HospitalInspections.org

Based on staff interview and document review, the hospital's administrative staff failed to submit their 3-year capital budget to the designated state planning agency for 1 of 1 year reviewed. The hospital administrative staff identified a census of 18 inpatients.

Failure to submit the hospital's 3-year capital budget to the state planning agency could potentially result in the hospital engaging in an expansion, or other major renovation to their hospital, without the knowledge of the state planning agency.

Findings include:

During an interview with Chief Financial Officer (CFO) on 3/25/14 at 4:15 PM, CFO stated the hospital administrative staff failed to submit a 3-year capital budget to the state planning agency for Fiscal Year 2013. The last budget was sent to the Iowa Bureau of Health Planning in the Iowa Department of Public Health on January 12, 2012.

Based on observation, document review, and staff interviews, the hospital failed to ensure all out-patients were informed of their patient's rights for patients that presented to 1 of 2 off site locations. (Montezuma Medical Clinic - Physical Therapy/Occupational Therapy) The hospital identified 630 patient visits per year at the Montezuma Medical Clinic.

Failure to inform patients of their patient rights could potentially result in the patient's inability to make their wishes known.

Findings include:

1. Observation during tour of the Montezuma Medical Clinic on 3/26/14 at 9:10 AM with Staff F, Vice President Operations, revealed the lack of patient rights available to the outpatients at the clinic.

2. Review of hospital policy titled "Patient Rights and Responsibilities", dated 1/14, revealed, in part, "Grinnell Regional Medical Center will inform each patient (both inpatient and outpatient), or when appropriate, the patient's representative (as allowed under State law), of the patient's rights, in a language or method of communication that the patient or representative understands. These rights should be presented to the patient or the patient's representative in advance of furnishing or discontinuing patient care whenever possible. Patient Rights and Responsibilities are posted in all outpatient areas and in the Patient Handbook in each inpatient care area. . . ."

3. During an interview on 3/26/14 at 9:10 AM, Staff F, Vice President Operations, acknowledged the lack of patient rights available to the out patients at the clinic.

Based on review of the Quality Improvement Plan, Quality Improvement activities, and staff interviews, the hospital quality staff failed to ensure the evaluation of all patient care services provided for 1 of 2 contracted services. (Sleep Study) The hospital sleep study staff reported completing approximately 120 sleep studies since 1/2013.

Failure to monitor and evaluate all patient care services for quality of care could potentially result in the failure of the hospital to address and correct problems .

Findings include:

1. Review of hospital policy/procedure "Contracted Services", reviewed 1/13, revealed in part... "1. The governing body delegates authority to the President/CEO, or senior management designee, to ensure that contracted services furnish services that comply with all applicable conditions of participation and standards for the contracted services."

2. Review of the Performance Improvement Plan reviewed 1/14 revealed in part... "XI. To assure that the appropriate approach to planning processes of improvement; setting priorities for improvement; assessing performance systematically; implementing improvement activities on the basis of assessment; and implementing improvement activities on the basis of assessment; and maintaining improvements, the Organizational Performance Improvement Program is evaluated for effectiveness at least annually and revised as necessary."

3. Review of Quality Improvement Plan from January 2013 through January 2014 revealed the contracted service for sleep study failed to report quality improvement activities regarding patient care services.

4. During an interview on 3/26/14 at 9:00 AM, Staff D, Director of Quality, acknowledged the contracted service sleep study had not participated in the hospital quality program since January 2013 when the contracted service took over duties for providing sleep study at the hospital.

Based on observations, policy review, and staff interviews the hospital failed to secure confidential patient information from unauthorized personnel in 2 of 3 medical records storage areas, located outside of the medical records department. The hospital had 3 medical records storages areas at the time of the survey.

Failure to secure patient medical records from unauthorized users could potentially result in the inappropriate use of a patient's identity or medical information.

