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Based on document review and interview, it was determined that the Hospital failed to ensure to protect and promote each patient's rights related to restraint use and supervision. Therefore, the Condition of Participation, 42 CFR 482.13 Patient Rights was not met.

Findings include:

1. The Hospital failed to ensure safety checks for psychiatric patients were performed every 15 minutes, as required by policy and practice. See A-144

2. The Hospital failed to ensure documentation of a one-hour face to face evaluation was completed, as required. See A-0178.

3. The Hospital failed to ensure all staff were trained and demonstrated competencies in the application and care of patients in restraints, prior to providing care and services to restrained patients. See A-0196.

4. The Hospital failed to ensure all staff were trained in Crisis Prevention Interventions, prior to providing care and services to patients. See A-200

5. The Hospital failed to ensure all direct care staff who apply or monitor restraints were certified in cardio-pulmonary resuscitation. See A-206

Based on document review and interview, it was determined for 2 of 3 (Pt #8, Pt #9) patient records reviewed on the Older Adult Behavioral Health Unit, the Hospital failed to ensure safety checks for psychiatric patients were performed every 15 minutes, as required by policy and practice. This has the potential to affect all patients receiving care on the Older Adult Behavioral Health Unit with a current census of 15 patients.

Findings include:

1. On 12/7/2021 at approximately 2:30 PM, chart reviews for Pt #8 and Pt #9, and were conducted with the Intake Clinical Coordinator for Behavioral Health (E #7). During the chart review the following 15 minute rounds monitoring sheet lack documentation that the 15 minute rounds were performed as required.

- Pt #8 admitted 9/30/2021, with a diagnosis of dementia with behavioral disturbance
12/5/2021 lacked documentation for the 2:30 PM rounding
11/28/2021 lacked documentation for the 6:00 AM, 6:00 PM. 6:15 PM, 6:30 PM and 6:45 PM rounding

-Pt #9 admitted 10/31/2021, with a diagnosis of borderline personality disorder
12/5/2021 lacked documentation for the 2:30 PM rounding
12/2/2021 lacked documentation 6:00 PM, 6:15 PM, 6:30 PM and 6:45 PM rounding
11/28/2021 lacked documentation for the 6:00 PM, 6:15 PM, 6:30 PM and 6:45 PM rounding
11/17/2021 lacked documentation for the 7:00 AM, 7:15 AM, 7:30 AM and 7:45 AM rounding
11/12/2021 lacked documentation for the 6:00 AM, 6:15 AM, 6:30 AM and 6:45 AM rounding
11/6/2021 lacked documentation for the 6:00 AM, 6:15 AM and 6:30 AM rounding

2. On 12/9/2021 at 1:00 PM, the policy titled " Safety Precautions Policy" (revised by the facility, 5/2020) was reviewed. The policy required "Procedure: A. All patients will be on 15 minute checks..."

3. During an interview conducted with E #7 on 12/7/2021 at approximately 4:30 PM, E #7 confirmed the findings and stated the "observation sheets should have been completed every 15 minutes on all patients."

Based on document review and interview, it was determined for 1 of 3 patient's (Pt #19) clinical records reviewed for violent restraints, the Hospital failed to ensure documentation of a one-hour face to face evaluation was completed, as required. This has the potential to affect all patients placed in violent restraints.

Findings include:

1. The Hospital's policy titled "Restraint and Seclusion" (revised by the facility, 5/2020) was reviewed on 12/10/21 at approximately 1:00 PM. The policy noted "The LIP responsible for the patient or a RN (Registered Nurse) or Physician Assistant with a documented competency performs an in-person evaluation within one hour of the initiation of restraint or seclusion used for violent or self-destructive behavior".

2. The clinical record of Pt #19 was reviewed on 12/10/21 at approximately 10:00 AM. Pt #19 presented to the Emergency Department (ED) on 10/9/21 at 9:10 PM. Pt #19 was aggressive and restrained by the Police Department and EMS (emergency medical services). Pt #19 was placed in 4-point leather restraints by the ED staff at 9:20 PM. The clinical record lacked documentation of a 1 hour face-to-face.

3. An interview was conducted on 12/10/21 at approximately 2:00 PM with the ED Registered Nurse (E #14). E #14 verbally agreed the 1-hour face-to-face documentation was not in the chart.

