HospitalInspections.org

Based on review of Emergency Department (ED) medical records, review of outpatient medical records and staff interviews it was determined the facility failed to provide the patient or a patient representative of a notice of their rights on admission and failed to document provision of the rights for 16 of 16 ED medical records reviewed and for 3 of 3 outpatient records reviewed. This had the potential to affect all patients who presented to the ED for treatment and all patients who presented for outpatient procedures.

Findings include:

1. A review of 16 ED medical records revealed no documentation of Patient Rights being discussed or documented as being provided to the patients or their representatives.

During interview on 8/31/10 at 1:15 PM, Employee Identifier (EI) #10, ED registered nurse (RN), confirmed Patient Rights were not given to or explained to the ED patients.

During interview on 9/2/10 at 12:30 PM, EI #1, the Director of Nursing (DON), confirmed the Patient Rights were not given to or explained to the ED patients.


2. A review of 3 outpatient records revealed no documentation of Patient Rights being discussed or documented as being provided to the patient or their representative.

On 9/1/10 at 12:35 PM the surveyor asked EI #10, the Licensed Practical Nurse (LPN) who does the outpatient pre-admission paper work, if the Patient Rights were provided to the patients prior to having outpatient procedures. EI #10 stated that he/she did not give or discuss the Patient's Rights with the patient.

Based on observations and interviews with facility staff, it was determined the Hospital failed to post written instructions informing outpatients and emergency room patients of their right to file a complaint with the State agency. This had the potential to affect all patients admitted through the Emergency Department and the outpatient departments.

Findings include:

1. During a tour of the Emergency Department (ED) on 8/31/10 at 10:18 AM it was noted that the hospital did not have posted the toll free State hot line phone number for patients to call to voice grievances.

An interview with Employee Identifier (EI) #9, ED registered nurse (RN), on 8/31/10 at 1:05 PM confirmed the toll free State hot line phone number was not posted.

An interview with EI #1, the Director of Nursing (DON) on 9/2/10 at 12:30 PM confirmed the State hot line phone was not posted in the ED on 8/31/10.


2. During a tour of the Outpatient Department on 9/1/10 at 10:05 AM it was noted the hospital did not have posted the toll free State hot line number for patients to call to voice grievances.

An interview with EI #1 on 9/2/10 at 12:30 PM confirmed the State hot line phone number was not posted.

Based on hospital policy review, medical record review and interviews with the Employee Identifier (EI) # 1, the Director of Nurses (DON), it was determined the hospital failed to assure orders for the use of restraints were not written on an as needed basis for Medical Record (MR) # 2, which was 1 of 1 patient who was restrained.


Findings include:

Facility Policy

Subject: Restraints

IV. Restraint Orders (Soft Restraints)

B. The physician must be notified and a time-limited order must be obtained for the use of restraints.

C. Orders must not exceed 24 hours. Even though the order may state up to 24 hours, every attempt is made to remove the patient from restraints as soon as possible.

F. If a patient is removed from restraints, a new order must be obtained if the patient is to be restrained again.


1. MR # 2 was admitted to the facility on 12/8/08 with diagnoses including Left Foot Crush Injury. Review of the Physician's Orders dated 12/16/08 at 7:30 revealed the physician documented, "... 3. restraints as needed per protocol..."

Review of the Doctor's Order Sheet dated 12/16/08 at 0800 which was completed by the Registered Nurse revealed soft restraints were to be utilized to the right wrist and left ankle and the patient was to be restrained for 24 hours. This Doctor's Order Sheet was not signed by the physician.

Review of the Nurse Note dated 12/16/08 revealed the nurse documented the following:
1200, "Restraints to L (left) arm and R (right) ankle to prevent self injury.
1245, "Restraints removed. Granddaughter here for a while. Will notify staff when she leaves."

Review of the Restraint Flow Sheet dated 12/16/08 revealed the staff documented the patient did not have restraints in place at 1:00 PM, 1:30 PM and were in place at 2:00 PM. Further review of the Restraint Flow Sheet dated 12/16/08 revealed the staff documented the patient did not have restraints in place at 7:30 PM and were in place at 8:00 PM.

