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Based on observation, hospital policy, and interviews, it was determined the hospital failed to ensure expired medications were not available for patient use.

This had the potential to negatively affect all patients served by this hospital.

Findings include:

Hospital policy: Storage of Medications in Patient Care Areas
Policy number: None
Date effective: 1/1/23

Policy:
...7. Medications bearing an expiration date will not be dispensed or distributed beyond the expiration date.
8. Expired... medications shall be returned to the pharmacy for proper credit and/or disposal.

A tour of the surgical suite was conducted on 10/22/24 at 10:32 AM with Employee Identifier (EI) # 3, Registered Nurse, Outpatient Services Manager.

An observation of the locked narcotic box revealed two vials of Fentanyl Citrate 100 micrograms (mcg) two milliliters (ml) with an expiration date of 9/1/24.
EI # 3 confirmed, during the tour, the medication vials were expired, and available for patient use.

Based on observations, review of hospital policy and procedure, and interviews with staff it was determined the hospital failed to ensure expired foods were not available for use.

This had the potential to affect all patients served by this hospital.

Findings include:

Hospital Policy: Expired Food
Issued: 10/24/24

Policy:

All food in the store room, refrigerator, deep freezers, walk in refrigerator, and walk in freezer will be thrown away on the expiration date or the "best if used by" date.

Procedure:


All food in the freezers will be thrown away on the expiration date or "best by" date.

1. A tour of the dietary department was conducted on 10/22/24 at 10:16 AM with Employee Identifier (EI) # 4, Cook, the following items were found in the dietary deep freezer.

Eight egg and cheese omelets expired on 9/14/24.

Three southern style chickens expired on 9/14/24.

The staff failed to ensure foods were discarded when expired.

An interview was conducted on 10/22/24 at 11:01 AM with EI # 4 who confirmed the egg and cheese omelets and southern style chickens were expired and available for patient use.

Based on observations and interviews with staff during a tour of the hospital by Life Safety Code and health surveyors, it was determined the hospital was not constructed, arranged and maintained to ensure patient safety.

This had the potential to affect all patients served by this hospital.

Findings include:

Refer to tags: K-0271, K-0321, K-0324, K-0345, K-0351, K-0353, K-0363, K-0741, K-0781, K-0908, K-0918, K-0923 and health survey citation A-724.

Based on observation, policies, and interviews, it was determined the hospital failed to ensure expired supplies were not available for patient use.

This had the potential to negatively affect all patients served at this hospital.

Findings include:

Hospital policy: Shelf Life of Sterile Supplies/Non-sterile Supplies
Policy number: PP 98
Date of review: 03/24

Purpose:

To establish policy and provide standard procedure for determining the expiration date of sterilized/non-sterilized supplies.

Policy:

The following shelf life will be assigned as indicated to all medical and surgical supplies ...
...4. supplies are theoretically sterile until pack is opened or damaged or by manufacturer expiration date.
5. All other patient use supplies will be removed from stock and discarded appropriately according to the manufacture expiration date. Supplies are to be checked monthly in each department for expiration dates ...

Hospital policy: Central Sterile Services
Policy number: 101.012
Effective date: 03/30/2022

...II. Policy:

...c. All supplies are to be checked for expiration on a monthly basis. When supplies have expired, they are immediately removed from circulation and turned in to the purchasing clerk.

A tour of the Surgery unit was conducted on 10/22/2024 at 10:32 AM. with Employee Identifier (EI) # 3, Registered Nurse (RN), Outpatient Services Manager.

In the Operating Room (OR) # 1:

Two Medline intravenous (IV) Securement Sets with an expiration date of 1/31/23.
One Rusch Sterile Slick Set with an expiration date of 12/28/21.
One Scope Valet Trapit Dual Polyp Trap with an expiration date of 7/18/22.
Eleven Precisor Hot Disposable Biopsy Forceps, 10 with an expiration date of 3/27/24, and one with an expiration date of 7/14/21.
Four Scope Valet Trapit Single Chamber Polyp Trap with an expiration date of 7/24/22.
Three Boston Scientific Resolution Clip, two with an expiration date of 1/7/21, and one with an expiration date 1/31/21.
Six 3M Steri-Drapes with an expiration date of 8/20/23.
Two 10 percent (%) 60 milliliter (ml) Neutral Buffered Formalin with an expiration date of 5/22.
Three Scope Valet Endoscopic Bite Blocks with an expiration date of 4/10/23.

In the OR hallway:
Twenty Biological Indicators for the autoclave with an expiration date of 2/25/23.

In the crash cart:
Two IV Securement Sets with an expiration date of 9/30/21.
Five Covidien Monoject 12 ml syringes with an expiration date of 5/31/23.

In the Pre-Op area:
One Braun 18 gauge (g) by (x) 1 ¼ inch needle with an expiration date of 9/1/21.
Two Bectin Dickinson (BD) BBL Culture Swab with an expiration date of 5/31/21 and 7/31/24.
Ninety Six BD 21 g x 1 inch Precision Glide Needle with an expiration date 9/20/19.
One Hundred BD 18 g x 1 ½ inch needle with an expiration date of 1/31/22.

An interview was conducted, during the tour, with EI # 3 who confirmed the supplies were expired and remained available for patient use.