Findings include:

I. Observation during the hospital environment tour on 3/26/14, beginning at 8:00 AM, revealed storage of radiology films and boxes of patient accounting records stored in the 3rd floor penthouse of the hospital, where the small emergency generator and other supplies were stored. Staff O, Director of Facilities Management, reported access to the area required a punch code, which had been issued to radiology, maintenance, security and public relations staff.

During an interview on 3/26/14 at 1:30 PM, Staff G, Director of Medical Records, reported the boxes of patient accounting records, stored in the penthouse, contained old patient billing remits, which contained basic patient identifiers, including name and social security numbers. Staff G reported the punch code lock limited the potential for unauthorized access to the radiology films and patient billing information but acknowledged that all the personal able to enter the area, did not have the need to access the patient information. During a follow-up interview on 3/27/14 at 9:30 AM, Staff G verified there were 31 boxes of patient accounting records stored in the penthouse.

During an interview on 3/27/14 at 9:30 AM, Staff F, Vice President of Operations reported 71,190 radiology films were stored in the penthouse.

During an interview on 3/27/14 at 10:30 AM, Staff Q, Administrative Assistant, reported she confirmed with Facilities Management that all staff within radiology, security, facilities management and public relations had the punch code to access the penthouse.

II. During a tour of the medical records department on 3/26/14 at 10:20 AM, Staff G reported the department stored a large quantity of medical records offsite at the Postels Community Health Park, a building owned by the hospital. Staff G was not sure who had a key to the locked storage area.

During a follow-up interview, Staff G reported 35,487 patient records were stored at Postels Community Health Park.

During an interview on 3/27/14 at 8:30 AM, Staff L, Physician Services Director, provided a document identifying the personnel able to access the record storage area at Postels Community Health Park. The list identified 27 keys issued, including the Facilities Management lock box, Emergency Preparedness and Administration key rings and the Integrated Medicine key cabinet, along with staff from Facilities Management (including maintenance and 1 housekeeper), Security, Administration (including Medical Staff Services Coordinator), Postels (including 2 secretaries), Mental Health Secretary, Physician Services Director and Health Information Management. Upon request, Staff L identified 10 of the 27 keys as having an appropriate need to access the area, which condensed the keys to the Facilities Management lock box, Security Director, Administration (excluding the Medical Staff Services Coordinator), Physician Services Director and Health Information Management.

Review of a Health Information Management policy titled "Secure Filing of Medical Records", reviewed in 11/2012, revealed in part "It is the policy of Grinnell Regional Medical Center that medical records are maintained in a secure and confidential manner. Areas being utilized for the storage of health information shall be restricted to authorized personnel. . . Medical Records is . . . responsible to safeguard the medical records against use by unauthorized individuals . . ."

Review of a Health Information Management policy titled "Confidentiality of Patient Information", reviewed in 11/2012, revealed in part ". . . information . . . will be handled with professional discretion and on a "need to know basis". . ."

Based on observation, staff interview and policy reviews, the hospital staff failed to ensure outdated medications and patient supplies were not available for patient use in 1 of 1 medical/ surgical units, 1 of 1 radiology emergency medical kits and 1 of 1 Cardiac rehabilitation (rehab) units. The hospital staff reported an average daily census of 15 patients on the medical/ surgical unit, 256 patients in the radiology department a week and approximately 20 patients a week in the cardiac rehab unit.

Failure to remove outdated medications and supplies for patient care areas could potentially result in patients receiving outdated medications and supplies after the manufacturer determined the drugs were no longer available for use.

Findings include:

1. Observation during the medical/ surgical environmental tour on 3/24/13 at 11:00 AM with Staff A, Vice President of Operations revealed the following expired supplies on the nursing unit.
a. Eight 2 ounce bottles of Pedialyte,with an expiration date 3/1/14 stored in a cupboard in the activity room.
b. One Dopamine (a drug used to increase cardiac output) 500 ml (milliliter) intravenous (IV) bag that expired 2/2012.