Based on document review and interview, it was determined in 4 of 5 (E # 21, E #23, E #25, E #26) personnel file records, the Hospital failed to ensure all staff were trained and demonstrated competencies in the application and care of patients in restraints, prior to providing care and services to restrained patients. This has the potential to affect all inpatients and outpatients who require the use of restraints.

Findings include:

1. The Hospital's policy titled "Restraint and Seclusion" (revised by the facility, 5/2020) was reviewed on 12/10/21 at approximately 1:00 PM. The policy stated, "VI Procedures: 1.0 Staff Training and Competence Our facility ensures staff, which has direct patient care responsibilities, including contract or agency personnel, receive training and are competent to minimize the use of restraint and seclusion, and to use them safely when their use is indicated..... Our facility educates and assesses the competence of staff in minimizing the use of restraint and seclusion prior to participation in any use of restraint or seclusion."

2. During employee' file review on 12/8/21 at approximately 12:00 PM, the "Position Description/Competency Based Evaluation" for Registered Nurses in the Adult Behavioral Health Unit, Registered Nurse in the Emergency Department and Adult Behavioral Health Certified Nurse Aides" for E #21, E #23, E # 25, and E #26 noted that employees must have documentation of restraint/seclusion training. The files indicated that:
a) E#21, Emergency Department Registered Nurse (ED-RN), Date of Hire (DOH): 11/16/21, lacked documentation of restraint/seclusion training ;
b) E#23, Older Adult Behavioral Health (OABH) RN, DOH: 10/4/21, ), lacked documentation of restraint/seclusion training ;
c) E#25, Certified Nurse Aide OABH, DOH: 6/4/21, ), lacked documentation of restraint/seclusion training ;;
d) E#26, Certified Nurse Aide OABH, DOH: 9/20/21, ), lacked documentation of restraint/seclusion training ;;

3. An interview was conducted with Human Resource Manager (E #4) during the file review. E #4 reviewed the files and verbally agreed the restraint training and CPI training had not been completed by the above listed employees and should have been.

Based on document review and interview, it was determined in 3 of 5 (E #23, E #24, E #26) personnel file records, the Hospital failed to ensure all staff were trained Crisis Prevention Interventions (use of nonphysical intervention skills), prior to providing care and services to patients. This has the potential to affect all inpatients and outpatients.

Findings include:

1. The Hospital's policy titled "Restraint and Seclusion (revised by the facility, 5/2020)" was reviewed on 12/10/21 at approximately 1:00 PM. The policy stated, "VI Procedures: 1.0 Staff Training and Competence Our facility ensures staff, which has direct patient care responsibilities, including contract or agency personnel, receive training and are competent to minimize the use of restraint and seclusion.... Our facility educates and assesses the competence of staff in minimizing the use of restraint and seclusion prior to participation in any use of restraint or seclusion.

2. The Hospital's policy titled "CPR, ACLS, PALS, NRP and CPI (revised by the facility, 02/21)" was reviewed on 12/10/21 at approximately 2:00 PM. The policy stated, ".... 5. All personnel routinely working in areas identified to be 'higher risk' are trained and shall be determined to be competent in performing CPI (Crisis Prevention Institute) techniques to deescalate, minimize and safely intervene in a patient related crisis situation. (Personnel identified as those working in the following hospital departments: Older Adult Behavioral Health Unit (OABHU).... 1. Competency shall be documented every 2 years. 2. Competency is validated by completion of the CPI course or its equivalent. 3. Competency shall be documented and a current copy of the CPI Course completion card (or its equivalent) will be placed in the individual's HR file."

2. During the employee's file review on 12/8/21 at approximately 12:00 PM, the "Position Description/Competency Based Evaluation" for Registered Nurses in the Adult Behavioral Health Unit, Registered Nurse in the Emergency Department and Adult Behavioral Health Certified Nurse Aides" for E #23, E #24, E #26, noted the employees must have documentation of CPI training. The employee files lacked the following documentation:
a) E#23, OABHU RN, Date of Hire (DOH): 10/4/21 lacked CPI training;
b) E#24, OABHU RN, DOH: 5/17/18, lacked CPI training;
c) E#26, OABHU Certified Nurse Aide, DOH: 9/20/21 CPI training;

3. An interview was conducted with Human Resource Manager (E #4) during the file review. E #4 reviewed the files and verbally agreed the CPI training had not been completed by the above listed employees and should have been.