Review of the Nurse Note dated 12/16/08 revealed the nurse documented the following:
2000 hours, "Assessment complete, see flow sheet. Alert, confused. Daughter at bedside. Requested to place in restraints before she left for the night. Restraints place on L hand and R foot..."
2230 hours, "Found at bottom of bed standing. Placed back in bed. Restrained, see flow sheet..."
0400 hours (12/17/08), "...Remains restrained, see restraint flow sheet..."
12/17/08, 0600 hours, "Daughter at bedside. Unrestrained..."

There was no documentation of physician orders for the patient to be placed back in restraints once they had been removed.


An interview was conducted on 9/2/10 at 12:40 PM with EI # 1, who verified the above.

Based on medical record review, hospital policies and an interview with Employee Identifier (EI) # 1, the Director of Nurses (DON), it was determined the nursing staff failed to:

1. Clarify physicians' wound care orders for 4 of 4 patients with wounds. This effected Medical Record (MR) # 1, MR # 8, MR # 12 and MR # 13.
2. Clarify physicians' orders for 2 of 2 patient with a colostomy. This effected MR # 1 and MR # 13.
3. Provide PICC (Peripherally Inserted Central Catheter) care every 72 hours for 1 of 1 patient with a PICC. This effected MR # 13.
4. Failed to document foley care was provided for 1 of 1 patients with a foley catheter. This effected MR # 13.

These deficient practices effected 4 of 13 medical records reviewed.


Findings include:


1. MR # 1 was admitted to the facility on 8/6/10 with diagnoses including Duodenal Perforation, Clostridium Difficile, Colitis and Hypertension. Review of the Physician's Orders dated 8/6/10 revealed the physician orders included, "...Routine ostomy tube care. Routine skin incision care."

There was no documentation the nurse clarified the physician's orders for ostomy tube care or wound care, including the sites, what the areas were to be cleaned with and what dressings, if any were to be applied.

Review of the Decubitus/Pressure Ulcer Report dated 8/6/10 revealed the patient had a reddened area to the buttocks which was "quarter sized", a mid-line surgical site which measured 3-4 inches, a JP (Jackson Pratt) drain to the right, a J-tube (Jejunostomy tube) located in the left lower abdominal quadrant and a G-tube (Gastrostomy tube) located in the right upper abdominal quadrant.

Review of the Medication Administration Record (MAR) revealed, "Routine skin and ostomy care q (every) shift and clean with NS (Normal Saline and dry with 4 x 4's". This care was documented as having been performed on 8/7/10 at 9:00 AM and 3:00 PM, 8/8/10 at 2:00 PM and 8/9/10 at 11:00 AM

Review of the MAR revealed, "Routine skin/ostomy care q (every) shift: clean with NS (Normal Saline) and dry with 4 x 4". This care was documented as having been performed on:
8/10/10 at 12:00 AM, 9:00 AM and 7:00 PM
8/11/10 at 6:00 AM, 9:00 AM and 10:00 PM
8/12/10 at 6:00 AM, 3:00 PM and 9:00 PM
8/13/10 at 10:45 AM and 9:00 PM
8/14/10 at 6:00 AM and 5:00 PM
8/15/10 at 4:30 AM and 9:00 AM
8/16/10 at 6:00 AM and 11:45 AM
8/17/10 at 11:30 AM
8/18/10 at 9:00 PM
8/19/10 at 9:00 PM
8/20/10 at 6:00 AM, 10:00 AM and 9:00 PM
8/21/10 at 6:00 AM, 8:40 AM and 9:00 PM
8/22/10 at 6:00 AM, 8:00 AM, and 9:00 PM
8/23/10 at 5:00 AM and 8:05 AM
8/24/10 at 8:50 AM and 9:00 PM
8/25/10 at 6:00 AM and 9:00 PM
8/26/10 at 9:00 AM and 5:00 PM
8/27/10 at 1:00 PM and 9:00 PM
8/28/10 at 6:00 AM, 9:00 AM and 9:00 PM
8/29/10 at 6:00 AM, 9:00 AM and 9:00 PM


