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Based on observation, interview and document review, the facility failed to ensure emergency supplies were locked and secured in 1 of 1 room (procedure room and overflow emergency department (ED) room).

Findings include:

On interview and tour 4/14/25, at 11:50 a.m. during walk through tour of the nursing care area, a cart with a defibrillator on top, was present in the room identified by registered nurse (RN)-B, also the nurse manager, as the procedure room and overflow emergency department (ED) room. The cart had a key lock present on it, but the drawers were able to be opened and noted to have 2 intravenous (IV) needles present in one drawer and tuberculin syringes with needles present in another drawer with various size syringes present.

On interview and tour 4/14/25 at 3:50 p.m., a tour of the procedure room was completed. RN-A, also identified as surgery manager, stated the cart and defibrillator was nursing's cart and nursing staff check the defibrillator and maintain the cart. RN-A indicated she does not have a key for the cart.

On interview 4/15/25 at 9:55 a.m., RN-C, in the procedure room, stated the cart was anesthesia's but the nursing staff do the daily checks on the defibrillator. The cart remained unlocked and RN-C was able to open the drawers and two IV start kits remained present and 5 tuberculin syringes with needles. RN-C stated the rest of the needles in the cart were all blunt and the rest of the syringes did not have needles on them. RN-C stated she thought the nurse manager possibly had a key to lock the cart and would check further into getting the cart secured.

On interview 4/15/25 at 9:57 a.m., RN-C stated she spoke with RN-B and nursing responsibility is to check the defibrillator but the cart is surgery's responsibility. RN-C added the nursing department does not have a key for the cart.

On interview 4/15/25 at 3:21 p.m., RN-B stated the cart in the procedure room has always been surgery's cart and not nursing. RN-C added regardless of whose cart it is, it should be secured but no one knows who has the key for the cart.

On interview 4/16/25 at 9:04 a.m., the director of patient services (DPS) confirmed the cart in the procedure room should be secured or be re-evaluated for storing of syringes and needles. The DPS added everyone seems to think it is everyone else's responsibility but had determined it is anesthesia's cart.

A request for securing carts was requested but applied to Emergency Crash Carts only.

Based on observation, interview and document review, the facility was found to be out of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital.

Findings include:

Please refer to the Life Safety Code inspection tags: K0353, K0363, and K0920.

Based on observation and interview, the facility failed to ensure potentially hazardous areas were secured from unauthorized access.

Findings include:

Observation on 4/16/25 at 9:00 a.m., with the maintenance manager identified the Emergency department (ED) entrance to the facility was located at one end of a long hall with the nursing station facing away from the hall located at the opposite end. Unauthorized persons who entered with an ED patient, or wandered into the hall from the acute care area, or attached long term care facility had the potential to gain access to the restricted areas identified in the hall. A door with a sign X-Ray Room 2 was located to the left side of the hall, from the ED entrance and was unsecured. The door opened into the X-ray procedure room with no Radiology staff visible and staff were not aware the room had been accessed until it was made known by calling out and knocking loudly on the door.

Observation and interview on 4/16/25 at 9:15 a.m. with the Radiology manager identified she left the door unsecured during the day because patients entered and exited the X-ray room through that door, but reported the door was locked when an X-ray exam was being performed. She confirmed an unauthorized person could possibly enter the area without knowledge of X-ray staff as there was no notification the exam room door had been opened.

Observation on 4/16/25 at 9:20 a.m., with the maintenance manage identified an alcove located across the hall from the ED room, which contained stored equipment and a closed door with a sign, "Boiler Room". The door had a key lock and opened to access the boiler and facility operating equipment. The maintenance manager opened the door by depressing the handle and confirmed the door was unlocked at the time of observation. Immediately through the door was a small landing area with a cement stairway which extended down two flights of stairs to the main cement floor, a distance of 14 feet from the top of the stairs to the floor below. The stair railing consisted of a single pipe rail on the outside edge of the stairs and was open between the stairs and the handrail.

Interview on 4/16/25 at 9:25 a.m., with the maintenance manager identified the door accessing the boiler/equipment room should be locked, but he had failed to lock the door when he left the area. He reported he was not aware of the potential risk of an unauthorized person entering through the unsecured door and accessing the boiler room, and associated equipment, but agreed it was a hazard that needed to be addressed.

Interview on 4/16/25 at 2:45 p.m., with the administrator identified his expectation for doors accessing restricted areas of the facility to be kept locked unless authorized staff were present to avoid the potential for accidents.

A policy for security of restricted areas was requested but not provided by the end of the survey period.

Based on observation, interview, and document review, the critical access hospital (CAH) failed to ensure insulin was administered per standard of practice and manufacturer recommendations during 1 of 1 insulin administrations.


