The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

MARGARET R PARDEE MEMORIAL HOSPITAL 800 N JUSTICE ST HENDERSONVILLE, NC 28791 Nov. 16, 2017
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation during tour and staff interview the facility failed to remove expired equipment accessible to staff for use on patients from patient care areas.

Findings included:

Observation during tour on 11/14/2017 at 1600 showed the following equipment was accessible to staff for immediate use on patients in the emergency department: Two Percutaneous Sheath Introducer Kits which expired on [DATE] (1 month and 15 days ago); an Angiography Drape Pack which expired on [DATE] (14 days ago); a Xeroform Occlusive Gauze Strip Overwrap which expired on ,d+[DATE] (5 months and 14 days ago), an Internal Jugular Puncture Kit which expired on ,d+[DATE] (9 months and 14 days ago); and two Blood Culture Collection Tubes which expired on [DATE] (12 days ago).

Interview conducted on 11/14/2017 at 1630 with Care Coordinator (CC) #1 revealed no one person is assigned to inspect the emergency department for expired equipment, rather the task is assigned on occasion to various staff members, normally nursing assistants throughout their shifts. Interview revealed CC #1 was not aware of any policy in reference to removing expired equipment from the emergency department, however expired equipment should not be accessible to staff for use on patients in direct care areas.

NC 717