Review of the MAR revealed, "Apply Silvadene cream q (every) shift to G-tube site". This care was documented as having been performed on:
8/10/10 at 9:00 AM and 7:00 PM
8/11/10 at 6:00 AM, 9:00 AM and 10:00 PM
8/12/10 at 6:00 AM and 9:00 PM
8/13/10 at 10:45 AM and 9:00 PM
8/14/10 at 6:00 AM and 10:00 AM
8/15/10 at 4:30 AM and 9:00 AM
8/16/10 at 6:00 AM and 11:45 AM
8/17/10 at 11:30 AM
8/18/10 at 9:00 PM
8/19/10 at 9:00 PM
8/20/10 at 6:00 AM, 10:00 AM and 9:00 PM
8/21/10 at 6:00 AM, 8:40 AM and 9:00 PM
8/22/10 at 6:00 AM, 8:00 AM, and 9:00 PM
8/23/10 at 5:00 AM and 8:05 AM
8/24/10 at 9:00 AM and 9:00 PM
8/25/10 at 6:00 AM
8/26/10 at 9:00 AM and 5:00 PM
8/27/10 at 1:00 PM and 9:00 PM
8/28/10 at 6:00 AM, 9:00 AM and 9:00 PM
8/29/10 at 6:00 AM, 9:00 AM and 9:00 PM


An interview was conducted on 9/2/10 at 12:35 PM with EI # 1 who verified the above.


2. MR # 8 was admitted to the facility on 8/21/10 with diagnoses including Intractable pain in the left leg. Review of the Physician's Orders dated 8/23/10 revealed physician orders, "...wound vac care (as) protocol..."

There was no documentation the nurse clarified the physician's orders of the site, what was to be used to clean with and the type of foam dressing to be applied or the negative pressure to be applied.

Review of the Patient Progress Notes dated 8/23/10 at 1335 revealed the nurse documented, "Dsg (dressing) L (left) wound vac changed..."

An interview was conducted on 9/2/10 at 12:46 PM with EI # 1, who verified the above.


3. MR # 12 was admitted as a Swing Bed patient on 8/25/10 with diagnoses including Status Post left foot partial amputation, Hypertension, decreased mobility and strength and Anemia.

Review of the Physician's Orders dated 8/25/10 revealed orders for, "...Wound VAC to left foot - change dressing every 72 hours..." Further review of the Physician's Orders dated 8/25/10 revealed, "...Wet to dry dressing until wound vac available..."

There was no documentation the nurse clarified the physician's orders of the site, what was to be used to clean with and the type of foam dressing to be applied or the negative pressure to be applied. Nor was there documentation the nurse clarified the physician's orders for what type of wet to dry dressings were to be applied to what areas or how often the wound care was to be performed.

Review of the Nursing Narrative dated 8/27/10 at 0800 hours revealed the nurse documented, "... lt (left) foot bandaged with conform and 4 x 4 gauze..." Further review of the Nursing Narrative dated 8/27/10 at 1830 hours revealed the nurse documented, "...Wound Vac applied to L (left) foot..."

Review of the Medication Administration Record dated 8/25/10 at 1600 hours and 8/26/10 at 1400 hours revealed the nurse documented having performed wet to dry dressing change to the left foot. There was no documentation of the type of wet to dry dressing that was applied.

Review of the Medication Administration Record dated 8/30/10 at 1850 revealed the nurse documented having performed wound vac care to the left foot. There was no documentation of the solution used to clean the wound, the type foam used to dress the wound or the negative pressure applied to the wound VAC dressing.



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4. MR #13 was admitted to the Swing Bed unit of the facility on 8/27/10 with diagnosis of methicillin-resistant Staphylocccus aureus (MRSA) left shoulder. Review of the Physician's orders dated 8/27/10 revealed the physician admission orders including, "....Foley to GU (genitourinary) bag...Colostomy care..." There were no orders for PICC line care or PICC line dressing changes. There were no orders for left shoulder wound care.

There was no documentation the nurse clarified the physician's order for colostomy care or foley care.