Findings include:

P3 had current physician order for insulin aspart U-100, 100 units/ml, subcutaneous solution (Novolog U-100 insulin aspart) sliding scale dose subcutaneous as directed. Per the medication administration record (MAR), Novolog Flexpen 100 units/ml, 3 ml pen was to be used for administration. Sliding scale included 70-150 (mg/dl blood glucose) no insulin, 151-200 give 2 units, 201-250 give 4 units, 251-300 give 6 units, 301-350 give 8 units and >350 call provider three times a day at 8:00 a.m., 12:00 p.m. and 5:00 p.m.

On observation and interview 4/14/25 at 12:54 p.m., registered nurse (RN)-D brought insulin pen and needle into P3's room. RN-D had P3 check his blood sugar using his implanted glucose sensor and P3 stated it was 192. RN-D checked the above sliding scale and indicated P3 would get 2 units of regular insulin. Using a Novolog FlexPen 100 units/ml, RN-D placed a NovoFine needle onto the syringe. RN-D dialed insulin pen to 2 units and injected in P3's right upper thigh per his request. RN-D did not prime (removing air and ensuring the medication flows freely) the needle. RN-D stated priming the needle is not required for insulin injections.

On interview 4/15/25 at 8:47 a.m., RN-C stated using the NovaFine needle and Novolog FlexPen, you would prime the needle with 1 unit of insulin.

On interview, 4/15/25 at 8:48 p.m., RN-E stated to prime the needle for an insulin pen, you would use 2 units of insulin to ensure the patient gets the full dose.

Review of the Novolog FlexPen instructions, (Novolog FlexPen Instructions for Use) dated 4/23 include use a new needle for each injection. Complete an "air shot" using 2 units holding syringe with needle end upwards and watch for solution to come out of the tip of the needle prior to dosing insulin pen.

On interview 4/15/25 at 3:21 p.m., RN-B, also identified as the nurse manager, stated she was unsure if an insulin pen required priming of the needle. RN-B did look up the policy and stated it says 1-2 units to prime the needle on the long term care policy and procedure but was unable to locate a policy and procedure for the hospital. RN-B indicated she was not aware of that requirement and will talk to the pharmacist.

On interview 4/16/25 at 9:02 a.m., the director of patient services (DPS) stated she would expect staff to prime a new needle on an insulin pen with 2 units of insulin prior to injecting the ordered dose. The DPS stated for procedures such as this for nursing services, they use Dynamic Health procedures for nursing practice.

A Dynamic Health procedure (copyright and published 2025) included preparing injection device prime pen needle according to manufacturer or facility practice, typically with 0.5 units and dial pen as ordered.

Based on observation and interview the facility failed to prevent the potential for cross-contamination by storing clean and sterile medical supplies in 1 of 1 designated dirty utility rooms.

Findings Include:

Observation on 4/16/25, at 12:30 p.m., of the soiled utility room was noted to contain a hopper, linen carts identified for soiled linens, and a separate cart for biohazard linen. A sink, with cleaning supplies and various pieces of equipment were also being stored in the room. A partial wall with a height of approximately 4 feet from the floor and open to the room, separated two metal carts with an open cover from the rest of the room. The first cart contained: gloves, masks, Kleenex, bags, central line (sterile) dressing kits, sterile gauze dressings, ace wraps, sterile gauze sponges, sterile Steri-strips, sterile suction catheters, and sterile nasogastric tube (NG) supplies. The second cart contained: skin cleaning and prep supplies, sterile Tegaderm, Opti foam, Telfa and other sterile dressing supplies, ice and heat packs, sterile InterDry and burn net packages, O2 tubing, cannula, masks, humidifiers for oxygen, large syringes, spill kits, ambu bags (used for CPR), IV solution bags, and misc. supplies.

Interview on 4/16/25 at 1:15 p.m.,with the director of nursing (DON), confirmed soiled and clean areas needed to be separated. She reported the practice of storing clean and sterile nursing supplies in the soiled utility room presented the potential for cross-contamination of the items located on the two carts. She identified staff carrying contaminated items passed by the carts when entering and leaving the soiled utility room and presented the potential for cross contamination..

Interview on 4/16/25 at 2:00 p.m., with the infection preventionist identified she performed infection control rounding and clean and dirty items were supposed to be stored separately but reported in this facility clean and sterile items had been stored in the soiled utility room for an extended period of time. She identified the potential for cross-contamination from soiled items stored in the dirty utility room, and from use of the hopper located in the room.

Review of the February 2025, Infection Prevention Program and Authority policy identified the goal of improvement of healthcare by identifying, preventing, and controlling hospital associated infections. The infection prevention program was to survey the facility to identify and mange infection potential issues and report to the Quality committee to develop interventions for areas of concern. Department leaders were also identified as having responsibility for infection control by identification, providing education and involvement in developing resolutions for identified infection control issues









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