Based on document review and interview, it was determined for 2 of 5 (E #24, E #26) Older Adult Behavioral Health (OABH) Unit personnel, who may respond to and/or assist with restraint/seclusion, the Hospital failed to ensure all direct care staff who are involved with restraint application or monitoring were certified in cardio-pulmonary resuscitation. This has the potential to affect all patients who require the use of restraint and/or seclusion.

Findings include:

1. The Hospital's policy titled "Certifications: CPR, ACLS, PALS, NRP, and CPI" (revised by the facility, 2/21) was reviewed on 12/10/21 at approximately 2:00 PM. The policy stated, "Policy & Procedure 1. All employees who have patient contact shall be determined to be competent in BLS (Basic Life Support). 1. Employees will present a valid BLS card prior to the start of department orientation.

2. During the employee's file review on 12/8/21 at approximately 12:00 PM, the "Position Description/Competency Based Evaluation" for Registered Nurses in the OABH, Registered Nurse in the Emergency Department, Emergency Department Technicians and Adult Behavioral Health Certified Nurse Aides" for E #24 and E #26 noted they must have documentation BLS (Basic life Support) certification. The following employee files lacked a BLS certification:
a) E#24, OABH RN, DOH: 5/17/18;
b) E#26, Certified Nurse Aide OABH, DOH: 9/20/21;

3. An interview was conducted with Human Resource Manager (E #4) during the file review. E #4 reviewed the files and verbally agreed a current Basic Life Support certification had not been completed by the above listed employees and should have been.

Based on document review and interview, it was determined that the Hospital failed to ensure adequate qualified staff were available for patient care. Therefore, the Condition of Participation, 42 CFR 482.23, Nursing Services, was not met, as evidenced by:

Findings include:

1. The Hospital failed to ensure an adequate number of qualified staff were available to provide safe patient care. A-392.

2. The Hospital failed to ensure that vital signs were monitored and that the documentation of the blood transfusion was completed in accordance to policies and procedures. See A-410.

Based on document review and interview, it was determined the Hospital failed to ensure an adequate number of qualified staff were available to provide safe patient care. This has the potential to affect all inpatients, outpatients and staff, as evidenced:

Findings include:

1. On 12/8/2021 at 11:00 AM, the document titled the "Position Description/Competency Based Evaluation" for Registered Nurses in the Adult Behavioral Health Unit, Registered Nurse in the Emergency Department, Emergency Department Technicians and Adult Behavioral Health Certified Nurse Aides: noted they must have documentation of restraint/seclusion training, CPI training and BLS (Basic life Support) certification.

2. On 12/8/2021 at 11:30 AM, the document titled the The "Position Description/Competency Based Evaluation" for Registered Nurses noted, "Must obtain and maintain ... Current certification in Advanced Cardiac Life Support (ABCS) and Pediatric Advanced Life Support (PALS) ..."

3. On 12/8/2021 at 11:45 AM, the document titled The "Position Description Title: Registered Nurse: Emergency Department" (not dated) noted; "Must obtain and maintain current certification in /Basic Life Support (BLS). Current certification in Advanced Cardiac Life Support (ACLS) and Pediatric Advanced Life Support (PALS) is required within (6) months of hire."


4. The employee file of E#21 (Emergency Department Registered Nurse) was reviewed on 12/8/21 at approximately 12:00 PM. The Contingent Job Offer letter dated 11/16/21 noted that E #21 was hired by the hospital. The Human Resources Department New Employee Checklist for E #21, noted "Hospital Orientation (if applicable) 12/13/21. The employee file lacked documentation of an orientation. The employee file noted ACLS certificate and the PALS certificate expired on 9/2021. The employee file had a sticky note which noted "Picked up one shift on 11/24 still needs to present certifications". The November Staff scheduled noted E#21 worked 11/24/21 from 11:00 PM to 3:00 AM.


5. The employee file of E#22 (Operating Room Surgical Technician/Date of Hire: 6/15/04) was reviewed on 12/8/21 at approximately 12:15 PM. E #22's "Department Orientation and Initial Competency Assessment (DOICA) Behavioral Health Unit- Float Staff" form dated 11/29/21 noted " ... Performance Criteria ... CPI (Crisis Prevention Intervention) training- required to have prior to assisting with physical hold ... Te comment section contained "Didn't have any preceptor Just observed myself ... All myself by watching others". The employee file lacked documentation of restraint training and CPI training. The staff assignment sheet dated 12/6/21 noted E#22 was assigned in the Behavioral Health Unit from 3:00 PM to 7:00 PM.