During an interview on 3/24/14 at 11:00 AM, Staff A stated all the supplies identified on the medical/ surgical floor were expired and available for patient use.


2. Observation during the radiology tour on 3/25/14 at 9:00 AM with Staff B, Interim Director of Radiology revealed the following expired medications and supplies in the emergency drug box located in the MRI (Magnetic Resonance Imagery) office:
a. Two 1,000ml ).9% normal saline IV bags with an expiration date 3/1/13.
b. Two atropine sulfate 0.1 mg/ml - 10ml luer jet syringes with an expiration date of 6/12.
c. One epinephrine pen 0.3mg (milligram) with an expiration date 9/12.
d. Two epinephrine 1:10,000 luer lock syringes with an expiration date 6/1/12.
e. Four nasopharyngeal airways, one with an expiration date of 2/14, two with an expiration date of 6/13 and one with an expiration date of 11/13.
f. Two bacteriostatic 0.9% sodium chloride 30ml vials with an expiration date of 11/1/12
g. One Easycap II carbon dioxide detectors with an expiration date of 5/2003
h. Two epinephrine 1:1,000 ampules with an expiration date of 10/1/12
i. Two 1ml carpujets of diphenhydramine 50mg/ml with an expiration date of 2/1/12

During an interview on 3/25/14 at 9:00 AM, Staff B stated all the supplies identified in the radiology emergency box were expired and available for patient use.

3. Observation during the tour of cardiac rehab on 3/25/14 at 2:30 PM with Staff C, Manager of Cardiac Rehab revealed five 10ml normal saline flushes in the crash cart with an expiration date 10/2010.

During an interview on 3/25/14 at 2:30 PM, Staff C stated the supplies identified in the cardiac rehab crash cart were expired and available for patient use.

Review of the hospital policy Emergency Drug Boxes, reviewed 12/13 stated in part... "E. Emergency drug boxes will be checked for content and expiration dates quarterly by the Pharmacy Department."

Based on observation, staff interview, and hospital policy review, the hospital failed to ensure 1 of 2 radiation exposure cords were secured to not allow staff access into the x-ray room during testing of patients. The hospital staff reported completing an average of 177 x-ray's a week.

Failure to secure radiation exposure cords could allow staff access to the x-ray room while performing a procedure and exposing staff to unnecessary radiation.

Findings include:

1. During tour of the radiology department on 3/25/14 at 9:00 AM with Staff B, Interim Director of Radiology revealed a radiation exposure cord in x-ray room 2 not secured and reaching approximately 5 feet into the x-ray room. This would allow staff access to the x-ray room during the procedure.

2. During an interview on 3/25/14 at 9:00 AM, Staff B agreed the radiation emitting cord was not secured and would allow staff access to the x-ray room during x-ray procedures. Staff B said the cord should be secured at a short length to not allow staff access to the x-ray room during procedures.

3. Review of the hospital policy Maintenance of Radiology Equipment, reviewed 12/13 stated in part... "D. All Technologists will inspect all equipment they use in an on-going fashion. Any unsafe conditions or malfunctions of any kind will be reported to the Radiology Director immediately.

Based on observations, document review and staff interviews, the Foodservice Director failed to ensure dietary staff properly stored frozen foods and maintained a sanitary kitchen environment. The administrative staff identified a census of 18 patients and the Nutrition Services Lead Cook identified the department served approximately 60 patient meals daily.

Failure to store frozen food properly and maintain a sanitary kitchen environment could potentially result in poor food quality and the contamination of patient food.

Findings include:

1. During the initial kitchen environment tour on 3/24/14 at 10:45 AM, the following concerns were identified:

The Kitchen Aid Mixer, covered with a plastic bag and stored as clean, had a loose white powdered substance and dried white food residue on the underside of the mixer head, and along the entire top edge of the bowl lift mechanism. During an interview at the time, Staff M, Director of Nutrition Services, acknowledged the mixer had not been cleaned since it was last used . She reported the mixer should be cleaned after each use and not covered until cleaned. Staff M asked dietary staff, present at the time, if the mixer had been used that morning and staff denied use that day.

