HospitalInspections.org

Based on observation, interview, and document review, the Critical Access Hospital (CAH) 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 Life Safety Code Inspection tags K131, K712, K918, K901, K281, K251, K923, K353, K347, K341, K351

Based on observation and interview, the Critical Access hospital failed to ensue safe and secure practices were followed for storage of medication and items for administration of IV medications in Room 102 also known as the infusion room.

Findings include:

On 7/20/18, at 9:00 a.m. during a walk through of the Infusion room a yellow, metal tool type cart was positioned to the right of the entrance door against the wall. The top drawer contained a lock with the key left inserted in the lock. The director of nursing indicated this cart contained medication and supplies utilized for patients coming to the hospital to receive medications including antibiotic therapy, chemotherapy, blood product and other infusions as ordered.

The DON indicated this cart was supposed to be kept locked when not in use and the last patient to receive IV medication left at 4:00 p.m. on 7/19/18. The DON futher indicated he believed the key had been left in the lock since that time.

At 9:05 a.m. the DON opened the drawer of the cart to reveal the following drugs: 1.) Four (4) 5 milliliter(ml) syringes containing 500 units of heparin per syringe; 2.) Two (2) 20 ml vials of sterile water; 3.) Five (5) vials of Epinephrine 1:1000 10mg/ml; 4.) Benadryl one vial of 50 mg/ml; 5.) One (1) vial Decadron 20 mg/5 ml; 6.) Epinephrine 1:10,000 0.1 mg/ml-2 10 ml syringes.

In a subsequent interview the DON verified this room was located beside the exit door located at the end of the hall and which exited to the helicopter pad. The process is patients are placed in this room to receive IV medications and a nurse checks on them, but there is not a staff person in attendance at all times. It was also confirmed that persons in the infusion room would be able to access the medication and equipment stored in this cart if it was not secured.

A policy for storage of medications was requested, but not provided.

Based on record review and staff interview the facility failed to provide test documentation in accordance with the 2012 edition of the Life Safety Code (NFPA 101) section 9.1.3.1 and the 2010 edition of NFPA 110 the Standard for Emergency and Standby Power Systems. This deficient practice could affect the safety of all 15 patients and an undetermined amount of staff and visitors if the generator failed to operate during a power outage.

Findings include:

On the facility tour between 9:00 am to 12:00 pm on 07/23/2018 record review and staff interview revealed:
1) The monthly generator log did not address the required testing data.
2) Annual load bank test was not performed.

This deficient conditions was confirmed by the Environmental Services Manager.