Ridgeview Medical Center

“PROVISIONS CFR(s): Provisions include equipment, supplies, and medication used in treating emergency cases. Such provisions must be kept at the hospital and be readily available for treating emergency cases to meet the needs of patients. The available provisions must include the following: (i)Drugs, blood and blood products, and biologicals commonly used in life saving procedures; (ii) Equipment and supplies commonly used in life-saving procedures; and (iii) each emergency services treatment areas must have call in system for each patient. This Standard is not met as evidenced by: 48300 Based on interview and document review, the facility failed to ensure staff were knowledgeable about, and followed, hospital policy related to ensuring life-saving medical equipment was not expired when the equipment lacked a manufacturer expiration date. This had the potential to affect patients who required life-saving emergency supplies. Findings include: During a tour of the emergency department (ED) on 5/13/26 at 9:00a.m., a daily pediatric crash cart checkoff sheet was observed which instructed that each day the infant and pediatric Ambu bags (valve masks used during cardiopulmonary resuscitation [CPR] to help deliver air into the lungs) were to be checked. Both sections housed check marks on 5/1/26 through 5/13/26. An infant Ambu bag identified a manufacture date in 2017 and the pediatric Ambu bag identified a manufacture date in 2018. During the tour, registered nurse (RN)-A, the nurse manager, stated the charge nurse checked the crash carts daily which were indicated as completed by a check mark. RN-A explained that part of the check should be to check the “outdate” (date an item was no longer to be used). RN-A stated the Ambu bags were good for five years past the manufacture date, so the inspected pediatric and infant Ambu bags needed to be replaced. During an interview on 5/13/2026 at 9:48 a.m., RN-B stated she often worked as a charge nurse and completed the crash cart checks. During a crash cart check, RN-B confirmed all the drawers were locked and the required supplies were on the cart; however, RN-B stated she did not check the expiration dates of the supplies as she thought someone else tracked this. RN-B stated if a supply item did not have an expiration date listed on the package, she would contact the materials department to see if the supply item was still okay to use. During an interview on 5/13/2026 at 1:12 p.m., RN-C stated she was currently a charge nurse and completed crash cart checks. During a crash cart check, RN-C confirmed all the drawers of a crash cart were locked and the required supplies were on the cart; however, RN-B stated she did not check the expiration dates of the supplies and did not know who would check them. RN-B indicated she would call central distribution (materials department) to ask how long the supply item was good for if the supply item did not have an expiration date. An ED Pediatric Crash Cart Content “#1” form, dated 2026, identified the contents of the cart, the item number, the manufacture’s number, quantity, and expiration dates. The expiration date section for the following cart contents lacked identified expiration date entries: electrode for the defibrillator, infant Ambu bag, pediatric Ambu bag, The following contents identified the expiration date section had a hand drawn line across the associated box: 40 millimeter (mm) soft oral airway, 30mm soft oral airway, 10 French suction catheter, 12 French suction catheter. The form lacked the identified date of any check, or the staff member who performed the check. An ED Pediatric Crash Cart Content “#2” form, dated 2026, identified the contents of the cart, the item number, the manufacture’s number, quantity, and expiration dates. The expiration date section for the following cart contents lacked identified expiration date entries; however, contained a hand-drawn line across the expiration date entry box: Broselow tape 2019 “typically updated every 2 years or when new tape available,” infant Ambu bag, pediatric Ambu bag, 40 mm soft oral airway, 30mm soft oral airway, 10 French suction catheter. The form lacked the identified date of any check, or the staff member who performed the check. A NICU (neonatal)/Nursery Crash Cart Contents, dated 2026, identified the contents of the cart, the item number, the manufacture’s number, quantity, and expiration dates. The expiration date section for the following cart contents lacked identified expiration date entries; however, contained a hand-drawn line across the expiration date entry box: defibrillator pads, four different sizes of neonatal blood pressure cuffs, catheter with mucus trap, catheter suction kits (three different sizes), infant, neonatal, preemie resuscitation masks, infant Ambu bag, AA batteries, 40mm oral airway, sterile scissors. The form lacked the identified date of any check, or the staff member who