Based on observations, hospital policies and procedures, Centers for Disease Control and Prevention (CDC) Guidelines for the Prevention of Intravenous (IV) Catheter-Related Infections, updated 2/28/24, CDC Hand Hygiene in Healthcare Setting, reviewed 1/8/21, and interviews, it was determined the hospital failed to ensure staff:

1. Performed hand hygiene per hospital policy.
2. Disinfected the rubber septum of a medication vial with alcohol per hospital policy.
3. Scrubbed the access port of the needless IV tubing prior to administration of IV medication per CDC Guidelines.
4. Donned gloves prior to IV medication administration.

This did affect Patient Identifier (PI) # 25, one of one observation of an Endoscopy, PI # 2 and an unsampled patient, in two of four medication administration observations, and had the potential to negatively affect all patients served by the hospital.

Findings include:

Hospital policy: Hand Hygiene
Policy number: 201.007
Effective date: 10/29/19

Purpose:
To reduce the transmission of infectious pathogens

Policy:
All staff members involved with patient care shall practice proper hand hygiene...

Procedure:
Decontaminate hands before donning sterile gloves ...
Decontaminate hands after contact with a patient's intact skin (i.e. when taking a pulse or a blood pressure) ...
Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.
Decontaminate hands after removing gloves.

CDC Hand Hygiene in Healthcare Settings reviewed 1/8/21.

Glove Use

...perform hand hygiene prior to donning gloves...

Perform hand hygiene immediately after removing gloves...

...Wearing gloves reduces the risk of healthcare workers acquiring infections from patients...

Hospital policy: Safe Injection Practices
Policy number: PP XXI 2b
Date reviewed: 03/24

Policy:

Safe Injection Practices are a set of recommendations within Standard Precautions, which are the foundation for preventing transmission infections during patient care in the hospital setting.

Procedure:

1. Proper hand hygiene...is performed prior to preparing and administering medications
2. Injections are prepared using aseptic technique...
4. The rubber septum on a medication vial is disinfected with alcohol prior to needle insertion into the vial. This includes newly opened vials after the dust cap is removed...


CDC Guidelines for the Prevention of IV Catheter-Related Infections, updated 2/28/24

Needleless IV Catheter Systems

Recommendations:
...4. Minimize contamination risk by scrubbing the access port with an appropriate antiseptic (...70 % alcohol) and accessing the port only with sterile devices...

1. An observation was conducted on 10/22/24 at 12:05 PM of Employee Identifier (EI) # 5, Licensed Practical Nurse, administered IV antibiotics for PI # 2. EI # 5 removed the previously administered antibiotics bag, disinfected the patient's IV access port using an alcohol pad, and connected the new antibiotic bag to the patient's IV access port for administration of the IV medication. EI # 5 failed to don gloves prior to the disinfection of the IV access port and administration of the antibiotic,

An interview was conducted on 10/24/24 at 12:00 PM with EI # 2, who confirmed the medication was given without following the hand hygiene policy.

2. An observation was conducted on 10/22/24 at 12:05 PM of EI # 7, Registered Nurse (RN), administered IV antibiotics to an unsampled patient. EI # 5 removed the previously administered antibiotics bag, disinfected the patient's IV access port using an alcohol pad, and connected the new antibiotic bag to the patient's IV access port for administration of the IV medication. EI # 5 failed to don gloves prior to the disinfection of the IV access port and administration of the antibiotic.

An interview was conducted on 10/24/24 at 12:00 PM with EI # 2, who confirmed the medication was given without following the hand hygiene policy.


3. An observation was conducted on 10/24/24 at 7:24 AM of an Endoscopy for PI # 25.

EI # 3, Outpatient Services Manager, donned gloves, without performing hand hygiene, started an IV catheter on PI # 25, then removed gloves. EI # 3 failed to perform hand hygiene prior to donning gloves and after removing gloves.

EI # 8, Certified Registered Nurse Anesthetist (CRNA), and EI # 9, RN, donned gloves then transferred, per stretcher, PI # 25 into the Operating Room (OR) for the procedure. EI # 8 and EI # 9 failed to perform hand hygiene prior to donning gloves.

EI # 10, scrub tech, donned gloves to assist with the non-sterile procedure. EI # 10 failed to perform hand hygiene prior to donning gloves.

EI # 8 removed gloves, donned clean gloves, opened sterile syringe, withdrew Propofol and administered the Propofol IV to PI # 25. EI # 8 failed to perform hand hygiene after removing gloves, disinfect the rubber septum with alcohol prior to insertion of the needle, and disinfect the access port prior to administration of the Propofol.

At the end of the procedure, EI # 9 and EI # 10 removed gloves and failed to perform hand hygiene. EI # 9 donned gloves, without performing hand hygiene, to assist in transfer of PI # 25 to the recovery room (RR).

EI # 11, RN, donned gloves placed monitors on the patient, discontinued the IV, removed monitors from the patient, then assisted the patient with dressing. EI # 11 failed to perform hand hygiene prior to donning gloves and after contact with inanimate injects in the immediate vicinity of the patient.

An interview was conducted on 10/24/24 at 11:55 AM with EI # 2, Director of Nursing, who confirmed staff did not follow hand hygiene per hospital policy, disinfect rubber septum of vial and access port of IV per CDC Guidelines.













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