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Based on observation and interview, it was determined the facility failed to ensure equipment and supplies commonly used in life saving procedures were readily available for treating emergency cases.

Findings were:

Facility Policy entitled, "Crash Carts", stated in part, "Two adult crash carts and one Pedi cart will be stocked and available for use at all times. The Pedi Cart is located in the emergency room and the adult Carts are located in the Emergency Room and across from the nurse's Station.
Routine Crash Cart Checks: Nursing staff will be responsible for checking whether the crash cart has been open and/or locked when doing their shift Defibriller Checks.
Checks will be done twice each month (by day and night shifts). Check expiration dates on all supplies and if expired supplies are found, they are to be replaced. Checks should be verified by two nursing personnel (one being a licensed nurse)."

Facility Policy entitled, "Risk Management-Emergency Room Safety" states in part, "#9. Proper equipment and supplies:
a. Equipment should be checked prior to use.
b. Sterilized instruments are to be checked monthly by Central Supply.
c. Stock is checked daily by Central Supply


In a tour of the facility the morning of 11/07/2017, the following expired supplies were available for use in the Emergency Department:
ER Trauma Room:
Airway 30 Fr. Expiration date 2017-10
Vaseline Petrolatum Gauze 3X9 inches X5 expiration date 2015-09
Vaseline Petrolatum Gauze 3X9 inches X3 expiration date 2017-01
Vaseline Petroleum Gauze 3X9 inches X 3 expiration date 2016-12
Pink Laboratory tube expiration date 2016-03
Green Laboratory tube expiration date 2016-03
Protected Disposable Scalpel X2 expiration date 2017-09
Yankauer Suction Instrument Expiration date 2017-05
Neonatal Pediatric Endotracheal Tube Holder X2 expiration date 2015-02
Neonatal Pediatric Endotracheal Tube Holder X1 expiration date 2014-02
Suction Connecting Tubing 6 feet long X3 expiration date 2015-08
Suction Connecting Tubing 6 feet long X1 expiration date 2015-09
Suction Connecting Tubing 6 feet long X1 expiration date 2016-08

Emergency Department Room #3:
Plain Packing String 1X15 opened bottle available for use
Other medical supplies stored in an open closet were hung on a board with hooks, some of the packaging had been punctured with the hook making some supplies no longer sterile and inappropriate for patient use.

The above findings were confirmed with the Chief Nursing Officer on 11/07/2017.

Based on document review and staff interview the facility failed to follow policy and procedures related to storage requirements for blood and blood products.

Findings were:

Facility Policy No. 1 Blood and Blood Components Storage, reads in part, "B5. Check of Functionality of system. The laboratory also undertakes a monthly check of the blood bank monitoring system. Alarm checks should also be done after any maintenance operation or temperature control adjustments."

Review of facility Blood Bank Refrigerator Checks Log revealed the "Check on Functionality of System" monthly alarm checks were not done April 2017 and June 2017.

The above finding was confirmed by the Laboratory Manager during a tour on the morning of 11/07/2017.

Based on review of facility documents, observation and interview, the facility failed to ensure that the premises were clean and orderly.

Findings were:

In an article published by Spectrum Health in July, 2014 it was stated "The heavier corrugated cardboard shipping boxes might harbor vermin or insects and spread the pests to areas where the boxes are stored after delivery. Corrugated cardboard boxes are not appropriate as storage units in medical or clean supply rooms. These boxes are not appropriate because they are an excellent harbor for insects and pests."
In a tour of the Radiology Department on the morning of 11/07/2017 revealed the following:

A large foam wedge pillow with no covering was stored on a top shelf
Oxygen concentrator with no wheel was stored on the floor in CT room
Biohazard container was stored on the floor in CT room
Radiation protective aprons were dirty with stains. Radiology Staff #1 stated, "They could probably all be wiped down"
2 Trash Cans with no lids
CT scanner footrest attachment stored on the floor when not in use.
"Pappose board" on floor leaning against the wall was dusty

Tour of the Emergency Department and other patient areas on the morning of 11/07/2017 revealed the following:

ER Trauma Room under-sink was used as storage area
Water stained ceiling tile noted in bathroom next to Lab,
2 water stain ceiling tiles by nurse's station,
Call light in patient bathroom by laboratory not secured
7 cracked/chipped floor tiles on patient unit hallway between double doors
Patient room 110 had a layer of dust on the window blinds, this could lead to patient complication and/or infection control issues.

Tour of the Kitchen on the morning of 11/07/2017 revealed the following:

No trash receptacle by hand washing sink.
Chipped paint and rust on door frame entry to dishwasher room.
3 water stain ceiling tiles
Multiple corrugated cardboard delivery boxes were used to store food items in the freezer.
17 corrugated cardboard delivery boxes were used to sore food items in the dry goods storage room,
Rubber flaps covering the food disposal were torn away allowing for potential splash-back when the disposal is in use.
Ceiling vent above the food preparation area was dusty and dirty, blowing lint in areas where food is being prepared.

Small hole on the walls were noted throughout the hospital from nails/screws where picture/frames had been hung

The above findings were confirmed by the Chief Nursing Officer and the Support Service Manager on the morning of 11/07/2017.