HospitalInspections.org

Based on observation, interview and record review the hospital failed to ensure the patients' right to receive care in a safe setting in that 1) expired supplies and equipment were available for patient care and 2) sterilized instruments were not prepared to reduce the bioburden in 1 out of 3 hospital patient care areas surveyed (Emergency Department, ED)

Findings included:

1) During a tour of the hospital's emergency department on 01/31/12 between 3:40 PM and 5:05 PM, the surveyors observed expired supplies and equipment available for use in the Emergency Department (ED) including

ED Trauma Room 2
4 packaged safety intravenous catheters 16 gauge 1-1/4 inch expired 04/10
1 pediatric /infant lumbar puncture tray with an expiration date of 07/11

ED Trauma Room 1:
1 autoguard winged shielded intravenous catheter 18 gauge expired 03/11

ED Room 210
1 packaged hypodermic needle 25 gauge expired 04/10

During the tour, Hospital Personnel #2 verified the above expired items.


2) During a tour of the hospital's emergency department on 01/31/12 between 3:40 PM and 5:05 PM, the surveyors observed sterilized instruments for use in patient care were not prepared to reduce the bioburden in 1 out of 3 hospital patient care areas surveyed (Emergency Department, ED) including


ED Trauma Room 2
2 sterilization pouches with hemostat tips closed

ED Trauma Room 1
3 sterilization pouches with hemostat tips closed
1 sterilization pouch with scissor tips closed

ED Room 210
1 sterilization pouch with hemostat tips closed

During the tour, Hospital Personnel #2 verified the instrument tips touched.

An interview with Hospital Personnel #18 on 02/02/12 at 10:50 AM reflected the sterilization pouches with instruments touching "did not get pulled."

Review of the hospital policy "Decontamination and Sterilization of Sterile Supplies" approved 02/25/10 reflected "instruments, such as scissors, clamps, hemostats, etc. will be packaged open to allow for proper sterilization."

Based on observation, interviews and record review, the facility failed to ensure that outdated, unusable drugs and biologicals were not available for patient use, in that expired drugs were observed in 1 out of 3 hospital patient care areas surveyed (Emergency Department, ED).

Findings included

During a tour of the hospital's emergency department (ED) on 01/31/12 between 3:40 PM and 5:05 PM, the surveyors observed expired drugs and biologicals available for patient use including:

ED Trauma Room 2:
5 -20 ml [milliliter] bottles of 1% Lidocain 10 mg/ml [milligrams per milliliter], expired 01/01/12.
1-20 ml bottle of 2% Lidocain 10 mg/ml, expired 12/10/11
2 vials of Nitropress Sodium Nitroprusside injection 50 mg/2 ml, expired 01/01/12

ED Trauma Room 1:
1 Quick Clot First Response Advanced Clotting Sponge 50, expired 11/11

ED Nurses' Station:
1 bottle of 2% Lidocain injection in the locked rapid response induction box, expired 01/01/12

ED Room 210
1 bottle of Peroxide 118 ml expired 11/11

During the tour, Hospital Personnel #2 verified the above expired items.

An interview with Hospital Personnel #17 on 02/02/12 at 11 AM reflected the expired medications in the ED "were missed."

Review of the hospital policy "Drug Storage" revised 04/06/10 reflected "all areas are checked daily by pharmacist or tech; all outdated drugs are pulled from all areas, placed in box in office and returned in a timely manner."