Initial Comments:
This report is the result of a an annual Registration survey conducted on March 14, 2012, at the Hillcrest Women's Medical Center. It was determined that the facility was in compliance with the requirements of the Pennsylvania Department of Health Regulations 28 Pa Code, Chapter 29, Subchapter D, Ambulatory Gynecological Surgery in Hospitals and Clinics.
Plan of Correction:
No POC Required STANDARD
Recommendation
Name - Component - 00
Observations:
A tour of the facility conducted on March 14, 2012, resulted in the following recommendations. Submission of a plan of correction is encouraged, but not required.
Findings:
1) The storage room on the second floor had several outdated items: four 1000 ml containers of normal saline irrigation solution that expired in September 2009, and 20 Surflo IV Catheters that had expired in April 1998.
2) 25 BD Eclipse Injection Needles that had expired in September 2009, were observed in a supply cabinet in Procedure Room #2.
3) One 1000 ml container of sterile water that had expired March 2008, in the bottom shelf of the metal cabinet outside of Procedure Room #2 .
4) A review of the Patient Safety Committee meeting minutes revealed that the Committee only met twice in the last year. (June 2011 and October 2011)
5) A review of the crash cart revealed that the weekly checks for completeness and operation of the crash cart did not show when the AED and the suction equipment were tested.
Plan of Correction:POC is optional and not required.
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