HospitalInspections.org

Based on observations and interview the Critical Access Hospital (CAH) failed to ensure the safe storage of oxygen tanks. Findings include:

Per observation during the physical environment tour at 10:25 A.M. on 4/14/10, there were 6 portable oxygen tanks stored in an unsecure manner in an oxygen storeroom. The tanks were standing in a row against a wall and a chain was loosely draped over the top 2-3 inches of the innermost 3 tanks in a manner that would not prevent the tanks from falling. This observation was confirmed by the Director of Plant Operations at the time of the tour.

Based on observation and interview the hospital failed to ensure storage of drugs in the pharmacy remained secured at all times and outdated intravenous solutions where not available for patient use. Findings include:

1. Throughout the 3 days of survey, 4/12 - 4/14/10, the door to the hospital pharmacy, which exits to a public hallway, was observed to be periodically left open and accessible to unauthorized individuals. Per interview at 1:10 PM on 4/13/10, the staff pharmacists acknowledged the pharmacy door is frequently left open but stated pharmacy staff is always in attendance in the front area of the pharmacy where multiple drugs are stored and dispensed. The pharmacist stated leaving the door open was for the convenience of hospital staff. However, per observation on 4/13/10 at 3:05 PM and 4/14/10 at 1:18 PM the pharmacy door was observed open and no pharmacy staff were present in the front area, allowing the opportunity for unauthorized access. The pharmacist was observed in the back room area of the pharmacy facing a computer with their back to the pharmacy entrance.
Per 'Administrative Rules Vermont Board of Pharmacy', effective 10/1/09, rule 10.16 (c) "The institutional pharmacy must be secure from access when the institutional facility is closed. It must be secure from access by unauthorized personnel at all times. Only support personnel directly involved in the prescription dispensing process and non-pharmacist management shall be allowed entry into the institutional pharmacy and then only when a pharmacist is present in the institution".

Per "Practice Standards of ASHP 1996-97 (American Society of Hospital Pharmacist)guidelines: minimum standard for pharmacists in institutions. "ASHP Statement on Pharmacist's Responsibility for Distribution and Control of Drug Products" state: A fundamental purpose of pharmaceutical services in any setting is to ensure the safe and appropriate use of drug products and drug-related devices.......This involvement should include decisions and actions with respect to the evaluation, procurement, storage, distribution, and administration of all drug products".

2. During a tour on 4/12/10 at 2:45 PM of the Emergency Department with the Nurse Manager several bags of outdated intravenous solution bags were found in the clean storage room to include: D5 1/2 with 20 KCL (potassium), D5 1/2 with 40 KCL, Lactated Ringers, 1/2 Normal Saline and D5 1/4 Normal Saline. The expiration dates included 1/10 through 4/1/10 and were confirmed by the Nurse Manager.