HospitalInspections.org

Based on observation, policy review, and staff interview, the Critical Access Hospital (CAH) failed to protect the safety of patients, staff, and the public by not securely storing oxygen tanks in 1 of 1 oxygen storage area (located by the ambulance entrance). Failure to securely store oxygen tanks placed any person in the vicinity at risk for injury had the tanks fallen or become damaged.

Findings include:

Review of the policy titled "Hazard Communication Program" occurred on 04/10/19 at approximately 11:00 a.m. This policy, dated 07/2016, stated, ". . . VII. Compressed Gases A. General Safety: 1. All cylinders, whether empty or full, are properly chained, capped and secured so they cannot fall. . . . 5. Cylinders are always handled as full cylinder and handled with care. . . . Improper handling of compressed gas cylinders can produce a hazard called 'rocketing.' If an accidental rupture occurs, or if a valve assembly is snapped off, a cylinder can blast its way through a concrete wall. . . ."

Observation on 4/10/19 at 9:30 a.m. of the oxygen storage area, located by the ambulance entrance, showed four oxygen "K" tanks stored unsecured in the northeast corner of the storage room.

During interview on 04/10/19 at 9:30 a.m., an administrative maintenance staff member (#3) confirmed the CAH staff failed to store four oxygen tanks in a secure manner.

Based on observation, policy review, and staff interview, the Critical Access Hospital (CAH) failed to store medications in a manner to prevent unauthorized access for 2 of 2 crash carts located in the Emergency Department. Failure to store all medications securely may result in unauthorized access to medications.

Findings include:

Review of the policy titled "Medication Management" occurred on 04/10/19. This policy, revised 01/26/17, stated, ". . . Medications are stored in a secured area to prevent diversion, and locked when necessary, in accordance with law and regulation. . . ."

Observation of the Emergency Department (ED) on 04/09/19 at 9:15 a.m. with an administrative staff member (#2) showed two unlocked crash carts containing medications used in the event of an emergency. Medications included Epinephrine (stimulant), Atropine (blocks nerve impulses), Romazicon (used to reverse sedation), Narcan (opioid antagonist), and similar medications administered for various emergency events.

During interview on 04/09/19 at 9:25 a.m., the administrative staff member (#2) confirmed the CAH staff do not lock the crash carts in the ED, nor do they close the doors to the ED. The staff member (#2) agreed this practice may result in unauthorized access to medications.

Based on observation, review of manufacturer's instructions, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff followed manufacturer's instructions for the use of chemicals used for cleaning and disinfecting equipment for 1 of 1 central processing room. Failure to follow manufacturer's instructions may result in transmission of organisms and pathogens from equipment to patients.

Findings include:

Observation in the Central Processing Department on 04/09/19 at 8:50 a.m. with an administrative saff member (#2) and a central supply (CS) aide (#1) showed a container with a label identifying Virex 256 cleaner next to the sink used to clean istruments. The manufacturer's instructions stated, ". . . Dilute one half ounce of chemical per one gallon of water. . . ." The CS aide (#1) stated staff use the cleanser to wash insruments prior to sterilization. The CS aide (#1) stated she fills the sink half full of water and adds approximately one tablespoon [0.5 fluid ounces] of the Virex 256. The CS aide confirmed she did not measure the water or the chemical. The administrative staff member (#2) filled the sink half full and determined it contained one and one half gallons of water.

The administrative staff member (#2) confirmed the CAH staff failed to follow the manufacturer's instructions for the Virex 256 and failed to use enough to clean/disinfect instruments properly.