HospitalInspections.org

Based on observation, interview, and document review, the hospital failed to ensure 1 of 1 oxygen tank was stored in a secure manner on the E Unit.

Findings include:

Observation and interview during a tour of the facility completed on 1/22/24 at 12:45 p.m., on the E unit with the safety administrator (SA) identified an oxygen tank was observed free-standing and unsecured on a two inch high wooden platform in the oxygen storage room. The SA stated oxygen tanks could be stored in that manner as long as they were stored off the floor on a platform. During a follow-up observation and interview on 1/23/24 at 11:30 a.m., with the SA, the oxygen tank remained stored free-standing and unsecured on the wooden platform in the oxygen storage room. The SA was unaware the oxygen tank was not secured while stored in that manner. He verified the oxygen tank could have tipped over and fallen off of the wooden platform, which could potentially cause the cylinder to fracture and allow the compressed gas to become a projectile.

Observation and interview on 1/24/24 at 11:10 a.m., with registered nurse (RN)-B (the RN supervisor), the program administrative supervisor principal (S) and RN-A identified the oxygen tank was no longer in the oxygen storage room. RN-B stated SA had removed it from the storage room the day before and was not certain where it had been brought to. RN-A stated oxygen tanks were brought to the unit from the facility warehouse and were stored in the oxygen storage room. RN-A indicated nursing staff completed visual checks of the storage rooms and verified oxygen tanks needed to be secured in a stand to prevent them from tipping over and potentially causing the cylinder to fracture. RN-A was unaware an oxygen tank had been stored in an unsecured manner in the storage room.

During an interview on 1/24/24 at 11:50 a.m., the executive director stated it it was an expectation staff stored oxygen in a secure manner for safety purposes.

Review of facility policy titled Compressed Gases dated 3/1/22, identified oxygen tank cylinders were to be stored in a secured manner to prevent the cylinder from falling or rolling.

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

Findings include:

Please refer to Life Safety Code inspection tags: K-0293, K-0353, K-0363 and K-0920 for additional information.

Based on interview and document review, the hospital failed to develop written arrangements with other hospitals. This has the potential to affect all patients in the event of limitations or cessation of operations to maintain the continuity of services to hospital patients.

Findings include:

Interview and document review on on 1/22/24 at 11:05 a.m., with the safety administrator (SA) identified during review of the 8/22/23, Emergency and Continuity of Operations Plan the SA stated in the event the patients had to be emergently evacuated to another hospital, the hospital would transfer them to another hospital within their sister healthcare hospital system. The SA was not aware of any written transfer agreements. There was no documentation to support a contractual transfer agreement was in effect as required.

During an interview on 1/24/24 at 10:10 a.m., state program administrative supervisor principal (S) confirmed the facility did not have a written transfer agreement with another hospital.

During an interview on 1/24/24 at 11:50 a.m., executive director (ED) stated the facility would transfer their patients to another hospital within their healthcare system when an emergency arose. The ED confirmed the hospital did not have a written transfer agreement with another hospital to transfer patients to during an emergency.