HospitalInspections.org

Based on observation, interview, and policy review the facility failed to replace or remove older cylinders of medical gas equipment. There are six (6) inpatients and six (6) emergency room patients who might be affected, should there be a failure of the cylinders.

Findings include:

Observation on 10/14/16 at 2:15 PM with the Manager of Respiratory services to a small building about 75 feet from the main facility, revealed eight (8) cylinders of medical gasses which are substantially rusted and covered in cobwebs. The exact number of cylinders cannot be determined due to poor lighting and due to the fact that some of the cylinders are covered by shelving.

Interview during the observation with the Manager of the Engineering Department upon his arrival, confirmed that a.) these were old cylinders from years ago before the facility downsized and b.) the small building is not airconditioned during the hot months.

Review of undated policy #3017 revealed that 'The Hospital Engineering Department assumes responsibility for the oxygen storage system and for the ordering of liquid oxygen and the exchange of all cylinders."

Based on observation, interview, record review the facility failed to provide an appropriate and safe storage area for one (1) can of flammable anesthetic medication. There were six (6) patients and six (6) employees in the emergency department (ED) at that time

Findings include:

Observation on 10/15/14 at 11:45 a.m. revealed a can of Ethyl Chloride (a highly flammable anesthetic for the skin) in the MDG machine (this is a locked electrical medication dispensing machine which can only be accesses by the pharmacy and nurses). Continued review of the can revealed no evidence of labeling the can as a flammable anesthetic.

The Quality Improvement nurse immediately removes the can to a non-patient care area and states she did not know that there is a regulation regarding particular handling of this medication.

Review of policy reference #5005 entitled "Storage of Flammable Materials", revealed in part "Flammable drugs will be stored in the pharmacy in compliance with State, Federal, and Manufacturer's regulations."

Review of the Gebauer Company's safety data sheet (the manufacturer of the Ethyl Chloride) revealed in part "Store in a cool, dry, well ventilated area...Do not store near...non-explosion proof electrical equipment."