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A. Based on observation, interview, and record review, the provider failed to ensure medical supplies in the emergency room (ER) and the operating room (OR) were not being used beyond their expiration dates. Findings include:

1. Observation on 10/11/11 from 3:45 p.m. through 5:00 p.m. of the ER revealed the following medical supplies and their expiration dates:
*Two 18-gauge intravenous (IV) catheters - August 2011.
*Two 24-gauge IV catheters - September 2011.
*Two petrolatum gauze pads - August 2010.
*Sixty-eight cotton-tipped applicators - July 2010.
*Five cotton-tipped applicators - January 2011.
*Seven silver nitrate applicators - September 2011.
*Six 4-0 polysorb sutures - August 2011.
*Four 5-0 Monosof sutures - August 2011.
*One bottle of antibacterial hand cleaner - December 2004.
There was also a clear plastic perineal bottle with a red label stuck to it labeled "alcohol." There was no date on that bottle when it had been filled with the alcohol. There was no way to tell how long that alcohol had been in that bottle and if the alcohol had expired.

Interview at that time with registered nurse A confirmed:
*The above supplies had expired and were still available for use.
*She was not sure why the alcohol was in that perineal bottle or how long it had been in there.
*The nursing staff were supposed to check the supplies in the ER for outdates when they had free time.
*Checking for outdates was included on the nursing duties checklist.

2. Observation on 10/12/11 from 11:50 a.m. through 12:25 p.m. in the OR revealed the following sutures and their expiration dates:
*Six 6-0 chromic gut - July 2008.
*Five 6-0 polysorb - December 2010.
*Two boxes (three dozen in each box) 6-0 surgipro - December 2010.
*One 6-0 coated Vicryl - July 2004.
*Three 8-0 coated Vicryl - January 2004.
*One 5-0 coated Vicryl - January 1991.
*Four 5-0 coated Vicryl - July 1995.
*One 5.0 Monosof - August 2011.
There was also a small bottle of antimicrobial hand gel on the anesthetist's cart with an expiration date of September 2004.

Interview that same day at 3:45 p.m. with the director of nursing (DON) confirmed the above sutures and antimicrobial hand gel in the OR and the antibacterial hand cleaner in the ER had expired. She was also aware of the expired supplies in the ER. She further revealed the nurses had a duties list that included checking the ER and the OR for expired medical supplies whenever they had time. She also stated she had thought the staff had been doing better with that task and was disappointed there had been outdates found.

3. Interview with the DON on 10/13/11 at 11:20 a.m. revealed she had thought the provider had a policy for checking medical supply outdates, because the staff had been doing the checks. She had been unable to find that policy before the end of the survey.

Review of the January through December 2011 nursing duties check list revealed ER and OR supplies had been scheduled for monthly checks for outdates. Further review revealed ER supplies had not been checked in April, May, and June 2011. OR supplies had not been documented as checked by a nurse from January through October 2011.



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B. Based on testing, observation, and interview, the provider failed to ensure one of one observed blanket warmer temperature was maintained at a safe temperature. Findings include:

1. Observation and testing on 10/12/11 at 11:20 a.m. of the nursing station blanket warmer revealed:
*The temperature of the blanket warmer was set at 110 degrees Fahrenheit (F).
*The temperature gauge on the blanket warmer read 160 degrees F.
*Testing by this surveyor revealed the internal temperature was 153 degrees F.

Interview on 10/12/11 at 11:30 a.m. with the DON revealed:
*Nursing staff did not monitor the temperature of the blanket warmers.
*Nursing staff only filled the blanket warmer with more blankets when it ran low.
*She had been told the safe temperature was 110 degrees F for the blanket warmer.
*She was not aware of a policy that guided the use of and monitoring of the blanket warmer.

Based on observation, policy review, and interview, the provider failed to:
*Maintain biologicals in a secure location in one randomly observed central supply room.
*Ensure one of two opened multi-use vials in the emergency room (ER) was dated when opened.
*Ensure two of two opened multi-use vials in the ER were discarded after 30 days.
Findings include:

1. The following items were found unsecured in the central supply room at 3:30 p.m. on 10/11/11:
*Fifteen 1000 milliliter (ml) bags of lactated ringers injection.
*Thirty 100 ml 0.9 percent (%) sodium chloride injection.
*Twenty-eight 250 ml sodium chloride injection.
*Twenty-six 1000 ml 0.9% sodium chloride injection.
*Eight 1000 ml 0.45% sodium chloride injection.
*Thirty-nine 1000 ml 5% dextrose/0.45% sodium chloride injection.