6. The "Nursing Supervisor Report Sheet" dated 12/3/21 noted "12-2-21 Pt #2 (Medical/Surgical inpatient) was administered 2 U PRBC (units/packed red blood cells). Both units pulled from Lab at same time ... Second unit sat out 1845 (6:25 PM) until started at 2315 (11:15 PM). ERS (Electronic Record System) entered both units verified by the same nurse (E#23)." The attachments to the Report Sheet noted Pt #2 was admitted on 11/29/21 with an infected wound to the Medical Surgical Unit room #216 and the 2 units of PRBC were administered by E#23."

7. The employee file of E#23 (Older Adult Behavioral Health Unit Registered Nurse/Date of Hire: 10/4/21) was reviewed on 12/8/21 at approximately 12:30 PM. The employee file lacked documentation E#23 was oriented to the Medical/Surgical Unit and/or competent to administer blood products.

8. The employees files of E#21, E#23, E#24 E#25, E#26, E#27 were reviewed on 12/8/2021 at 2:00 PM. The employee files lacked the following documentation:: E#24, OABH RN, DOH: 5/17/18, lacked CPI training and a BLS certification; E#25, Certified Nurse Aide OABH, DOH: 6/4/21 lacked restraint training; E#26, Certified Nurse Aide OABH, DOH: 9/20/21 lacked restraint, CPI training and BLS certification; and E#27, Emergency Department RN, DOH: 7/28/21 lacked CPI training, ACLS and PALS certification.

9. The staffing sheets were reviewed throughout the survey on 12/7/21 through 12/10/21. The following was identified:
a) The staffing sheet noted on 11/11/21, 11/12/21, 11/13/21. 11/14/21, 11/17/21, 11/18/21, 11/19/21, 11/20/21, 12/4/21 and 12/7/21, E#1 (Emergency Department Manager) was assigned patients in the Emergency Department.
b) The staffing sheet dated 12/1/21 noted E#2 (Director of Nursing) was assigned patients on the Medical Surgical Unit from 7:00 AM to 7:00 PM and was also the House Supervisor from 7:00 AM to 3:00 PM.
c) The staffing sheet dated 12/2/21 noted the following:
1) E#28 (ED RN) was assigned to patients from 7:00 AM to 7:00 PM in the Emergency Department as well as a House Supervisor from 3:00 PM to 7:00 PM.
2) E#2 (Director of Nursing) was assigned to patients from 7:00 AM to 3:00 PM and was also assigned as the House Supervisor.
3) E#23 (OABH RN) was assigned patients on the Medical Surgical Unit from 3:00 PM to 7:00 AM (see #3).
d) The staffing sheet dated 12/3/21 noted the Medical Surgical Unit was staffed only with 2 Registered Nurses in orientation (E#29, DOH: 12/1/21 and E#30, DOH: 11/24/21) from 7:00 AM to 7:00 PM.
e) The staffing sheet dated 12/4/21 noted the Medical Surgical Unit was staffed from 7:00 AM to 7:00 PM with E#29 (orientation) and E#31 (Recovery Room Nurse).
f) The staffing sheet dated 12/5/21 noted the Medical Surgical Unit was staffed from 7:00 AM to 7:00 PM with E#29 (orientation) and from 7:00 AM to 11:00 AM with E#32 (Operating Room Nurse), 11:00 AM to 3:00 PM with E#33 (Operating Room Registered Nurse) and 3:00 PM to 7:00 PM with E#34 (Operating Room Nurse) and lacked a House Supervisor from 7:00 AM to 3:00 PM.
g) The staffing sheets for November and December 2021 noted the following staffing assignments for E#28 (Emergency Department Registered Nurse orientee, DOH: 10/11/21)
1) Orientation on 11/5/21, 11/8/21, 11/12/21, 11/13/21, 11/23/21, 11/29/21, 12/2/21, 12/6/21 and 12/7/21.
2) Staff Nurse assigned to patients on 11/16/21, 11/22/21, 12/3/21 and 12/5/21.

10. During an interview on 12/8/21 at approximately 3:00 PM, E#1 (Manager of Emergency Department) verified the findings and stated "ED (nurse) orientation is at least 12 weeks (long). It's pretty intense." E#1 reviewed the November and December 2021 staffing sheets and verbally agreed E#28 was in orientation and stated "I had to use E #28 as a staff nurse because we don't have enough staff to cover shifts." During an interview on 10/9/21 at approximately 11:00 AM, E#1 stated "Over the weekend (12/3/21, 12/4/21, 12/5/21) a nurse in orientation from Med/Surg quit because he/she wasn't comfortable working by his/herself."