The Hobart Mixer, cover with a yellow bag and stored as clean, had a white dried food substance on the mixer head by the switch and the underside of the mixer head. The mixer had scattered chips in the paint on the mixer head and base, resulting in a surface that could not be sanitized and the potential for paint chips contaminating contents of the mixer bowl.

The 2-door True freezer, located by the south kitchen door, revealed multiple improperly stored packages of unlabeled and undated food, some of which were not properly sealed/closed. During an interview at the time, Staff P, Dietitian, reported the frozen items should be labeled, dated and sealed. Staff M reported she has asked staff to keep frozen items in their original case, so the contents can be easily identified and the box dated. Staff M confirmed unlabeled packages could lead to problems with product identification. The improperly stored packages identified included (unlabeled packages identified by Staff M).
a. One each partial cases of beef patties and chuck steak burgers with an unsealed bag open to air.
b. One bag of sausage pizza crumbles was unsealed and lacked a date.
c. One partial bag of grilled chicken breast was unsealed.
d. Four 5 pound sausage rolls lacked a label and two of them lacked a date.
e. One partial bag of ground ham lacked a date and label.
f. One partial bag of chicken breasts was unsealed.
g. One partial bag of lemon pepper tilapia lacked a label and date.
h. One partial bag of gluten-free breaded fish had a hole in the bag with one fish filet partially exposed through the hole and lacked a label and date.
i. One partial package of vegetable burgers lacked a label.
j. One unsealed bag of soup bones lacked a label and date.
k. One partial case of cube beef steak fritters, one breaded cod loins and one unbreaded cod loin had unsealed bags that were open to air.

2. During an interview on 3/25/14 at 2:15 PM, Staff N, Dietitian, reported dietary staff should ensure products stored in the freezer are securely closed/sealed, labeled and dated.

3. Review of a document titled "Additional Surveyor Checklist for Kitchen Sanitation", identified by Staff N, as used monthly to monitor the kitchen for sanitation issues, revealed in part ". . . Refrigerator and Freezers: . . . All foods covered, dated and labeled? Packaging in freezers ok? . . ."

Based on document review, policy review and staff interviews the hospital failed to include assessment of their potential need for water and fuel, as part of the planning for emergency fuel and water agreements, in order to meet the needs of the patients and staff caring for the patients, and ensure patient safety in the event of a disruption in their normal service. The administrative staff identified a census of 18 patients, and an average patient census of 14.

Failure to ensure emergency water and fuel are available to meet the hospital's critical functions during an emergency inhibits the hospital's ability to ensure patient safety and quality of care while responding to and recovering from a disruption in service.

Findings include:

Review of a hospital policy titled "Emergency Management Plan", reviewed in 9/2012, revealed in part ". . . The objective of the Emergency Management Plan is to effectively prepare for, manage an emergency and restore the hospital to the same operational capabilities as pre-emergency levels . . . Management of Space, Supplies, and Equipment: Essential supplies . . . water, . . . utilities must be provided to meet shelter requirements for up to two weeks . . ." The policy lacked calculations to identify the facilities potential needs for potable/non potable water and fuel in the event of a disruption in their normal supply and failed to identify their usual supply on hand, to determine the timeframe in which additional supplies would be needed.

Review of hospital policies titled "Failure of Electrical System" and "Failure of Domestic Water Distribution System", both reviewed in 3/2014, lacked calculations to identify the facilities potential needs for potable/non potable water and fuel in the event of a disruption in their normal supply and failed to identify their usual supply on hand, to determine the timeframe in which additional supplies would be needed.

Review of a document from Anderson Erickson, dated 3/11/14, revealed an agreement for emergency water, signed by their representative, but lacked a signature from a hospital representative and lacked details to identify if the water would be potable and/or non potable and the extent to which the company could meet the facilities needs, in regards to the amount and delivery timeframe.

