HospitalInspections.org

Based on observation and interviews with facility staff, the facility failed to maintain patient care equipment in safe operating condition by failing to properly secure gas cylinders as two oxygen cylinders in the gas storage room were unsecured. This potentially could have caused a safety hazard.

The findings were:
During a tour of the facility on the morning of 8/6/13, two large green oxygen cylinders were observed to be unsecured in the gas storage room. This finding was confirmed during the tour on 8/6/13 at 8:50 am by staff # 28 and # 29.

Based on observation and interviews with staff # 20 and 33, the facility failed to maintain a safe environment, equipped with appropriate medical supplies; as there were 46 expired medical supplies found in the physical therapy department, emergency department, and the Lab Phlebotomy department. These medical supplies were available for patient use causing a potential for non-sanitary environment and failure to maintain patient safety.
Findings were:
On the afternoon of 8/5/13 during a tour of the facility, accompanied by staff # 20 and 33 expired medical supplies were observed; ER Trauma Room: Attached to the chest tube tray, sterilized hemostats, expired 7/7/12; sterilized curved forceps, expired 10/3/12, and sterilized 4x4 gauze pads, expired 9/26/12; Pressure infuser 1000 ml, expired 12/12. Found in ER Overflow Room: Intubation stylet, 2.5-4.5 mm, expired 6/13. Found in ER Clean Utility Room: Isopropyl alcohol, 70%, 16 oz. bottle, expired 4/13. Found in the Lab Phlebotomy Room: Green top lab tubes, 15 expired 5/13. Found in Physical Therapy Department 26 Iontophoresis Patches expired 9/2011, 10/2012, 5/2012, and 1 bottle of sterile water 30 cc expired 6/2013.
The facility did not provide a policy for expired medical supplies for the surveyors to review.
These findings were confirmed during the tour on the afternoon of 8/5/13 by staff # 33 and staff 20.

Based on review of documentation and interviews with facility staff, the facility failed to assure the safety of patients in non-medical emergencies by failing to conduct fire drills in accordance with facility policy. There was no fire drill conducted in March 2013 and three fire drills conducted in 2013 did not have the time documented to determine on which shift they were held. This potentially could have resulted in a lack of preparation in the event of an emergency.

The findings were:
The fire drill records for August 2012 to July 2013 were reviewed on 8/6/13. The records reflected drills were conducted on 8/3012 at 4:15 pm, 9/27/12 at 5:50 pm, 10/25/12 at 10:25 (am or pm not documented), 11/29/12 7:30 pm, 12/21/12 at 7:00 am, 1/31/13 (no time documented), 2/28/13 9:55 am, 4/23/13 (no time documented), 5/2/13 at 9:15 am, 6/28/13 (no time documented), and 7/29/13 4:45 pm. The fire drill documentation sheet reflected the facility shifts were 8 am to 4 pm, 4 pm to 12 mn, and 12 mn to 8 am.

The facility policy entitled "Fire Safety Plan" with a revision date of 11/14/11 reflected in part "4d. Drills shall be conducted quarterly on each shift to familiarize facility personnel with the signals and emergency action required under varied conditions."

These findings were confirmed in an interview with staff # 28 and 29 on 8/6/13 at 11:15 am.