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.

BEAVER DAM COMMUNITY HOSPITAL 707 S UNIVERSITY AVE BEAVER DAM, WI 53916 May 27, 2014
VIOLATION: UNUSABLE DRUGS NOT USED Tag No: A0505
Based on observation, interview and policy review the hospital failed to ensure expired items were unavailable for use in 5 of 7 areas (Ortho Clinic, OR {Operating Room} central core storage, Patient Care Area {PCA} 2, PCA 3, and PCA 5) . This has the potential to affect all 22 patients served at the facility during this survey.


Findings include:

Facility policy #IC-025-13 entitled; "Supplies Labeling and Expiration Process" dated 02-2013, states; "Outdated, mislabeled or otherwise unusable medications, food and/or supplies will not be used"

"3. Each department is responsible for identifying expiration dates for the products they supply."

1. Per observation, while touring the Ortho Clinic with Compliance Officer A on 05/27/14 at 12:30 PM, it was noted that 85 outdated vacutubes with expiration dates of 03/14 and 30 surgical scrub/nail cleaners with expiration dates of 04/14 were kept in exam room #4 (used as a supply room). These findings were confirmed at the time of the tour by RN lead B who stated that clinic staff were responsible for removal of outdated supplies.

2. Per observation, while touring the OR Central Core Storage with Compliance Officer A on 05/27/14 at 1:00 PM, it was noted that 3 bottles of "Dr. Yaish Topical Solution" or tetracaine kept in the medication refrigerator were labeled with 2 different expiration dates; 02/2014 and 07/2014. Pharmacist C was interviewed at the time of the tour, C stated that the medication was incorrectly labeled.

3. Per observation, while touring PCA 2 with Compliance Officer A on 05/27/14 at 1:50 PM, it was noted outdated medications were kept in the medication room refrigerator. Two 10 ml vials of Succinylcholine with expiration dates of 12/01/2013 were found. Director of Medical-Surgical Services D was interviewed at the time of the tour, D stated that the outdated medication should have been removed.

4. Per observation, while touring PCA 3's Supply Core with Compliance Officer A on 05/27/14 at 2:00 PM, approximately 50 outdated Hemoccult cards (04/2014) and 2 culture swabs (04/2014) were found on the storage shelves. Director of Medical-Surgical Services D was interviewed at the time of the tour, D stated that the outdated supplies are monitored by the unit staff.

5. Per observation, while touring PCA 3's Supply Core with Compliance Officer A on 05/27/14 at 2:10 PM, approximately 10 outdated Hemoccult cards (04/2014), 1 pediatric Fleets enema (04/2014), and 1 mineral oil Fleets enema (01/2014) were found on the storage shelves. Director of Medical-Surgical Services D was interviewed at the time of the tour, D stated that the outdated supplies should have been removed.
VIOLATION: DISPOSAL OF TRASH Tag No: A0713
Based on observation, interview and policy review the hospital failed to ensure availability of spill kits for hazardous waste. in 1 of 1 area (Family Practice clinic). This has the potential to affect all 22 patients served at the facility during this survey.


Findings include:

Facility policy #EC-016-12 entitled; "Hazardous Materials & Waste Spills" dated 12/2011 states its purpose: "To ensure that personnel are safely handling, transporting, storing, and disposing of hazardous materials. and to ensure that personnel are prepared to properly respond to the spill of a hazardous material."

The MSDS (material safety data sheet) for 10% Neutral Buffered formalin states;

"EMERGENCY OVERVIEW
Warning! May cause respiratory tract irritation. Harmful if inhaled. Harmful if absorbed through the skin. May cause lung damage. May cause pulmonary edema. May cause eye irritation and transient injury. May cause severe skin irritation. May cause reproductive and fetal effects. Contains formaldehyde which can cause cancer. May cause allergic respiratory and skin reaction."

1. Per observation, while touring the procedure room in the Family Practice Clinic with Compliance Officer A on 05/27/14 at 1:30 PM, approximately 30 specimen containers containing 30 ml of 10% Neutral Buffered formalin were found kept in the cabinet above the sink. Clinic Staff E was interviewed at the time of the tour, E stated there was no spill kit available for a formalin spill and was not aware of any special procedure for that eventuality.