Review of a document from New Century Farm Service revealed an agreement for emergency fuel service, signed by both parties, but lacked an agreement date and details to identify the extent to which the company could meet the facilities needs, in regards to the amount and delivery timeframe.

During an interview on 3/26/14, at 1:15 PM, Staff R, Safety and Security Director, reported the hospital has policies and procedures for utility disruption, but acknowledged the projected needs are not included in the existing plans. Staff R reported he has been working on developing more complete plans to include departmental projected needs.

I. Based on observation, document review, and staff interviews, the acute care hospital failed to ensure the completion of periodic electrical preventative maintenance checks 2 of 2 sleep number beds in Sleep Study area in the hospital and for 1 of 1 exam table, 1 of 1 ultrasound machine, and 1 of 1 hydrocollator at 1 of 2 provider-based off-site locations (Montezuma Medical Clinic - Physical Therapy/Occupational Therapy). The hospital completed an average of 20 patient sleep studies per month. The hospital furnished therapy services during 630 patient visits per year at the Montezuma Medical Clinic.

Failure to conduct periodic preventative maintenance inspections for all electrical equipment could potentially result in equipment failure when needed or in harm for patients and/or staff.

Findings include:

1. Observations during the tour of Sleep Study in the hospital on 3/25/14 at 1:30 PM, with Staff L, Director of Physician Services, revealed the following. There was a sleep number bed in each of the two rooms used for conducting sleep studies. Both sleep number beds lacked evidence of electrical safety checks.

Observations during the tour of the Montezuma Medical Clinic on 3/26/14 at 9:10 AM, with Staff S, Director of Physical Therapy, revealed the following items in Exam Room 8 lacked evidence of periodic maintenance checks.
- Exam table was last checked 9/2000
- Ultrasound Machine was last checked 7/2006
- Hydrocollator machine lack evidence of electrical safety check

2. Review of hospital policy titled "Equipment Management Plan", dated 3/14, revealed, in part, ". . . All electrical equipment must be inspected by Engineering Services department before being placed into service. . . ."

Review of hospital policy titled "Electrical Safety Electrical Beds", dated 3/14, revealed, in part, ". . . Annual Preventative maintenance will be performed on all other functions of the bed not covered by Bio-Tech Services."

3. During an interview on 3/26/14 at 9:10 AM, Staff F, Vice President of Operations, and Staff S, Director of Physical Therapy, acknowledged the lack of current electrical safety checks for the equipment in the Montezuma Medical Clinic - Physical Therapy/Occupational Therapy.

During an interview on 3/26/14 at 9:40 AM, Staff O, Director of Facilities, stated patient care equipment was to be checked a minimum of annually.

During an interview on 3/27/14 at 7:45 AM, Staff T, Maintenance, acknowledged the patient care sleep study beds had not had any previous electrical safety checks.

During an interview on 3/27/14 at 8:45 AM, Staff L, Director of Physician Services, stated the sleep study beds were purchased and put into service in April 2013.



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II. Based on observation, review of policies and procedures, and staff interviews, the Acute Care Hospital failed to secure the 2 of 20 full oxygen cylinders found in the Cardio-Pulmonary storage closet. The administrative staff reported a census of 18 inpatients.

Failure to secure full oxygen cylinders in an upright, vertical position to prevent the cylinders from falling over could potentially result in an explosion injuring patients, staff, and visitors and/or causing property damage to the area.

Findings include:

1. An observation on 3/25/14 at 1:45 PM, with Staff E, Registered Nurse Nursing Manager revealed 2 full small unsecured oxygen cylinders in the Cardio-Pulmonary storage closet; the closet contained 20 secured oxygen cylinders of various sizes. At the time of the observation Staff E, a registered Nurse, immediately laid the 2 unsecured oxygen canisters horizontally on the floor.

2. A review of the policy, titled "Compressed Gas and Oxygen Use", revised 7/11, states in part ... 1. Cylinders must be secured at all times so they cannot fall.