There was no documentation the nurse obtained orders for PICC line care, PICC line dressing changes or for left shoulder wound care.

Review of the physician's orders revealed a physician's order dated 8/30/10 "Flush PICC line-both ports every shift; change PICC line dressing every 72 hours"

There was no documentation the nurse clarified the physician's order for the type of solution or the amount of solution that was to be used to flush the PICC line. There was no documentation the nurse clarified the physician's order for what the PICC line site was to be cleaned with and for what type of dressing was to be applied.

Wound Care:
Review of the nursing narratives revealed:
8/27/10 at 12:20 PM " ...sutures and staples to lt (left) shoulder, bruised and covered with 4x4's, sutures to lt AC (antecubital) lt arm in sling, MRSA-pt on contact isolation ..."
8/27/10 at 10:00 PM "...L (left) shoulder with dressing D/I (dry and intact) ..."
8/28/10 at 12:40 AM "...Dressing intact to L shoulder no drainage to drsg ..."
8/28/10 at 6:30 AM "...Dressing change to L shoulder ...drainage present ..."
8/28/10 at 8:00 AM "...Dressing to lt (left) shoulder intact dry at this time ..."
8/28/10 at 2:45 PM "...Serous drainage soaked lt shoulder dressing ....new dressing applied..."
8/29/10 at 6:00 AM "...Dressing to L shoulder intact and dry ..."
8/29/10 at 5:30 PM "...Dressing change done ..."
8/29/10 at 8:15 PM "...Dsg (dressing), DI (dry and intact) to L shoulder ..."
8/30/10 at 12:15 AM "...Dsg intact to L shoulder ..."
8/30/10 at 8:00 PM "...Dsg D&I (dry and intact) to L shoulder ..."
8/30/10 at 9:30 PM "...Dsg changed to L shoulder with serosanquinous drainage noted to gauze. Cleansed and dsg reapplied with paper tape ..."

Review of the Interdisciplinary Patient/Family Teaching Record dated 8/27/10 revealed no documentation in the Skin Problem/Focus area or interventions.

Review of the Swing Bed Care Plan dated 8/27/10 revealed "Problems and Needs ...skin breakdown ...#11. Treatment as per last MD orders ..."

Review of the medication administration record (MAR) revealed no documentation of the left shoulder wound care, including the site, what the area was to be cleaned with and what dressings, if any was to be applied or how often the wound care was to be performed.

During interview on 8/27/10 at 3:40 PM EI #11, registered nurse (RN), confirmed there was no order for wound care to the left shoulder.

During interview on 9/2/10 at 1:05 PM EI #1 confirmed there was no order for left shoulder wound care.

Colostomy Care:

Facility Policy

Colostomy/ Ileostomy Care

Charting:
1. Date, time and procedure
2. Condition of stoma and surrounding skin
3. Type of appliance and dressing applied
4. Patient's response
5. Signature and title

Review of the Nursing narratives:
8/27/10 at 12:20 AM "...intact LLQ (lower left quadrant) colostomy ..."
8/27/10 at 6:30 PM "...Pt with LLQ colostomy draining formed stools ..."
8/28/10 at 12:40 AM "...L (left) upper quad (quadrant) colostomy intact ..."
8/28/10 at 6:30 AM "...colostomy changed ..."
8/28/10 at 8:00 AM "...Colostomy bag intact ..."
8/29/10 at 6:00 AM "...colostomy changed, new wafer and bag applied ..."
8/29/10 at 5:30 PM "...Colostomy bag changed out ..."
8/29/10 at 8:15 PM "...Colostomy bag intact to abdomen ..."
8/30/10 at 12:15 AM "...Colostomy intact to abd (abdomen) ..."
8/30/10 at 6:00 AM "...Colostomy intact ..."
8/30/10 at 10:00 AM "...Colostomy bag and wafer changed due to leakage under wafer ..."
8/30/10 at 10:00 PM "...Colostomy bag clean and intact to L (left) abdomen ..."

