HospitalInspections.org

Based on observation, record review, and interview, the facility failed to keep supplies and medications readily available for emergency cases when,

A.) Expired medical supplies were available for use,
B.) and the facility did not monitor the temperatures of the radiology department's medication refrigerator, where the oral contrast was held for CT (computed tomography) scans, to maintain its efficacy.

Findings include:

A.) An observation, on the morning of 4/21/25, of the facility's emergency department revealed the following expired medical supplies:
(1) Foley Catheter tray with an expiration date of 11/30/2024
(1) Ophthalmic Burr with an expiration date of 8/1/2024
(1) Morgan Medi-Flow lens with an expiration date of 10/28/2024
(1) Lactated Ringer 1000 ml with an expiration date of 7/1/2023

Review of the facility provided document Central Supply Expired Supply Procedure (undated) reflected, "1. Supplies are checked on a monthly basis for date validity. 2. Expired supplies are marked as expired, destroyed, and disposed of. 3. Supplies with valid expiration date is then restocked.
During the tour of the emergency department on 4/21/25, Staff #1, Director of Nursing confirmed the findings and removed the items from use.

B.) An observation, on the morning of 4/21/25, of the facility's radiology department revealed the small refrigerator contained (6) bottles of Oral Contrast dye. The package instructions included Store between 0 degrees and 30 degrees Celsius (32 degrees - 86 degrees Fahrenheit).

The refrigerator log revealed "Instructions: Log to be maintained for refrigerator in CT room. Radiology tech will record the time and temperature every morning, once daily. If corrective action needs to be taken circle the date and explain action on log."

Review of the log revealed missing temperature checks for May 1,4, 5, 6, 9, 10, 14, 15, 18, 19, 20, and 21.

During an interview, in a conference room on the morning of 4/22/24, Staff #3, Radiology Director confirmed the missing refrigerator check dates and stated they should be checked daily.

Based on record review, and interview, the facility failed to follow its infection control policy when (1) out of (5) patient suspected of having a highly infections enteric disease was not placed on proper precautions pending diagnostic testing results, this failure places other patients at risk of contracting a communicable disease.

Findings include:

Review of the facility provided document Synopsis of Types of Precautions and Patients Requiring the Precautions (undated) reflected, "In addition to Standard Precautions, use Contact Precautions for patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient's environment. Examples of such illnesses include: 2. Enteric infections with a low infectious dose or prolonged environmental survival, including, a. clostridium difficile ...In the absence of a physician's order the charge nurse shall have the authority to initiate isolation procedures as soon as an infections process is suspected."

Review of Patient #1's Physician's orders dated 3/28/2025 reflected, "CLOSTRIDIDIUM DIFF ANTEGENS AND TOXIN 1X."
Review of Patient #1's medical records dated 3/28/2025 reflected, Isolation N/A (not/applicable)"
Review of Patient #1's laboratory ordered test for C diff Toxin and C diff antigen collected 3/30/2025 and reviewed on 3/30/2025 as Negative.

During an interview on the afternoon of 4/22/2025, in an administrative office, Staff 4, RN confirmed the patient had orders to check for C diff and the patient needed to be placed on contact isolation until the results came back negative.