HospitalInspections.org

Based on document review and interview, the facility failed to carry out an annual periodic evaluation of the services and programs provided.

During review of documentation provided by staff #O, the facility was unable to produce a documented review (program evaluation) of the utilization of services for 2010. The last annual review conducted was on 7/29/2010 for the services of 2009.

The facility failed to carry out a review of the utilization of services, including the number of patients served and the volume of services. The facility failed to review and update policies and procedures annually. Due to the lack of a program evaluation, the facility was unable to take into consideration the results of an evaluation to determine if any changes were needed.

During an interview with the Director of Quality on 04/18/2012 at 0900, the findings were discussed and confirmed.

Based on document review and interview the facility failed to have a quality assurance program that included corrective actions, evaluation of corrective actions, and measures to improve quality on a continuous basis resulting in the potential to fail to improve upon quality issues identified as being in need of improvement.

On 4/17/2012 at approximately 1500 during document review it was revealed the facility's quality assurance program did not have action improvement plans identified nor a timeline for the reassessment of improvement measures. Each department identified areas for improvement and goals set for improvement but failed to have a distinct action plan or timeline in which the goals were to be reanalyzed.

On 4/18/2012 at approximately 0900 a meeting with the Director of Quality confirmed the quality assurance program was not distinct in the action plans to be initiated for each department and the timelines for monitoring and reanalysis were "ongoing".

Based on observation, interview and policy review, the facility failed to ensure that medications and biologicals are maintained in accordance with acceptable standards of practice. Findings include:

During observation in the Radiology department on 04/16/2012 at 1100, it revealed that the crash cart contained two (2) 500 ml bags of normal saline that were both outdated October 2010.

During a review of the crash cart in the emergency department at 1135, it revealed one (1) 500 ml bag of normal saline outdated March 2012.

A review of the West Shore Medical Center policy titled Nursing-General Crash Cart Checks last revised 12/11 reads under 1. "Facility-wide checks of crash carts are performed on a regular basis to ensure: d. Items with expiration dates are replaced."

The findings in both the radiology department and the emergency department were confirmed by staff B at the time of the observations.

On 04/17/2012 at 0900, a visit and observation was conducted at the off site location of West Shore Medical Center Physician Services-General Surgery with staff K (Physician Practice Office site Coordinator.).
The following items were found to be outdated per manufacture expiration date, opened and not dated or a multidose vial opened greater than 28 days.
A. Exam Rooms #1, #2 and #3 (One in each room)
One (1) opened jar of Silver Nitrate- not dated when opened
One (1) opened bottle of Normal Saline-not dated when opened

B. Medication Room
One (1) multidose vial Sensorcaine-opened 02/29/2012
Three (3) unopened vials of Lidocaine- outdated April 1 2012
Two (2) opened vials of Lidocaine-dated as opened on 02/13/2012-had outdated on 01/04/2012
Two (2) vials of Lidocaine outdated March 1 2012.
One (1) opened tube of Lidocaine Jelly-not dated when opened

Also noted during the observation was the storage of patient care items under the sink in 3 of 4 examination rooms. Items stored under the sinks were extra gloves, pillows, bath blankets and paper used to cover the examination tables.

A review of policy titled Medical Management policy # 7.02 Monitoring Medications it reads under #3 Non controlled substances-injectables section C. Dispensing 4) "When opened, all vials are labeled with date and initials of the employee who opens the vials. " d. Disposal 2) "Dispose of opened medication 30 days after opening."

Observations and findings were confirmed by staff K at the time of the findings.

During an interview with staff J on 04/18/2012 at 1430, a request was made for a policy addressing the storage of patient care items under sinks or under sink storage. Staff J was unable to locate a policy for the Physician Practice that addressed under sink storage.












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On 04/16/2012 at approximately 1330 during observation on the medical surgical floor findings include:

Crash cart: Two (2) Arterial blood gas syringes outdated 04/2011 and 11/2011
Two (2) Tincture of benzoin packets outdated 08/2011
Four (4) chlora prep vials outdated 05/2011
Two (2) 500 ml bags of normal saline outdated 03/01/2012
Clean supply room: One (1) Paracentesis tray outdated 10/2011
Patient supply cupboards located outside each patient room. In 4 of 5 cupboards the following items were found:
Nine ( 9) culture tubes; two ( 2) outdated -12/2011, two (2) outdated -11/2011,
two (2) outdated - 08/2011, one (1) outdated -07/2011,
and two (2) outdated -11/2010
Eight (8)-tincture of benzoin packets two (2) outdated -05/2011, and six (6) outdated -07/2011

Findings verified by staff #E during observation. Staff E was unable to provide a policy for the proper storage and handling of medical supplies and the removal of outdates.