3. During an interview on 3/26/14 at 7:24 AM, Staff E stated her staff was horrified to learn that oxygen tanks were unsecured, and she was adding oxygen storage to her annual training agenda.

Based on observations, policy review and staff interviews, the hospital dietary staff failed to use sanitary practices during food preparation and patient meal service. The administrative staff identified a census of 18 patients and the Nutrition Services Department identified an average service of 60 patient meals daily.

Failure to use sanitary practices could potentially result in contamination of the patient's food leading to foodborne illness.

Findings include:

1. Observations during food preparation and meal service revealed the following concerns:

On 3/24/14, from 12:05 PM to 12:40 PM, Staff I, Lead Cook, wore a pair of disposable gloves and touched multiple surfaces, including, but not limited to, counter tops, convection oven handles, freezer door handle, storeroom door, potholders, plates, serving utensils, apron and handled bread sticks with the contaminated gloves. At one point, Staff F removed the soiled gloves and donned clean gloves without washing his hands.

On 3/25/14, from 11:50 AM to 12:22 PM, Staff J, Cook, wore a pair of disposable gloves and touched multiple surfaces, including but not limited to, freezer handle, fryer basket, sheet pan, plates, serving utensils, pant leg and handled french fries with the contaminated gloves. Twice, Staff J removed the soiled gloves and donned clean gloves without washing her hands.

On 3/25/14, from 1:35 PM to 1:40 PM, Staff H, Cook, wore a pair of disposable gloves and touched multiple surfaces, including, but not limited to a garbage can lid, a personal drink cup (base and lid), countertop, apron and handled brownies with the contaminated gloves. Staff H removed her gloves previous to handling the drink cup, used an ungloved hand to handle the drink mug, then donned clean gloves without washing her hands.

On 3/26/14, from 12:00 PM to 12:22 PM, Staff H wore a pair of disposable gloves and touched multiple surfaces, including, but not limited to sink faucet handles (on 3 separate occasions), sheet pan, knife, counter top, cardboard box, pant legs, Oreo packets and touched cheesecake and Oreos with the contaminated gloves.

2. Review of a hospital policy titled "Disposable Glove Use", revised in July 2012, revealed in part ". . . 4. Disposable gloves are intended to be task-specific. They should never be worn continuously. . . 7. Gloves must be changed at the following times: . . . b. After hand contact with non-food surfaces . . ."

Review of a hospital policy titled "Prevention of Food Borne Disease", revised in July 2012, revealed in part ". . . 3. b) Gloves . . . should be replaced after each activity to prevent cross-contamination . . ."

Review of a hospital policy titled "Hand Care and Hand Washing", revised in July 2012, revealed in part ". . . 1. When to wash hands: . . . f. When donning gloves for working with food . . ."

3. The Food Code, published by the Food and Drug Administration and considered a standard of practice for the food service industry, in both the 2005 and 2013 editions requires food employees to clean their hands after handling soiled equipment and utensils, during food preparation, as often as necessary to remove soil and prevent cross contamination when changing tasks and before donning gloves for working with food.

Based on observation, document review, and staff interview, the hospital failed to ensure the development of policies and procedures for 1 of 2 provider-based, off-site locations (Montezuma Medical Clinic - Physical Therapy/Occupational Therapy). The hospital furnishing therapy during 630 patient visits per year at the Montezuma Medical Clinic.

Failure to develop specific policies and procedures for the Montezuma Medical Clinic resulted in staff not having access to review the policies and the procedures as needed to ensure staff followed the policies and procedures.

Findings include:

1. Observation during tour of the Montezuma Medical Clinic on 3/26/14 at 9:10 AM with Staff T, Director of Physical Therapy, revealed the lack of policies and procedures for the Montezuma Medical Clinic - Physical Therapy/Occupational Therapy.

2. Review of hospital policy/procedure titled "Policy and Procedure Development", dated 1/12, revealed, in part, ". . . Departmental policies are written to meet the needs of the department. . . ."

