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Based on observation, staff interview, and policy and procedure review, the facility failed to ensure that equipment, supplies, and medications used in treating emergency cases are kept at the facility and are readily available for treating emergency cases in three (3) out of five (5) departments surveyed.

Findings Include:

On 12/15/2022, at 10:04 a.m., during an observation of Crash Cart #2 on the Med/Surg floor with Staff Nurse #1, the following expired items were found:

One (1) Secondary Intravenous set, expired 12/01/2021
Three (3) 18-gauge Winged Insite Intravenous Catheters, expired 05/31/2021
One (1) King LTS D Airway Kit, expired 11/13/2021
One (1) King LTS D #5 Airway Kit, expired 11/01/2022
One (1) King LTS D #4 Airway Kit, expired 02/01/2022

On 12/15/2022, at 10:08 a.m., an interview with Staff Nurse #1, revealed the pharmacy was responsible for medication expiration dates on crash carts, and respiratory was responsible for the expiration dates of supplies on crash carts.

On 12/15/22, at 11:25 a.m., during a tour of the Emergency Room (ER), with ER Nurse #2, the following expired items were observed:

On Intravenous Supply Cart #1:
Two (2) Huber needles 1 inch, expired 08/31/2022
Three (3) 3-way stopcock male luer locks, expired 04/17/2021
Two (2) Microbore extension set, 8-inch, expired 7/01/2020
One (1) Biopatch, expired 01/31/2022

In Isolation Room:
Three (3) Swabcaps, expired 05/01/2022
One (1) King LTS D Airway Kit, size 3, expired 11/13/2021
Two (2) 250 milliliter bags of 5% Dextrose, expired 07/01/2021
Two (2) 250 milliliter bags of 5% Dextrose, expired 10/2022

On Intravenous Supply Cart #2:
76 Blue Top lab tubes expired 09/30/2022

In Trauma Room #1, on Pediatric Crash Cart:
One (1) Sterile Pediatric McGill Forceps, expired 07/07/2022
One (1) Sterile Towel, expired 09/15/2022
One (1) Pediatric Colorimetric Carbon Dioxide Detector, expired 08/2018
One (1) Shiley Nasal Tracheal Cuffed Tube, expired 09/10/2022
One (1) Intubating Stylet 10 French, expired 07/04/2021
One (1) Intubating Stylet 10 French, expired 07/31/2022
Two (2) Intubating Stylet 10 French expired 10/2020
Four (4) Vials of Amiodarone 150 milligrams/3 milliliters, expired 11/2022

In Trauma Room #1, on Adult Crash Cart:
One (1) Sterile McGill Forceps, expired 09/07/2022

In Trauma Room #2, on Adult Crash Cart:
Eight (8) .17-ounce packets of lubricating jelly, expired 04/2022

On 12/15/2022 at 11:40 a.m., an interview with Emergency Room Nurse #2, revealed that all Emergency Room staff are responsible for keeping up with expiration dates on Emergency Room supplies, other than the medications and supplies on the crash carts. Crash cart medications are monitored by the pharmacy, and crash cart supplies are monitored by Respiratory.


Review of facility's Policy Number MM.05.01.19, "Control of Unused/Expired Medications", dated May 2022, revealed "every month the pharmacy tech will check all areas where drugs are stored and return all expired and unused drugs to the pharmacy. If an expired or unusable medication is found by a nurse or other personnel, it is returned to the pharmacy immediately."

Review of facility's Policy Number NURS 0176, "Crash Cart Restocking", dated 5/2022, revealed " ...all crash carts in the hospital will be checked on a monthly basis by pharmacy for medication dates and integrity ... after use of the crash cart on A-South, the nursing department will be responsible for notifying pharmacy and a yellow lock will be placed on the cart to notify staff that the cart needs to be restocked. The charge nurse in ER will restock their own carts as soon as possible for re-use ...when the yellow lock is put on the used crash cart this is a flag to Pharmacy, Respiratory Therapy and Purchasing to check the cart and re-supply needed items ..."

During Exit Conference on 12/15/2022 at 1:30 p.m., survey findings were discussed and no further documentation was submitted for review.