Review of the ADL (activities of daily living) Performance documents revealed:

Colostomy:
8/27/10 day and evening shift toilet use "...total dependence (full staff performance of activity) and required 1 person assist (physical contact) ..."
8/28/10 night, day and evening shift toilet use "....total dependence (full staff performance of activity) and required 1 person assist (physical contact) ..."
8/29/10 Night shift toilet use "...total dependence (full staff performance of activity) and required 1 person assist (physical contact) ..."
8/29/10 Day and evening shift toilet use "...total dependence (full staff performance of activity) and set up only (help limited to providing or placing article/device within reach of patient"
8/30/10 Night, day and evening shift toilet use "...total dependence (full staff performance of activity) and required 1 person assist (physical contact) ..."

Review of the Swing Bed Care Plan dated 8/27/10 revealed "Problems and Needs ...Colostomy ...Goals ...Colostomy site will be clean and healthy ...1. Monitor stool every shift. 2 Empty pouch as needed and monitor for any leakage ...3. When changing wafer, remove carefully from skin. Do not rip or jerk ...4 Wash skin around stoma with product of facilities choice ..."

Review of the medication administration record (MAR) revealed no documentation regarding colostomy care.

Interview on 8/27/10 with EI #11 confirmed there was no specific order for colostomy care.

Interview on 9/2/10 at 1:00 PM with EI #1 confirmed the order was just "colostomy care" and that the care should have been documented on the MAR.

PICC line care:

Facility Policy dated 6/1/10

PIC Line Dressing Change

Purpose: The PIC line dressing must be replaced if it becomes soiled or loosened. If it is a gauze dressing, it must be replaced if it becomes wet. Sterile site care and sterile dressing shall be administered every 72 hours and PRN (as needed) if loosened, soiled or wet. Ointments will not be used on the insertion site of any PIC catheter.

Procedure:
1. Assemble equipment
2. Wash hands
3. Put on clean gloves
4. Carefully remove the old dressing from the patient's skin around the edges, slowly working towards the insertion site
5. Firmly grasp the catheter hub or extension, and remove the old dressing
6. Wash hands
7. Open the sterile dressing kit and create a sterile field. Put on sterile gloves
8. Use the Chlora prep to cleanse the skin surface, working in concentric circles from the site outward, for approximately five inches.
9. Apply skin protectant prep pad around area to be dressed
10. Place 2x2 drain gauze around PIC, not to occlude insertion site.
11. Without touching the underside of the dressing material, apply the dressing to the catheter site. The exit site should be in the center of the dressing field.
12. Apply a piece of tape securing the latex injection cap or extension set to either the patient's skin or to the outside of the sterile dressing.
13. Label the site with the date and time of dressing change and initial.
14. Document the procedure on the clinical note and medication administration record.


Review of the nursing narratives revealed:
8/27/10 at 10:00 PM "...PICC line flushes well ..."
8/29/10 at 8:15 PM "...PICC line intact to AC (antecubital) and flushes well ..."
8/30/10 at 12:15 AM "...PICC Line intact to AC ..."
8/30/10 at 6:00 AM "...PICC line intact ..."
8/30/10 at 8:00 PM "...PICC line intact to AC ..."

Review of the Swing Bed Care Plan dated 8/27/10 revealed "Problems and Needs ...PIC line ...Goals ...Site will remain free of s/s (signs and symptoms) of infection with interventions used daily. Line will remain patent ...1. Flush every shift. 2. Dressing change every 72 hours and PRN soiled dsg. 3. Monitor for s/s of infection."

Review of the MAR revealed:

MAR PICC line flushes:

There was no documentation that PICC line was flushed 8/27/10, 8/28/10, or 8/29/10.

"Order date ... 8/30/10 Flush PICC line both ports every shift" There was no documentation that this was done on the 3-11 or the 11-7 shift on 8/30/10.

"Order date ...(No date documented)PICC line flush every shift." There was no documentation that this was done on the 11-7 shift or the 7-3 shift on 8/31/10.

Order date ...8/31/10 ...Flush PICC line with 10 cc (cubic centimeters) NS (normal saline) every shift Both ports" There was no documentation that this was done on 8/31/10.