Review of the drug and biological storage policy revealed "All drugs and biologicals would be stored and locked patient areas which were not accessible to unauthorized persons. That policy included medications, intervenous solutions, saline flushes, crash cart supplies, antiseptics, syringes, needles, and other medical supplies."





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2. Observation on 10/11/11 from 3:45 p.m. through 5:00 p.m. of the ER revealed:
*One opened 10 milliliter (ml) multi-use bottle of lidocaine 1% had not been dated when opened to establish an expiration date of thirty days after opening.
*One opened 20 ml multi-use bottle of lidocaine hydrochloride 1% had a handwritten open date of 8/20/11. That bottle of lidocaine should have been discarded thirty days after opening or on 9/19/11.

Interview at that time with registered nurse A confirmed the above findings. She further stated multi-use bottles of medications should have been dated upon opening and were only good for thirty days from the opened date.

Interview on 10/12/11 at 4:10 p.m. and again on 10/13/11 at 11:25 a.m. with the director of nursing confirmed multi-use bottles of medications should have been dated upon opening. All multi-use vials of medications other than Lantus (insulin) expired in thirty days and should have been discarded.

Review of the provider's May 2011 medication disposition policy revealed all opened multi-use vials should have been dated thirty days from initial use to indicate when the vial should have been discarded. Lantus was discarded in 28 days of first use due to loss of potency.

Based on record review, interview, and policy review, the provider failed to ensure two of eight closed emergency room (ER) patients' (8 and 16)records reviewed included all appropriate documentation. Findings include:

1. Review of patient 16's closed ER medical record revealed:
*The patient had been admitted on 10/6/11 at 10:09 p.m. for lower abdominal pain and lower back pain.
*Earlier in the day patient 16 had been diagnosed with a urinary tract infection and had been started on Bactrim twice a day.
*Nurses' notes written at 10:20 p.m. revealed the provider had called with verbal orders for Toradol 30 milligrams (mg) intramuscular (IM) injection to be given to the patient for pain.
*The Toradol 30 mg IM had been given to the patient by the nurse at 10:32 p.m. and had been documented on the emergency room/outpatient medication administration record.
*There was no other written documentation in patient 16's record of the verbal or telephone order given by the provider to the nurse anywhere else in the chart.

Interview on 10/13/11 at 10:40 a.m. with registered nurse (RN) B revealed:
*All verbal orders received by an RN in the ER should have been read back to the provider and documented on the provider order sheet as a "read back" verbal order (RBVO).
*That provider order sheet with the RBVO should have then gone to medical records.
*Medical records would have then obtained the provider's signature on the RBVO "right away."

Interview on 10/13/11 at 10:40 a.m. with the director of clinical services confirmed there had been no RBVO in patient 16's closed ER record. She also stated they had "just missed that one."

Interview on 10/13/11 at 11:25 a.m. with the director of nursing (DON) also confirmed the above finding. She stated there should have been a RBVO documented on the ER record provider order sheet by the RN.

Review of the provider's May 2011 verbal orders policy revealed:
*Verbal or telephone orders required a verification or "read back" of the complete order to prevent errors in communication with the providers.
*The order would have then been documented on the order sheet "read back" to verify appropriate double-checks of medications ordered verbally.
*Telephone orders should have only been taken when there had been an urgent need to initiate or change an order.
*The physician should have signed the order on the next visit to the facility.

Review of the provider's July 2011 emergency department policies revealed:
*Medication should not have been administered by a nurse without an order from a provider on the staff.
*Verbal orders should have been written and countersigned.

2. Review of patient 8's closed ER medical record revealed:
*The patient had been admitted to the ER on 7/9/11 at 6:30 p.m. for a laceration of the left knee that had occurred at 8:00 a.m. that same day.
*The patient had been discharged in stable condition from the ER at 7:30 p.m. after the wound had been cleansed and dressings applied.
*There was no documentation on the ER medical record of any vital signs taken on patient 8 either on admission to the ER or at discharge.

Interview on 10/13/11 at 10:40 a.m. with registered nurse (RN) B revealed all ER patients should have had at least one set of vital signs completed and documented on admission to the ER.

Interview on 10/13/11 at 11:25 a.m. with the DON confirmed there had been no vital signs documented in patient 8's ER medical record. She further stated vital signs should have been taken on patient 8 on admission to the ER.

Review of the emergency department admitting policies reviewed July 2011 revealed:
*Admission to the ER included obtaining and recording vital signs.
*Nursing service personnel were responsible for assessing the patient and taking the patient's vital signs.
*The ER permanent record should have contained history, findings, treatment, and disposition of the case.
*The nurse should have made a real effort to secure adequate information for the physician and gotten a good history.
*Before going off duty the nurses should have checked the records of all the patients on their shift for completeness.