HospitalInspections.org

Based on observation and interview, the facility failed to ensure all drugs and biologicals on two anesthesia carts were kept in a secure area, and locked when appropriate. The facility census at the time of the survey was 329.

Findings include:

A tour of the third floor surgery was completed on 10/29/12. An anesthesia cart was found unlocked and contained a syringe of Lidocaine (a local anesthetic) .

A second anesthesia cart contained a bottle of Sevoflurane (general anesthetic) and a bottle of Isoflurane (general anesthetic) in a drawer that would not lock due to the locking mechanism had broken on the cart.

On 10/29/12, these findings were confirmed with Staff Y.

During an interivew on 10/29/12, Staff Z stated the drawer lock on the anesthesia cart was broken and needed repaired.

Based on observation and policy review, the facility failed to ensure expired medications were not available on the anesthesia cart for patient use. The facility census at the time of the survey was 329.

Findings include:

A tour of the third floor surgery was completed on 10/29/12. One anesthesia cart contained a syringe of Lidocaine(a local anesthetic) with an expiration date of 09/25/12.

On 10/29/12, these findings were confirmed with Staff Y.

The facility's policy Disposition of Out-Dated/Unusable Drugs was reviewed on 10/29/12. The policy stated all outdated or unusable drugs are to be held in the pharmacy department.

Based on observation and interview, the facility failed to ensure expired supplies were not available for patient use. The facility census at the time of the survey was 329.

Findings include:


A tour of the third floor surgery was completed on 10/29/12. The equipment storage room had 2 packages of Scotchcast One-Step splint with expired dates. The first was lot number 18230351 with an expiration date of 08/2010. The second was lot number 23003330 with an expiration date of 01/2011.

The manufacturer's instructions for use stated to refer to the expiration date which appears on the package for the product's shelf life.

During an interview on 10/29/12, Staff X stated the expired splints were still able to be used on patients.

One anesthesia cart had surgical gloves lot number TN101153980 with an expiration date of 06/2010 stored in the cart.

One anesthesia cart had two expired intravenous start kits, lot number 10HB1837 expired 05/2012 and lot numebr 11AB0864 expired 09/2012. The cart contained a syringe of Lidocaine with an expiration date of 09/25/12.

On 10/29/12, the findings were confirmed with Staff Y.

Based on observation and interview, the facility failed to identify and control infections of patients and personnel by having dust build-up on wall vents and torn equipment in the surgery rooms. This had the potential to affect approximately all surgical patients. The facility census at the time of the survey was 329.

Findings include:

A tour of the third floor surgical area was completed on 10/29/12. During tour of the surgical rooms seven and eight, the air vents on the walls were noted to have dust build-up. Staff B confirmed this finding during tour on 10/29/12.

During an interview on 10/29/12, Staff X stated the operating room vents are supposed to be cleaned daily during the terminal cleaning at the end of the day.

On 10/29/12, a chair was observed in operating room 11 that had a tear on it's horizontal surface.

Staff Y confirmed this finding on 10/29/12.