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Based on record review, policy review, and staff interview the hospital failed to assure the patient's medical record contained a discharge summary for five of twenty one medical records reviewed (patient #'s 1, 4, 11, 12, and 17.


Findings included:


- Patient # 1's closed record review on 2/22/17 revealed an admission date of 11/18/16 for a total laparoscopic hysterectomy (a minimally invasive surgical procedure to remove the uterus. A small incision is made in the belly button and a tiny camera is inserted) with a discharge date of 11/22/16. Patient #1's medical record lacked evidence of a discharge summary.


- Patient # 4's closed record review on 2/22/17 revealed an admission date of 10/31/16 for a total abdominal hysterectomy (a surgical procedure that removes your uterus through an incision in your lower abdomen) with a discharge date of 11/3/16. Patient #4's medical record lacked evidence of a discharge summary.


Interview on 2/22/17 at 4:50 PM, Business Office Administrator, Staff G stated they were not able to locate the a discharge summary for patient #1 and they did not show a record of completion for a discharge summary for patient # 4. Staff G stated they will look into a process to review the records for completion of discharge summaries.


- Patient # 11's closed record review on 2/22/2017 revealed an admission date of 6/7/2016 for left total knee arthroscopy with a discharge date of 6/10/2016. Patient #11's medical record lacked evidence of a discharge summary.


- Patient # 12's closed record review on 2/22/2017 revealed an admission date of 8/31/2016 for left total knee arthroscopy with a discharge date of 9/2/2016. Patient #12's medical record lacked evidence of a discharge summary.


Business Office Manager Staff G interviewed on 2/22/2017 at 4:50 PM acknowledged they did not have a discharge summary for patient #11 and patient #12 and they would have to do a late discharge summary for these patients.


- Patient #17's closed medical record reviewed on 2/22/17 revealed an admission date of 6/15/16 for a Left Total Knee replacement with a discharge date of 6/18/16. Patient #17's medical record lacked evidence of a discharge summary.


Staff I, RN (Registered Nurse), informatics specialist, interviewed on 2/22/17 at 2:30pm acknowledged patient #17's medical record lacked a discharge summary.


- The hospital's policy titled, "Medical Record Section from Medical Staff Rules and Regulations", dictated, " ...The record of discharged patients shall be completed thirty (30) days following discharge ..."

Based on observation, interview and policy and procedure review the hospital failed to ensure expired medications were removed and discarded from 1 of 3 endoscopy rooms (#2) and from 1 of 5 pain management rooms (Room E). Failure to remove and discard expired medications puts all patients at risk for receiving medications that are ineffective and unsafe for use.


Findings include:


- Observation on 2/20/17 at 3:51 PM revealed endoscopy room 2 with a vial of Epinephrine (a medication used to treat severe allergic reactions to insect stings or bites, foods, drugs and other allergens) 1 vial expired 2/1/17.


Interview on 2/20/17 at 3:54 PM, Registered Nurse (RN) Staff E verified the expired vial of Epinephrine. The medications was removed, discarded, and replaced.


- Observation on 2/20/17 at 3:59 PM revealed pain management room E with Sodium Chloride (a liquid solution with salt added) 2 vials expired on 10/16.


Interview on 2/20/17 at 3:59 PM, RN Staff E verified the expired vials of Sodium chloride and removed, discarded, and replaced.


Policy and Procedure review on 2/20/17 revealed policy "Expired/Unusable Medications" states ...to ensure proper disposal of expired medications ...all outdated or unusable medications are to be removed from normal medication distribution and relocation to a designated area in the pharmacy ...upon locating expired medications in any medication storage area, the expired medication is to be taken to the pharmacy ...each outdated medication pulled from floor stock shall be replaced.

Based on observation, interview and policy review the hospital failed to ensure outdated and opened sterile medical supplies were removed from patient use in 3 of 6 anesthesia carts, 2 of 2 crash carts and 1 of 6 operating room cabinets (Operating room (OR) #2). This deficient practice or failure of the facility not to dispose expired or opened sterile supplies placed all patients at risk for receiving ineffective and contaminated supplies.


