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GREENE COUNTY HOSPITAL CAH
DRUG AND BIOLOGICALS
Tag No.: C0886
Based on observation, staff interview, and policy and procedure review, the facility failed to ensure equipment, supplies, and medications used in treating emergency cases are kept at the Critical Access Hospitals (CAH) and readily available for treating emergency cases in three (3) out of five (5) departments surveyed.
Findings Include:
Observation on 1/11/2022 at 11:00 a.m., during a tour of the Emergency Room Trauma Room, the following expired supplies were found: On the back wall of trauma room:
Trach cannulas: (2) expired (exp) 1/2019 and (4) exp 5/14/2020
MAC 3 disposable intubation blades: (2) exp 6/14/2018
McGrath blade X3: (1) exp 6/22/2017
On Adult Crash Cart:
Slick endotracheal stylet 10FR: (2) exp 12/2018
IV administration set 15 drops/ml: (2) exp 12/31/2021
NS 10cc syringe: (5) exp 11/29/2019
Care Site Y-type blood tubing: (1) exp 7/11/2019
Pediatric Crash Site:
Twin Catheters: (2) exp 8/2020
Pediatric cuffed endotracheal tube: (1) exp 4/2019
BARD Nasogastric tube: (1) exp 9/30/2021
Observation on 01/13/2022 at 10:00 a.m., during a tour of the Radiology Department revealed the following expired medications and supplies were found:
In Xray Emergency box:
Adrenaline 1mg/1ml: (1) exp 9/2021
Normal Saline 10cc syringe: (5) exp 8/31/21
INT: (1) exp 7/2014
18g IV catheter: (3) exp 8/2021
22g IV catheter: (3) exp 1/1/21
IV start kit: (2) exp 9/30/21
On Supply Cart in Xray:
16 oz bottle of Hydrogen Peroxide: (1) exp 2/2021
INT: (1) exp 3/2021
LuerLock Vacutainer: (1) exp 1/2014
Box of 50 SkinPrep wipes: (1) exp 12/2018
In CT Emergency Box:
Adrenaline 1mg/1ml: (1) exp 9/2021
NS 10cc syringe: (5) exp 8/31/21
LuerLock INT: (1) exp 6/2015
IV start kits: (2) exp 9/31/21
22g IV cath: (3) exp 1/1/22
18g IV cath: (3) exp 8/202
Adult Ambu Bag": (1) "exp 4/2016
In CT room cabinet: RediCat Oral Suspension 450ml: (4) exp 1/2021
Interview with Nurse Practitioner (NP) on 01/11/2022 at 11:10 a.m., during tour of trauma room, revealed that this facility has a lot of traumas and "codes from the prison and local ATV Park", and they go through a lot of supplies due to this. Stated that LPN comes in every other day and checks expiration dates. Stated he was surprised that any expired supplies were found.
Interview with LPN, on 01/11/2022 at 11:15 a.m., revealed that she is responsible for the expiration dates in the ED and Central Supply. She states that she is usually "OCD" (obsessive compulsive) about the expiration dates and doesn't understand how she missed these items.
Interview with Administrator, on 01/11/2022 at 11:20 a.m., about expired supplies found in trauma room, revealed that the LPN, is usually very good at keeping up with expiration dates.
Interview on 01/13/2022 at 10:10 a.m. with Radiology Technician, revealed that she is responsible for expiration dates in Radiology Department. States that she has "so much work on her" and "has no help" that she feels overwhelmed.
Review of facility Policy Number 13-01, "Floor Stock", revealed " ...the pharmacy shall ensure the integrity (i.e., security, adequacy, storage, conditions, etc.) of floor stock. Pharmacy personnel shall check this stock regularly and report discrepancies to appropriate supervisors...".
Review of facility policy number 13-03, "Inspections: Patient Care and Drug Storage Areas" revealed:" ... Inspections shall include the main pharmacy, all nursing care units, drug storage units, emergency boxes and emergency carts, and all other areas where drugs are dispensed, administered, or stored ...".
Review of Policy 13-02, "Requisitions" revealed: " ...the pharmacy shall control the requisitioning and dispensing of drugs and supplies to patient care areas and to other departments and services...".
EMERGENCY AND SUPPLIES
Tag No.: C0888
Based on observation, staff interview, and policy and procedure review, the facility failed to ensure equipment, supplies, and medications used in treating emergency cases are kept at the Critical Access Hospitals (CAH) and readily available for treating emergency cases in three (3) out of five (5) departments surveyed.
Findings Include:
Cross refer to C-0886 for the facilities failure to ensure and maintain readily available emergency supplies used in life saving procedures.
During Exit Conference on 01/13/2022 at 12:30 p.m., survey findings were discussed, and no further documentation was submitted for review.