HospitalInspections.org

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

Findings include:

During a tour of the physical plant with the plant director on 3/1/17, at 1:00 p.m., the biohazard storage room in the hospital was observed to have several red biohazard tubs filled with containers of sharps/syringes and waste products. The plant director indicated the staff transports the biohazard waste to a shed located near the hospital when the storage room becomes full. The biohazardous waste containers are stored in the shed until the service department picks them up when needed. Tour of the biohazard storage shed near the hospital revealed a small shed located a few feet from the hospital. The shed stored several containers of red biohazard tubs which were filled with containers of sharps/syringes as well as hazardous waste material. The door to the shed was not secured nor did it have a visible lock. Interview with the plant director at this time indicated the biohazard storage shed was never locked. The plant director further confirmed that anyone could have access to the contents stored in the shed as it was not secured.

Interview with the Chief Executive Officer (CEO) on 3/1/17, at 3:00 p.m. indicated she was not aware that the storage shed that contained biohazardous waste had not been secured. The CEO agreed that biohazardous waste should be secured.

Review of the facility policy titled Hazardous Materials and Waste Management Plan included: the hospital has a commitment to provide a safe environment for its patient, visitors, staff and surrounding community.

Based on interview and document review the Critical Access Hospital (CAH) failed to ensure arrangements for emergency water were readily available in the event of an emergency and/or disruption of supply. This had the potential to affect all patients, staff and services provided in the facility.

Findings include:

During review of the CAH's emergency policies there was an agreement with Hy-Vee for back up potable drinking water. The agreement dated 3/23/15, indicated Hy-Vee would supply the hospital with drinking water for 3 days in the event of a disaster. The agreement did not include the amount that would be supplied. Although the CAH had a potable emergency supply agreement, there was no current plan specifying the amounts of water required by various CAH departments in the event of an emergency loss of water. Further review of the emergency policies identified an agreement with the city of Windom for backup water supply for non-potable water. The agreement dated 9/20/06, indicated the city of Windom would have 1500 gallons of water dedicated to the hospital each day that water is interrupted. Although the CAH had a non-potable emergency supply agreement, there was not a current plan specifying the amounts of water required by various CAH departments in the event of an emergency loss of water.

Interview with the director of maintenance on 3/1/17, at 2:45 p.m. confirmed there was no plan specifying the amounts of potable or non-potable water required by various CAH departments in the event of an emergency loss of water.

Based on observation, interview and document review the critical access hospital (CAH) was found to be out of compliance with Life Safety Code (LSC) requirements. These findings have the potential to affect all patients in the CAH.

Findings include:

Please refer to Life Safety code inspection tags at: K0293, K0300, K0321, K0324, K0345, K0346, K0353, K0354, K0711, K0712, K0907, K0908, K0913, K0918, K0920, K0921 & K0923.