Findings include:

- Anesthesia Cart in Operating Room (OR) #1 observed on 2/20/2017 revealed the following opened sterile supplies:

1. One 60 milliliter (ml) syringe opened and out of sterile package.
2. Four suction tubings opened and out of sterile packaging.


- Anesthesia cart in Operating Room (OR) #2 observed on 2/20/2017 at 2:30 revealed the following opened sterile and expired supplies:

1. One 60 milliliter (ml) syringe opened and out of sterile packaging.
2. Twelve nasal pharyngeal tubes (designed to be inserted into the nasal passageway to secure an open airway opened and out of sterile packaging.
3. Four endotracheal tube (a plastic tube inserted into the airway) (ET) with expiration date of 2/2016, 7/2016 and two ET tubes with an expiration date of 11/2016.
4. Five suction tubings opened and out of sterile packaging.


- Supply cabinet in OR #2 observed on 2/20/2017 revealed the following expired supplies:

1. Two packages of 3 x 8 inch Adaptec (a Vaseline nonstick wound covering) expired 8/2015.


Director of Nursing (DON) Staff C interviewed on 2/20/2016 at 3:00 PM acknowledged all six anesthesia carts had opened nasal pharyngeal airways; they removed them all and replaced them with packaged nasal pharyngeal tubes. Nasal Pharyngeal airway package provided by DON Staff C on 2/20/2017 revealed labeling that read "single use, sterile until opened with an expiration date of 3/2021.


- Anesthesia Cart in OR #3 observed on 2/20/2017 at 3:15 PM revealed the following opened sterile and expired supplies:

1. Two 60 ml syringe opened and out of sterile packaging.
2. One ET tube expired on 1/2017, three ET tubes expired 10/2016 and two ET tubes expired 5/2016.
3. One ET tube sterile package opened.

DON Staff C interviewed on 2/20/2017 at 3:25 PM acknowledged expired and opened supplies saying they were going to have to order new nasal pharyngeal tubes because anesthesia had opened so many.


- Observation on 2/20/17 at 2:54 PM revealed the crash cart in the post-operative area failed to ensure removal and discard of the following expired supply:

1. Broselow intubation module (a color coded system that helps provide quick and accurate medication dosage and correctly sized equipment for treatment in pediatric emergencies) 1 yellow kit expired on 9/16.


- Observation on 2/20/17 at 3:11PM revealed the post operation phase 1 area failed to remove and discard the following expired supplies:

1. Intravenous needles (IV needles inserted in a vein to for administration of medications and fluids) 18g x 1 1/16th" (gauge a measurement for a needle size) 1 expired on 9/15, 1 expired on 1/16 and 1 expired on 1/13.


Interview on 2/20/17 at 3:21 PM, Assistant Director of Nursing Staff B verified the expired supplies and removed, discarded and replaced them immediately.


Policy titled Rotation of Supplies reviewed on 2/20/2017 at 4:30 PM directed: ..."1. Rotation of sterile inventory is important for inventory control, cost containment, and to guarantee supplies are safe for use. At least once every 30 days (during the first week of each month), all supplies are checked for expiration of sterility and package integrity" ...


- Observation on 2/20/17 at 4:10pm of the emergency (crash) cart revealed three packages of povidone-iodine (an antiseptic to clean the skin) swab sticks (3 swab sticks in each package), two with an expiration date of 10/16 and one with an expiration date of 8/16. The emergency cart also revealed an "oxygen flow modulator set (a set of plastic tubing that can be attached to a device in the patient's trachea (windpipe) to deliver oxygen to it so the patient can breathe) with an expiration date of 6/16.


Staff H, RN (Registered Nurse) interviewed on 2/20/17 at 4:10pm explained the crash cart supplies are to be checked monthly by a staff member from the different departments as assigned, and if any supplies that have expired or are close to the expiration date they are replaced.