Based on document review and interview, it was determined that for 2 of 3 patient records (Pt #2, Pt #5) reviewed for blood transfusions, the Hospital failed to ensure that vitals signs were monitored and documentation of the blood transfusion administration was completed in accordance with approved policies and procedures. This has the potential to affect all patients receiving blood transfusions.

Findings include:

1. The Hospital's policy titled, "Blood Transfusion, Consent and Administration" (revised by the facility, 12/12/18), was reviewed on 12/8/21 and required, "Retrieve one unit of blood product from the Laboratory Blood Bank when the transfusion process is ready to begin, as blood should not be at room temperature...RELEASING OF BLOOD...Vital signs will be taken and documented on the transfusion record as follows: baseline, within the first 5 to 15 minutes after initiation, and hourly thereafter until, and including, one hour after completion of the transfusion".

2. The clinical record of Pt #2 was reviewed on 12/8/2021. Pt #2 was admitted to the ED (emergency department) on 12/3/2021, with a diagnosis of post operative infection. Pt #2 had orders, dated 12/3/21, to transfuse 2 units of packed red blood cells (PRBCs). The record indicated that both units of PRBCs were picked up from the Laboratory Blood Bank on 12/3/21 at 6:24 PM and 6:25 PM (one minute apart).

3. The clinical record of Pt #5 was reviewed on 12/8/21. Pt #5 was admitted to the ED on 7/15/21, with a diagnosis of anemia. Pt #5 had orders, dated 7/15/21 to transfuse one unit of PRBCs. The record indicated the unit was started 7/15/21 at 8:30 AM. Vital signs were documented 8:30 AM, 9:05 AM, 9:20 AM and not again until the transfusion was complete at 11:15 AM.

4. An interview was conducted with the Lab Manager (E #10) on 12/8/21 at 3:00 PM. E #10 agreed with the above finding that the two units of PRBCs were checked out from the Laboratory Blood Bank at the same time and should not have been.

5. An interview was conducted with the ED Director (E #1) on 12/9/21 at 3:45 PM. E #1 agreed with the above finding that the vitals signs were not appropriately during a blood transfusion.

Based on interview and document review, it was determined the Hospital failed to ensure Pharmaceutical Services established, implemented and maintained an ongoing competency evaluation process in compliance with current USP (United States Pharmaceuticals) <797> regulations. This has the potential to affect all inpatients and outpatients who receive Pharmaceutical Services from the Hospital.

Findings include:

1. The policy "Sterile Products-Maintenance and Use of Isolators" (revised by the facility, 12/1/21) was reviewed 12/9/21 at approximately 2:00 PM. The policy noted "Prior to using CSI's (Compounding Aseptic Isolators) or CACI's (Compounding Aseptic Contaminant Isolator), staff must have completed all orientation and training passing all didactic testing and competency evaluations required".

2. The pharmacy personnel files were reviewed on 12/10/21 at approximately 9:30 AM. A Pharmacy Technician (E #13) and a Pharmacist's (E #14) personnel files lacked documentation of a current media fill competency and finger tip testing competency for sterile compounding.

3. An interview was conducted on 12/10/21 at approximately 10:15 AM, with the Director of Pharmacy (E #9). E #9 agreed with the above findings stating, "I have not got those two employees (E #13 and E #14) competencies completed for this year for the media fill and finger tip testing".

Based on document review, observation, and interview, it was determined the Hospital failed to ensure expired medications were not available for patient use. This has the potential to affect all patients who receive care by the Hospital with a current inpatient census of 0 (zero) patients.

Findings include:

1. The policy titled, "Unusable Drugs" (revised by the facility, August 2016) was reviewed on 12/9/2021 at approximately 11:32 AM. The policy noted, "...Procedure: Pharmacy Storage of Unusable Drugs .... The pharmacy shall store unusable drugs in specially designated areas to prevent their distribution or administration and ensure they are disposed of safely. They shall not be returned to active pharmacy or patient stocks. "

2. On 12/7/2021 at approximately 12:56 PM, a tour of the Nuclear Medication Department was conducted. During the tour, the following expired items were found: 2 sterile water bottles expired (12/2020 and 6/2021).


