HospitalInspections.org

Based on observation and interview of the emergency room and crash carts, the facility failed to store drugs appropriately and keep drug efficacy dates current. This failed practice placed patients at risk for access to unmonitored drugs and limited or delayed treatment options during an emergency due to expired readily available drugs. Findings:

Observations in the emergency room on 9/11/18 at 3:25 pm, revealed multiple ophthalmic (eye) antibiotic ointments and solutions sitting on the counter in an open tray in the orthopedic exam room:

- Neomycin & Polymyxin B sulfates & Bacitracin Zinc Ophthalmic Ointment USP, 3.5 grams (g), Net Weight (Wt) 1/8oz.
- 1 Sulfacetamide Sodium Ophthalmic Solution USP, 10%, 15 milliliters (mL)
- 1 Cyclopentolate Hydrochloride Ophthalmic Solution USP, 1%, 2 mL
- 1 Tropicamide Ophthalmic Solution USP, 1%, 2 mL
- 1 Gentamicin Sulfate Ophthalmic Ointment USP, 0.3%, Net Wt 3.5 g (1/8 oz)
- 1 Erythromycin Ophthalmic Ointment USP, 0.5% (5 milligram (mg)/g), Net Wt 1g
- 2 Tetracaine Hydrochloride Ophthalmic Solution, 0.5%, 4 mL

During an interview on 9/11/18 at 3:40 pm, LN #1 stated the ophthalmic ointments and solutions should not be sitting out on the counter unmonitored.

During an observation of the crash cart located in the acute care department on 9/11/18 at 3:50 pm, revealed 2 Dextrose IV bag solutions that expired on "8/18" and 1 bottle of Lidocaine Hydrochloride 200mg/20mL that expired on 9/1/18.


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Based on observation and interview the facility failed to properly store medical supplies to maintain cleanliness, and optimal functioning. This failed practice placed patients at risk for infection and inaccurate cardiac monitoring. Findings:

Observations in the emergency department on 9/11/18 at 3:00 pm, revealed:

- electrocardiogram (EKG) electrode pads attached to each cardiac lead connected to the defibrillator;

- 2 open, undated packages of EKG electrode pads that were open to air on the crash cart and on the portable EKG machine.

-multiple blankets and paper towel rolls stored in the cabinets under sinks;


Observations in the acute care department on 9/11/18 at 3:50 pm, revealed:

- EKG electrode pads attached to each cardiac lead connected to the defibrillator;

- 2 open, undated packages of EKG electrode pads that were open to air on the crash cart and on the portable EKG machine.


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Based on observation, interview, and record review the facility failed to ensure: 1) high level disinfectants were used according to manufacturer's guidelines in the Sterile Processing and Radiology Department; 2) compromised sterile instruments and trays were not accessible for use; 3) laryngoscope blades had been cleaned and stored individually; 4) the integrity of the walls in the operating room had been maintained. The failed practices placed patients at risk for transmission of infectious organisms. Findings:

High Level Disinfectant

Observation in the ultrasound treatment room on 9/13/18 with Radiology Staff #1 revealed one opened gallon container of Cidex OPA, a high level disinfectant. The Cidex OPA container had been labeled to discard on 8/21/18.

In addition, a GUS Disinfection Soak Station for the ultrasound probes was present on the wall. The GUS disinfection container was filled with Cidex OPA and had a label to discard on 7/9/18.

During an interview, Radiology Staff (RS) #1 stated it was the radiology staffs' responsibility to monitor and document high level disinfection. In addition, confirmed both the Cidex OPA in the GUS container and the gallon container had expired and should have been discarded.

Review of the GUS Disinfection Soak Sanitation Log" and the endoscope high level disinfection logs revealed no documentation of the following:
" the date test strip had been opened;
" the discard date of the test strips;
" no open date of the gallon of Cidex OPA
" no discard date of the gallon of Cidex OPA
" no lot number of test strips used;
" no documented in/out time of submersion for HLD;
" no documented patient identifier.

Review of the manufacturer's instructions for use revealed, "CIDEX OPA Solution is a high level disinfectant for reprocessing heat sensitive semi-critical medical devices, for which sterilization is not suitable, and when used according to the Directions for Use... The user MUST adhere to the Directions for Use, as modification to the Directions for Use may affect the safety and effectiveness of the germicide." Review of the documentation logs for ultrasound probes and endoscopes did not follow the manufacturers' recommendations.

Observations on 9/12/18 revealed empty gallons of Cidex OPA in a regular trash container and not in a biohazard bag.
During an interview on 9/14/18 at 4:15 pm the Staff who perform high level disinfection for the endoscopes stated the empty containers of Cidex OPA were disposed of in the regular garbage. The facility had not policy on the disposal of the empty Cidex OPA containers.

Sterile supplies

Observations on 9/11/18 between 8:30 am and 4:00 pm, of the Emergency Code Carts in the Emergency Department and the Acute Care Nursing unit revealed multiple laryngoscope blades had been stored in a zipped laryngoscope blade kit and had not been stored in individual pouches to ensure sterility after use and maintain cleanliness before next use.

Observation in the Emergency Department 9/11/18 at 3:00 pm, revealed multiple sterile pouches of surgical instruments that were compromised. Multiple sterile packs had water marks; pouches of sterile instruments had discoloration of burn marks and water marks; and multiple pouches had no internal indicators confirming sterility.

Surgical suite

Observations on 9/12/18 at 9:30 am revealed the walls in the OR suite had multiple wall surfaces with peeling wall paper and cove base, leading to spaces and crevices that could harbor bacteria, dirt, dust, or moisture in a sterile environment.

Review of the surgery schedule from 5/10 - 8/18/18 revealed both endoscopic and open orthopedic cases had been scheduled in the OR.

During an interview on 9/13/18 between 9:00 am - 10:30 am the Facility Director confirmed the peeling wall paper and cove base in the OR. In addition, stated they had been looking at new wall sealant.

During an interview on 9/14/18 the Credentialing Staff stated no further surgeries had been scheduled due to the resignation of those Physician's.




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Based on record review an interview the facility failed to ensure the medical record was complete. Specifically, the endoscope number had not been documented and no documentation was found for extremity site marking or verification of the marking before a surgical procedure. Failure to document critical elements in the medical record prevents the facility to complete surveillance of past non-compliance that may have comprised patient outcome. Findings:

Record review on 9/14/18 between 9:00 am - 11:30 am revealed

Patient #17, admitted on 8/17/18 for a colonoscopy procedure had no documented scope number in the medical record.

Patient #18, admitted on 5/11/18 for a colonoscopy procedure had no documented scope number in the medical record.

Patient #22, admitted on 8/16/18 for a cyst removal on an extremity had no documentation of surgical site marking on the extremity or verification of marking prior to general anesthesia.

During an interview on 9/14/18 during the record reviews, HIM Staff #1 confirmed the lack of documentation for the scope number used and the site marking.

Review on 9/14/18 of the "Verification of Correct Site, Correct Procedure, and Correct Patient" policy, latest review date 11/15/18, revealed did not provide instruction on the documentation of site verification.



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