performed the check. Monthly checklists to provide evidence the crash carts were checked monthly for expired items was requested; however, none were provided - only the three forms dated 2026 were provided. During an interview on 5/13/2026 at 1:33 p.m. director of materials management (DMM) stated the materials department assisted with managing outdates on all crash carts. This process was managed with a paper check list for each crash cart and looked at monthly. DMM did not know how long Ambu bags could be used past the “manufactured on” date. During a follow up interview on 5/14/2026 at 1:19 p.m., DMM stated the facility wasn’t “doing a great job checking products with no expiration dates, and a product with no expiration date would be replaced if it looked damaged, was yellowing, and/or the packaging was wrinkled or open. During an interview on 5/13/2026 at 1:46 p.m., inventory and logistics manager (ILM) stated crash carts were checked once a year and all expiration dates were written on the Crash Cart Contents form. Then each month the form was reviewed and any supplies expiring that month were replaced. The ED Pediatric Crash Cart Contents form was reviewed with ILM. ILM stated only expiration dates printed on the supply item bag were documented on the form. Ambu bags had a manufactured-on date, so a line was drawn through the expiration date column. ILM did not know how long Ambu bags could be used past the manufactured-on date. During a follow up interview on 5/14/2026 at 11:54 p.m. ILM stated no one had asked about the manufactured-on date(s) or potential outdate for the Ambu bags. ILM would need to look into what the shelf life was for the Ambu bags. ILM stated a product used past the expected shelf life could break or might not work the way it was designed to work. During an interview on 5/14/2026 at 10:28 a.m., distribution technician (DT)-A stated she was responsible for the “yearly” documentation of the crash cart contents form and the monthly “review” of the form. DT-A stated a line was drawn through the expiration date column if a supply item did not have an expiration date printed on the packaging, and the manufactured-on date was not written down on the crash cart contents form. If a supply item did not have an expiration date, DT-A would check the packaging for openings and “crinkles,” and would look at the supply item through the packaging to see if it “looks old,” was discolored, or had cracks. DT-A “probably wouldn’t question” an Ambu bag dated 2018 if it “still looked ok”. DT-A did not know if there was a process for what to do it a supply item only had a manufactured-on date versus an expiration date. An email dated 5/14/26 at 12:00 p.m., from the manufacturer indicated the shelf life of the Ambu bags manufactured in 2017 and 2018 was 3650 days (10 years) from the date of manufacture. Additionally, the manufacturer did not recommend using expired products. During an interview on 5/15/2026 at 10:28 a.m., chief nursing officer (CNO) stated her expectation was that the charge nurses would check the crash carts for supply item availability and expiration dates. The CNO identified the facility had a procedure that listed outdates for some supplies that did not have expiration dates, but Ambu bags were not on that list. The CNO stated using a supply item past expiration or use by date could affect an item’s sterility, ability to prevent infection, or the item could be less effective than a newer item. During an interview on 5/15/2026 at 10:32 a.m., medical doctor (MD)-A stated they expect supplies to work when needed. MD-A expected the hospital to have a system to check for expiration and use by dates, and that an Ambu bag past the expected use by date might be brittle, and the seal and valve might not work properly, leading to less effective CPR. The Crash Cart Monthly Outdate/Content Verification procedure dated 1/10/25 indicated the purpose was to ensure that every crash cart was checked monthly to ensure products were not outdated and to verify standardized content. The procedure instructed each cart content list/products were checked for outdates monthly, and at the beginning of the calendar year for supplies expiring during that month and respectively that year. The outdates are logged on the Crash Cart Outdate form, and any expired product will be removed and replaced immediately. Staff will document the date and name of the tech performing the monthly check. The Process for Checking Medical Supplies for Outdates procedure dated 1/17/25 instructed distribution staff, at the end of every month, to check all products on the crash carts for outdates within the following cycle to ensure there is adequate time to replace the product. For a product not marked with an expiration date, contact materials management was to be contacted for assistance in determining if the product was able to be used or what the manufacturer’s recommended shelf life was for that product.”