MAR PICC line dressing change:
"Order date ... 8/30/10 ....PICC Line dressing change every 72 hours"
There was no documentation of PICC line dressing changes on 8/27/10, 8/28/10, 8/29/10, 8/30/10 or 8/31/10.

Interview on 8/31/10 at 3:40 PM with EI #11 confirmed there were no specific orders for PICC line dressing changes.

Interview on 9/2/10 at 1:15 PM with EI #1 confirmed there was no order for the type of dressing change that should have been done and there was no order for PICC Line flushes on admission.

Foley catheter care:

Facility Policy

Catherization-Urinary

Catheter care will be done by nursing personnel every shift on all patients with indwelling catheters.

Purpose:

To prevent uretheral irritation and inflammation

Equipment:

Catheter Care Kit

Procedure:
1. Explain procedure to patient.
2. Place patient in supine position with knees flexed and feet flat on bed.
3. Drape patient.
4. Open catheter care kit, swabs and ointment.
5. Put on clean gloves.
6. Cleanse meatal catheter with prep swab stick gently using circular motion.
7. Apply ointment to meatal catheter junction with jumbo swab stick.
8. Make patient comfortable.
9. Discard used materials in dirty utility trash can.

Charting:
1. Date, time, procedure.
2. Any signs of irritation.
3. Nurse's signature and title.

Review of the nursing narratives revealed:
8/27/10 at 12:20 PM "...foley catheter draining clear yellow urine and intact ..."
8/27/10 at 6:30 PM "...Foley catheter in place and draining well with clear yellow urine ..."
8/28/10 at 12:40 PM "...Foley cath ( catheter) intact with yellow urine flow to GU bag ..."
8/29/10 at 8:15 PM "...Foley cath intact to BSD (bedside drainage) draining yellow urine ..."
8/30/10 at 12:15 AM "... Foley cath intact to BDS ..."
8/30/10 at 6:00 AM " ...Foley cath intact ... "
8/30/10 at 8:00 PM "...Foley cath intact to BSD draining yellow urine..."

Review of the Interdisciplinary Patient/Family Teaching Record dated 8/27/10 revealed no documentation in the Genitourinary Problem/Focus area or interventions.
Review of the ADL (activities of daily living) Performance documents revealed:

Foley
8/27/10 day and evening shift toilet use "....total dependence (full staff performance of activity) and required 1 person assist (physical contact) ..."
8/28/10 night, day and evening shift toilet use "....total dependence (full staff performance of activity) and required 1 person assist (physical contact) ..."
8/29/10 Night shift toilet use "...total dependence (full staff performance of activity) and required 1 person assist (physical contact) ..."
8/29/10 Day and evening shift toilet use "...total dependence (full staff performance of activity) and set up only (help limited to providing or placing article/device within reach of patient "
8/30/10 Night, day and evening shift toilet use "...total dependence (full staff performance of activity) and required 1 person assist (physical contact)..."

Review of the Swing Bed Care Plan dated 8/27/10 revealed "Problems and Needs ...Catheter ...#1. Clean perineal area and catheter every day with warm water and soap ..."

Interview on 8/27/10 at 3:35 PM with EI #11 confirmed there were no orders for foley catheter care or documentation catheter care had been performed.

Interview on 9/2/10 at 1:10 PM EI #1 verified that there policy is for foley care to be done every shift and should be on the Cardex. EI #1 confirmed the foley care should be documented on the nursing notes with the time of the care documented.

Based on observations, facility policy review and staff interviews, the facility failed to assure that all medications available for patient use in the Emergency Department (ED) were not expired. This had the potential to affect all patients.