3. During an interview on 3/26/14 at 9:10 AM, Staff S, Director of Physical Therapy, acknowledged the lack of policies and procedures for the Montezuma Medical Clinic - Physical Therapy/Occupational Therapy.

I. Based on observation, document review, and staff interviews, the acute care hospital failed to ensure the completion of periodic electrical preventative maintenance checks 2 of 2 sleep number beds in Sleep Study area in the hospital and for 1 of 1 exam table, 1 of 1 ultrasound machine, and 1 of 1 hydrocollator at 1 of 2 provider-based off-site locations (Montezuma Medical Clinic - Physical Therapy/Occupational Therapy). The hospital completed an average of 20 patient sleep studies per month. The hospital furnished therapy services during 630 patient visits per year at the Montezuma Medical Clinic.

Failure to conduct periodic preventative maintenance inspections for all electrical equipment could potentially result in equipment failure when needed or in harm for patients and/or staff.

Findings include:

1. Observations during the tour of Sleep Study in the hospital on 3/25/14 at 1:30 PM, with Staff L, Director of Physician Services, revealed the following. There was a sleep number bed in each of the two rooms used for conducting sleep studies. Both sleep number beds lacked evidence of electrical safety checks.

Observations during the tour of the Montezuma Medical Clinic on 3/26/14 at 9:10 AM, with Staff S, Director of Physical Therapy, revealed the following items in Exam Room 8 lacked evidence of periodic maintenance checks.
- Exam table was last checked 9/2000
- Ultrasound Machine was last checked 7/2006
- Hydrocollator machine lack evidence of electrical safety check

2. Review of hospital policy titled "Equipment Management Plan", dated 3/14, revealed, in part, ". . . All electrical equipment must be inspected by Engineering Services department before being placed into service. . . ."

Review of hospital policy titled "Electrical Safety Electrical Beds", dated 3/14, revealed, in part, ". . . Annual Preventative maintenance will be performed on all other functions of the bed not covered by Bio-Tech Services."

3. During an interview on 3/26/14 at 9:10 AM, Staff F, Vice President of Operations, and Staff S, Director of Physical Therapy, acknowledged the lack of current electrical safety checks for the equipment in the Montezuma Medical Clinic - Physical Therapy/Occupational Therapy.

During an interview on 3/26/14 at 9:40 AM, Staff O, Director of Facilities, stated patient care equipment was to be checked a minimum of annually.

During an interview on 3/27/14 at 7:45 AM, Staff T, Maintenance, acknowledged the patient care sleep study beds had not had any previous electrical safety checks.

During an interview on 3/27/14 at 8:45 AM, Staff L, Director of Physician Services, stated the sleep study beds were purchased and put into service in April 2013.



22898


II. Based on observation, review of policies and procedures, and staff interviews, the Acute Care Hospital failed to secure the 2 of 20 full oxygen cylinders found in the Cardio-Pulmonary storage closet. The administrative staff reported a census of 18 inpatients.

Failure to secure full oxygen cylinders in an upright, vertical position to prevent the cylinders from falling over could potentially result in an explosion injuring patients, staff, and visitors and/or causing property damage to the area.

Findings include:

1. An observation on 3/25/14 at 1:45 PM, with Staff E, Registered Nurse Nursing Manager revealed 2 full small unsecured oxygen cylinders in the Cardio-Pulmonary storage closet; the closet contained 20 secured oxygen cylinders of various sizes. At the time of the observation Staff E, a registered Nurse, immediately laid the 2 unsecured oxygen canisters horizontally on the floor.

2. A review of the policy, titled "Compressed Gas and Oxygen Use", revised 7/11, states in part ... 1. Cylinders must be secured at all times so they cannot fall.

3. During an interview on 3/26/14 at 7:24 AM, Staff E stated her staff was horrified to learn that oxygen tanks were unsecured, and she was adding oxygen storage to her annual training agenda.