control over the temperature of that room or monitor that room as it relates to temperature or pressure".

Observation of the ED supply/storage room at 1:19 PM revealed a temperature of 78.8 degrees F with a minimum temperature reading memory noted at 78.4 degrees F and a maximum temperature reading memory of 79.0 F on the thermometer display.

During an interview on 06/07/23 at 1:43 PM with the ED Manager stated, "Staff does not check the temperature of the room because it is not on our checklist".

Observation on 06/08/23 at 9:59 AM of the ED storage room revealed the non-calibrated thermometer on the wall with a reading of 76.3 degrees F. Further observation revealed the Facilities Manager used an infrared thermometer to check the temperature of the electrical box with a reading of 79.3 degrees F located in the storage room. During an interview at 10:05 AM with the Facilities Manager stated, "The thermostat for the ED storage room is located in the ED breakroom". Observation of the ED breakroom thermostat revealed a temperature of 67 degrees F.

Observation on 06/08/23 at 10:30 AM of the third floor clean supply revealed a thermometer on the wall with a reading of 72 degrees F with a re-calibration date due on 07/23. During an interview on 06/08/23 at 10:30 AM, the Medical Surgical Director stated, "I notify someone from facilities if I need a new thermometer".

Observations on 06/08/23 at 11:10 AM of the Plant Operations temperature monitoring system revealed a temperature for the ED breakroom denoted at 67.75 degrees F. During an interview on 06/08/23 at 11:15 AM, the Facilities Manager stated, "We regulate the temperature for that room, but we don ' t monitor it. We set the temp (temperature) and it can ' t be changed".

During an interview on 06/08/23 at 11:35 AM, the Director of Facilities stated, "We don ' t check those thermometers in the breakrooms. They are not monitored. We do not get alerts if the temperatures are out of range. We go by ASHRAE standards of 72-78 degrees F".

Facility policy, entitled, "Temperature, Humidity, Air Pressures, and Filtration Requirements revealed, "Clean workroom or clean holding ...Design Temperature N/R (not recorded)".