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Based on observation, record review and interview the medical Director failed to enforce the facility's policy and procedure for the crash cart by having expired supplies in the treatment area and available for patient use.

Findings:

Record review of the facilities policy and procedure for expired medication, titled "Crash Cart", dated, 10/17/23.

"Purpose: to maintain functional integrity of emergency medications and equipment for immediate use in all areas of the hospital."
"The pharmacy will monitor the medication trays monthly to ensure appropriate medications par levels, and to verify the expiration dates."
"Once a month materials management and a licensed nursing staff will open the supply drawers of each crash cart to inspect the contents and expiration dates will be compared to the crash cart."

Observation on 05/29/24 at 10:30 am while reviewing stock in the Crash cart the following expired items were found in the crash cart ready for patient use:
01. Laryseal- Laryngeal mask airway size 5.
Ref- 038-94-35ouLot-161100114
Expired: 10/2021
Quantity: 2

02. Laryseal- Laryngeal mask airway size 4.
Ref- 038-94-240u
Lot-190600068
Expired: 05/2024
Quantity: 2

03. Milligan clamp in a sterilizer bag did not contain a sterile indicator or a date when sterilized. The sterility of equipment cannot be verified. Equipment clamp should not be in cart.

04. Parker Flex Tip PFHV trach tube size 7.5
Ref: H-PFHV-75
Lot: 1710-HV-1874L
Expired: 09/28/2022
Quantity: 2

05. Flexicare Laryseal Cuff inflator syringe
Lot: 130801551
Expired: 08/2018
Quantity: 1

06. Parker Flex tip PFHV trach tube size 6.0
Lot: 1808HV13001
Ref: H-PFHV-60
Expired: 07/28/23
Quantity: 2

07. Parker Flex tip PFHV trach tube size 6.5
Lot: 11611-HV-1790J
Ref: H-PFHV-60
Expired: 10/28/21
Quantity: 2
08. Dopamine HCL 200mg 40mg/ml
Lot: 08-033DK
Expired: 08/21/21

09. ET tube Hudson RCI
Ref: 5-10114
Expired: 03/15/2022
Quantity: 2

10. Naloxone HCL 0.4/ml 1ml bottle
B. No. 304467
Expired: 12/2023
Quantity: 2

Interview with the CEO, on 05/30/2024 at 10:35 AM, revealed that the crash cart should have been checked at least once a month by the pharmacy and once a month by the Materials management and a licensed nurse.

Based on observation, review of policies and confirmed in staff interview the person responsible for the daily operation of the kitchen failed to ensure that the storage temperature of food were maintained per the facility policy and health code.

Findings included:

Review of the facility policy Nutritional Services Department Plan (revised 11/2/2023) it stated "nutritional services follows the food service standards as issued by the local Health Department under which it is licensed."

Review of the City of Houston, Code of Ordinances, Chapter 20 Food and Drugs (2023) under Food Storage, it stated "if time without temperature control is used as the public health control up to a maximum of four hours:[1]The food shall have an initial temperature of 41°F (5°C) or less when removed from cold holding temperature control, or 135°F (57°C) or greater when removed from hot holding temperature;[2]The food shall be marked or otherwise identified to indicate the time that is four hours past the point in time when the food is removed from temperature control;[3]The food shall be cooked and served, served at any temperature if ready-to-eat, or discarded, within four hours from the point in time when the food is removed from temperature control; and[4]The food in unmarked containers or packages, or marked to exceed a four-hour limit shall be discarded."

Review of the facility policy Food Delivery (revised 10/6/2023), it stated "nutritional services personnel or nursing staff will pick up trays within two hours after meal service and return the trays to the designated are for dirty trays. If trays are left on the unit past the two-hour window, they are to be discarded as the food is no longer safe for consumption."

Surveyor observations on 5/30/2024 revealed the facility received their meals from their sister facility located at 123 Vision Park Blvd, Shenandoah, TX. The meals were transported in big black insulated carriers. Each tray was marked for each specific patient. Warm trays were warm to the touch and cold trays were cool to the touch.
Cold items of fruit in individual styrofoam containers were in a clear plastic bin. A clear plastic bag contained the afternoon snack of popsicles was next to the fruit in the same plastic bin. The clear plastic bin did not have an ice pack to ensure temperature maintained and no thermometer was observed to monitor for temperature.

All food observed had no date or time of preparation or food expiration.

An interview with Staff #1 on 5/30/2024 at 1:30 PM in the conference room confirmed the above findings.