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Based on observation, interview and document review, the critical access hospital (CAH) failed to store toxic cleaning products in a secure location. This practice had the potential to affect patients and the public that were in the facility.

Findings include:

During a tour of the nursing unit on 6/9/14 at 11:30 a.m., observations were made of chemical cleaners in an unlocked dirty utility room and a tub room. The chemical cleaners in the dirty utility room were stored on the counter and in a cabinet under the sink. The cleaning agents included; Vindicator, Crypton, Endozime Bio-clean, Cavi and Clorox (all disinfectants,deodorizers, sanitizers and enzymatic cleaners). The tub room cleaners were stored on top of the cupboard that included; Endozine and Cavicide. Another observation was made on 6/10/14 at 1:00 p.m. the tub room door was observed to be propped open with the same cleaning agents on the counter. The unlocked dirty utility room noted to have the same cleaning agents on the counter and in an unlocked cabinet under the sink. All cleaners were labeled "Keep out of reach of children". The surveyor was accompanied by the patient service director during the initial tour on 6/9/14, who confirmed the cleaning agents listed above should be locked for safety. The director of services also verified the unlocked rooms were not always supervised. Both rooms were located near patient rooms. The tub room was across from the designated Obstetric room.

The Material Safety Data Sheets indicated, "Precautions: Handling & Storing: Keep out of reach of children" and "rubber gloves and splash goggles are recommended with contact".

Based on observation, interview and document review the critical access hospital (CAH) did not ensure unauthorized personal did not have access to the pharmacy department without supervision. This practice had the potential to affect patients and the public that were in the facility.

Findings include:

During a observation of a medication pass on 6/9/14 at 2:00 p.m., licensed practical nurse (LPN)-A was observed to set up a medication for a patient. LPN-A checked the Omnicell for the ordered medication that included, ibratropim bromide 3 ml inhalant ( used for chronic pulmonary obstructive disease). The Omnicell (automated dispensing system) did not have this medication. LPN-A then indicated she needed retrieved the medication from the pharmacy department. The LPN received the pharmacy keys from registered nurse (RN)-A at this time and retrieved the medication- ibratropin bromide inhalant for the patient from the pharmacy. LPN-A signed off the medication on the pharmacy log book. No staff were present in the pharmacy during this time. LPN-A administered the medication to the patient who was located in their assigned hospital room.

It was noted that when LPN-A retrieved the pharmacy department keys from RN-A, the RN did not question the LPN why she needed the keys during this time. During interview with LPN-A on 6/9/14, at 2:30 p.m. she indicated it had been her practice to have access to the pharmacy when medication was needed due to it being absent from the Omnicell system.

On 6/10/14 at 10:00 a.m., the pharmacy log was reviewed with the facility pharmacist. The pharmacist confirmed the log had not been co-signed by the RN and that LPN's should not have unsupervised access to the pharmacy. The pharmacist further confirmed that he had not checked log book after the LPN had removed the medication from the pharmacy on 6/9/14.

Interview with RN-A on 6/10/14, at 1:00 p.m. stated it was not facility practice to allow the LPN to retrieve medication from the pharmacy without supervision, and RN-A should have gotten the medication from the pharmacy for LPN-A. She further indicated that only in emergency situations would she allow the LPN to have access to the pharmacy, but would supervise the LPN and co-sign the medication.

Interview with the director of clinical services on 6/10/14, at 1:30 p.m. indicated facility practice allowed only RN's to have access to the pharmacy, unless it was an emergency. She confirmed this was not an emergency situation for the LPN to have access to the pharmacy without RN supervision.

Review of the facility policy "Persons Authorized By The Pharmacist To Enter Hospital Pharmacy After Hours" dated 6/14, indicates that under emergency circumstance where a medication is needed and the RN is unable to enter the Pharmacy, she/he may delegate an LPN to obtain medication. The LPN will sign out the medication on the Pharmacy after hour log book. The RN needs to verify and co-sign the medication. No medication from the Pharmacy stock will be given until verification occurs. The Pharmacist will then follow through on checking the log book and completing his/her audit.