HospitalInspections.org

Based on observation and interviews, the hospital failed to ensure that supplies were safely maintained, in that, expired supplies were available for patient use.

On a tour of the hospital pre-operative (Pre-Op) area the afternoon of 04/12/10, the surveyor observed the following expired supplies available for patient use:
1) The Malignant Hyperthermia Cart contained 3 Central Venous Catheter, double lumen kits, with expiration dates of 03/08, 06/09 and 10/09.
2) The laboratory Pre- Op area contained the following supplies available for patient use:
35 - 20 gauge angiocath needles, expired 03/08.
59 - 22 gauge angiocath needles, expired 10/09.
1 - Bio-patch, expired 06/09.

In interviews the afternoon of 04/12/10, the Director of Pre-Op (Personnel # 6) and the Director of Quality (Personnel #4), verified the above expired supplies in the Pre-Op area. Both nurses agreed that these supplies had been available for patient use.

Based on observation and interview, the hospital did not ensure that their operating room (OR) register was complete for 4 of 4 patients who had surgical procedures on 04/05/10 (Patients # 26, 27, 28 & 29), in that, the OR register did not capture documentation for A) disposition of specimens, or B) any unusual occurrences for each OR case.

During a tour of the OR area the morning of 04/12/10, the surveyor asked to see the OR register. The OR Director (Personnel # 3) stated that the OR register was online, and demonstrated how it could be pulled up to view. To view the hospital OR register, required 2 separate reports, so as to include hospital staff (circulating nurse and scrub personnel) who were present in each operation.
Review of these 2 combined reports revealed that the OR register did not capture documentation for A) disposition of specimens, or B) any unusual occurrences for each OR case:
1) Patient # 26 - Left ear revision of stapedectomy with/removal 69662.
2) Patient #27 - Left eye retinal detachment, with PPV, peel, buckle laser & G 67113.
3) Patient # 28 - Left thyroid lobectomy, with frozen section 60220.
4) Patient #29 - Direct Laryngoscopy, with operative removal of 31541.

In an interview the morning of 04/12/10, the OR Director (Personnel # 3) was asked if she could show where the disposition of specimens or any unusual occurrences were documented in the OR register. She said "no," and verified that these aspects had not been captured on either of the 2 reports used for their computerized OR register, and that it was incomplete.