Findings include:

Facility Policy
Medications in the Emergency Department

Emergency Department nurse will periodically check for any outdated medications. (outdated medications will be returned to pharmacy)

An initial tour of the ED was conducted on 8/31/10 at 10:18 AM.
During this tour the following outdated 1000 cc (cubic centimeter) bags of intravenous (IV) solutions were found:

Emergency Treatment Room #1 supply closet:
(3) IV bags of 0.45% Sodium Chloride-expired 5/2009
(1) IV bag of 0.45% Sodium Chloride-expired 7/2009
(2) IV bags of 0.45% Sodium Chloride-expired 7/2010
(4) IV bags of 5% Dextrose and 0.9% Sodium Chloride-expired 5/2010
(3) IV bags of 5% Dextrose and 0.9% Sodium Chloride-expired 2/2009
(4) IV bags of 5% Dextrose and 0.2% Sodium Chloride-expired 12/2009

Emergency Treatment Room #2 supply closet:
(4) IV bags of 5% Dextrose and 0.9% Sodium Chloride-expired 5/2010
(2) IV bags of 5% Dextrose and 0.9% Sodium Chloride-expired 4/2010

An interview was conducted on 08/31/10 at 1:05 PM with Employee Identifier (EI) #9, the ED registered nurse (RN), who verified that the above medications were outdated.






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Based on observation and interview, the facility failed to assure all medical supplies available for patient use in the Emergency Department (ED) and the Outpatient Procedure room were not expired. This had the potential to affect all patients.

Findings include:

1. A tour was conducted on 08/31/10 at 10:18 AM in the ED. The surveyor found the following expired supplies:
ED Treatment Room #1
(32) 18 Gauge (GA) angiocaths expired-4/2010
(8) 22 GA angiocaths-expired 4/2010
(1) 22 GA angiocath-expired 5/2010
(23) 24 GA angiocaths-expired 4/2010
(4) 24 GA angiocaths-expired 1/2010
(7) Kendall Curity Eye Pads expired 10/2009

ED Treatment Room #2
(1) Endotracheal tube expired-8/2007
(2) Lazarus-Nelson Peritoneal Lavage trays-expired 6/2006
(8) 18 GA angiocaths expired-4/2010

An interview was conducted on 8/31/10 at 1:05 PM with Employee Identifier (EI) #9, the ED registered nurse (RN), who verified that the above supplies were outdated.

2. A tour was conducted on 9/01/10 at 10:05 AM in the Outpatient Procedure Room. During the tour the surveyor found the following expired supplies:
(3) 18 GA angiocaths expired-8/2006
(1) 18 GA angiocath expired-12/2007
(2) 18 GA angiocaths expired-2/2008
(4) 20 GA angiocaths expired-9/2007
(2) 20 GA angiocaths expired-4/2010
(1) 20 GA angiocath expired-8/2003
(5) 24 GA angiocaths expired 5/2003
(2) Olympus Endotherapy disposable injectors expired-/2010
(1) Captiflex Polypectomy Snare expired-10/2009

An interview was conducted on 9/1/10 with Employee Identifier (EI) #1, the Director of Nursing (DON), who verified that the above supplies were outdated.

Based on observation, interviews, review of Centers for Disease Control (CDC) Guideline for Disinfection and Sterilization in Healthcare Facilities, review of facility Autoclave Policy and Procedure and review of autoclave sterilization logs, it was determined the facility failed to ensure the autoclave was correctly monitored to prevent infections. This had the potential to affect all patients.

Findings include:

CDC Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 (page 91)

16. Monitoring of Sterilizers
d. Use biologic indicators to monitor the effectiveness of sterilizers at least weekly with an FDA (Food and Drug Administration) cleared commercial preparation of spores......

Facility Policy

Auto Clave Policy and Procedure
Approved 6/1/10

Heat Sensitive Tape Monitoring - Operators should use heat-sensitive sterilization indicator tape for each load to indicate the load has undergone an effective steam sterilization process. This tape only indicates that the proper temperature has been reached, but does not indicate it is heated for the proper length of time.

A tour of the Central Sterile area was conducted on 9/2/10 at 11:05 AM with Employee Identifier (EI) #8, the RN who sterilizes the equipment. An observation of the autoclave log book during the tour revealed no documentation of spore testing of the sterilizer.

During an interview on 9/2/10 at 11:15 AM, EI #8 confirmed he/she had not been doing the sterilizer spore testing but was aware it was suppose to have been done.

On 9/2/10 at 11:55 AM EI #1, the Director of Nursing, provided the aforementioned Autoclave Policy and confirmed the policy did not address the need for spore testing.