3. On 12/7/2021 at approximately 1:20 PM, an interview with the Manager of Radiology (E #12) was conducted. E #12 verbally agreed the supplies were expired and should not be available for use.


4. An observational tour of the Pharmacy was conducted on 12/7/21 at approximately 3:15 PM, with the Director of Pharmacy (E #9) and Education Coordinator (E #11). A 10 cc Bottle of 1% Lidocaine that expired on 10/22/21 and 9 vials of Definity (medication used during an echocardiogram) that expired on 12/1/21 were available for patient use.

5. During an interview on 12/7/21 at approximately 3:15 PM, E #9 verbally agreed the medications (Lidocaine and Definity) were outdated and should not be in stock for use.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of Full Survey Due to a Complaint conducted on December 7 & 8, 2021, the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety code portion of the Full Survey Due to a Complaint conducted on December 7 & 8, 2021, the surveyors find that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

A. Based on observation, document review and staff interview, it was determined the Hospital failed to ensure that oxygen cylinders were secured safety to avoid injury, property damage or fire in the facility. This has the potential to affect all patients who receive care on the 3rd floor Older Adult Behavioral Heath Unit, with a current census of 15 patients.

Findings include:

1. On 12/7/2021 at approximately 1:00 PM a tour of the Older Adult Behavioral Health Unit was conducted with the Intake Clinical Coordinator (E #7). During the tour, two (2) oxygen cylinders approximately half full, were observed standing free, unsecured in the kitchenette.

2. During an interview on 12/7/2021 at approximately 1:15 PM , E #7 verbally agreed the oxygen cylinders should have been secured in a stand or secured to the wall with chains and kept in a secure area.



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B. Based on observation, document review, and staff interview, it was determined the Hospital failed to ensure outdated or expired supplies were not available for patient use. This has the potential to affect all patients receiving care at this Hospital with a current inpatient census of 0 (zero) patients.

Findings include:

1. The policy titled, "QHC Stock Rotation and Expiration Policy" (revised by the facility, July 12, 2017) was reviewed on 12/9/2021 at approximately 2:30 PM. The policy noted, "...Procedure: The following are guidelines that should be followed .... The expiration dates of products and devices scheduled to expire during the next month shall be removed from stock and placed in the designated quarantine area until the product can be destroyed or returned ... ... Each department manager should conduct a quarterly review of supplies checking for expired or close dates and return to Materials Management for credit or disposition."

2. On 12/7/2021 at approximately 12:56 PM, a tour of the Nuclear Medication Department was conducted. During the tour, the following expired items were found: 1 package of Povadone-Iodine swabs expired 5/2021 and 2 sterile gloves expired 9/2021

3. On 12/7/2021 at approximately 1:05 PM, a tour of the X-Ray Department was conducted. During the tour the following items were found: 3 sterile gloves with the following expiration of 9/2021

4. On 12/7/2021 at approximately 1:20 PM, an interview with the Manager of Radiology (E #12) was conducted. E #12 verbally agreed the supplies were expired and should not be available for use.

Based on observation, document review, and staff interview, it was determined the Hospital failed to ensure hazardous materials were stored appropriately. This has the potential to affect all patients receiving care at this Hospital.

Findings include:

1. The policy titled, "Hazardous Materials and Waste Management Plan Policy" (revised by the facility, February 2020) was reviewed on 12/9/2021 at approximately 3:12 PM. The policy noted, "IV. Objectives: E. Inspections are conducted at least annually to assure that areas used to store and handle hazardous waste have adequate space, are separated from clean and sterile goods and foods and hazardous chemicals are stored appropriately to their hazards...VI. Process for Managing the Risks: Inventory of Hazardous Materials and Waste (EC.02.02.01.1) The Department Leadership assures their safe selection, storage, handling, use and disposal."

2. On 12/7/2021 at approximately 12:56 PM a tour of the Nuclear Medication Department was conducted. During the tour, the following hazardous item was found: 1 (one) "CrossTrans 206 Dielectric Oil". This product was marked "Harmful" and was an inhalation hazard. This hazardous item was in an under the counter cabinet that was not marked for hazardous materials.

3. On 12/7/2021, at approximately 12:50 PM and interview with the Manager of Radiology (E #12) was conducted. E #12 verbally agreed the supplies were hazardous and should not be stored in an unapproved area.