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|BAXTER REGIONAL MEDICAL CENTER||624 HOSPITAL DRIVE MOUNTAIN HOME, AR 72653||May 29, 2015|
|VIOLATION: EMERGENCY SERVICES POLICIES||Tag No: A1104|
|Based on observation, policy review and interview, it was determined the Emergency Department (ED) failed to ensure expired supplies were not available for patient use as stated per policy in five of five ED rooms surveyed. The failed practice did not ensure only current supplies were provided for patient care. The failed practice created the potential to affect any patient in the ED. Findings follow.
A. Review of policy titled "Infection Prevention in Materials Management" stated, "All manufactured supplies will be rotated as supplies are received and dispensed. Older supplies will be issued first to insure optimal shelf life. Sterile supplies which are outdated or are contaminated by a break in the protective packaging or by moisture will be removed from stock and will not be dispensed for patient use." Review of policy titled "Infection Prevention in the Emergency Department" stated, "Central Sterile Supply policies on storage and shelf life of sterile supplies shall apply to the Emergency Department."
B. During a tour of the ED on 05/29/15 from 0800 to 0830 the following expired items were observed:
1) ENT (Ear, Nose & Throat) Exam Room - 11 of 11 BLL Culture Swabs - 10 expired 10/2014 and one expired 01/2014
2) Room 9 - eight of eight BLL Culture Swabs - four expired 09/2014, three expired 07/14, one expired 01/2014; Cotton Swabs - 24 of 30 expired 07/2014
3) Room 14 - four of five BLL Culture Swabs expired 02/2014, 03/2015 and two expired 10/2014
4) Room 16 - two of five BLL Culture Swabs - expired 03/2014 and 07/2013
5) Trauma room - one of one 4-0 18" Prolene Blue Monofilament Suture - expired 01/2015
C. During an interview at the time of the tour, the Emergency Department Director confirmed the supplies were expired.