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46293

Based on observations, hospital policy, and staff 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 by this hospital.

Findings include:

Hospital Policy: Guidelines for Disposable Items - Handling, Storage, Use and Reuse, IC (infection control) - 213
Policy Number: 13107815
Effective Date: 02/2023

Policy:

...2. Disposable items will be stored...according to manufacturer's specifications...

4. No items shall be used after expiration dates...

1. A tour of the Emergency Department (ED) was conducted on 8/20/24 at 11:20 AM.

The following supplies were observed as expired and available for patient use within the ED:

Trauma/Bay 4:

- Eight Covidien Polysorb Braided Absorbable Sutures, size 4-0, from a 32 count box with expiration date 7/31/24.
- Three Shiley 4.0 mm (millimeter) Oral-Nasal Tracheostomy Cuffed Tubes with expiration date 8/14/24. One tube was in the pediatric airway box, the other two were in the purple drawer of the respiratory cart.
- 12 size 8.5 Protexis Latex Micro Surgical Gloves with expiration date 7/31/24.
- Two Becton Dickinson (BD) Insyte Autoguard 16 g (gauge) IV (intravenous) catheters with expiration date 4/30/24.

ED Bay 2:

- One BD Smart Site Extension Set with 0.2 Micron Low Protein Binding Filter with expiration date 5/27/24.
- One B Braun Filtered Extension Set with expiration date 10/31/23.

Employee Identifier (EI) # 4, Registered Nurse, confirmed the expired supplies at the time of the tour.

2. A tour of the Central Supply Room was conducted on 8/20/24 at 12:50 PM.

The following items were found to be expired and available for patient use:

- One Cardinal Health Non-Conductive Suction Tubing with an expiration date of 7/1/24.
- Six Covidien Kangaroo EPump ENPlus Spike with Flush bag with an expiration date of 6/30/24.
- Five Large Black Foam Kits with Triple Release Transeal with an expiration date of 8/2/24.
- 136 BD Smart Site Extension Sets with an expiration date of 5/27/24.

EI # 5, Materials Management, confirmed the expired supplies at the time of the tour.

3. A tour was conducted on 8/20/24 at 2:02 PM of the Emergency Room Supply Room.

The following supplies were found to be expired and available for patient use.

- 45 Cardinal Health Protexis Latex Micro-Surgical Gloves with an expiration date of 7/31/24.
- Three BD Safety Glide Insulin Syringes 1 ml (milliliter) with an expiration date 4/30/24.
- One Care Fusion Bone Marrow Aspiration/Intra Osseous Infusion Needle with an expiration date of 5/8/24.
- 14 BD Spinal Needles 22 g x (by) 1 inch with an expiration date of 4/30/24.
- 124 rolls of 3M brand Micropore Surgical Tape with an expiration date of 4/18/24.

EI # 5 confirmed the expired supplies at the time of the tour.

4. An observation of the Medical Surgical Crash Cart on 8/20/24 at 2:53 PM revealed the following expired items:

- Four BD Secondary Sets - Three with an expiration date of 1/20/23 and one with an expiration date of 4/30/24.
- One ICU brand Medical Primary Plum Set with an expiration date of 7/1/24.

EI # 5 confirmed the expired supplies at the time of the observation.

Based on observations and interviews during a hospital tour with hospital staff and the Life Safety Code surveyor, 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 Life Safety Code violations.

Base on review of Emergency Preparedness (EP) documentation, and interview with staff, it was determined the hospital failed to ensure their comprehensive EP Program was updated and reviewed biennially (every two years) to comply with the Federal EP requirements.

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

Findings include:

A review of the Emergency Management Plan (EP Plan and Program) revealed the last revision date was 3/08 and the last review date was 1/17.

An interview was conducted on 8/22/24 at 3:32 PM with Employee Identifier # 3, Director of Plant Operations, who confirmed there was no documentation the Emergency Management Plan had been updated and reviewed every two years as required.

Based on review of the hospital's Emergency Management Plan (Emergency Preparedness) policies and procedures, and interviews with staff, it was determined the hospital failed to ensure policies and procedures were updated and/or reviewed every two years.

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

Findings include:

A review of the Emergency Management Plan provided to the surveyor revealed the policies and procedures for Emergency Preparedness (EP) were last reviewed on 1/17.

An interview was conducted on 8/22/24 at 3:32 PM with Employee Identifier # 3, Director of Plant Operations, who confirmed there was no documentation the EP policies and procedures had been reviewed and updated every two years.