HospitalInspections.org

Based on observation, interview, and record review the Critical Access Hospital (CAH) failed to follow the currently established policy for the storage of medications; and failed to develop policies for the storage of supplies and gases that could potentially affect patient and staff safety in the Emergency Department. Findings include:

During a tour on 10/28/19 at 2:30 PM of the Emergency Department (ED), a supply room located directly behind the nurse's station was noted to be unlocked. This supply room contained 2 doors in which one could gain access; one on each side of the hallway where the ED patient rooms were located. The supply room contained numerous medical supplies and medications. Some of the items were the following: intravenous solutions, pre-filled normal saline (mixture of salt and water) syringes, enemas, needles, scalpels, and a large pair of pointed scissors. Per interview on 10/28/19 at 2:36 PM with the ED Director, s/he confirmed that the doors were unlocked and that anyone could walk into the supply room from either door. ED Room #7 was located diagonally across from the supply room. Per interview with the ED Director at that time, s/he stated that this room was a "safe room" utilized for patients who had psychiatric problems; and confirmed that there was a patient occupying this room at the time of the tour.

Per review of the policy "Storage of Medications in Patient Care Areas"-effective 4/27/15, it read, "All medications are stored in a secure environment that limits access to authorized personnel ... ...Medications that are not securely locked must be under constant surveillance."

While on tour, it was also noted that a supply room (#175 A) in the back area of the ED contained a cylinder of nitrous oxide (A colorless gas with a sweetish odor, prepared by heating ammonium nitrate.) and a cylinder of oxygen (A colorless, odorless reactive gas.). There was no sign on the door indicating that there were potentially hazardous gases present.

Per interview on 10/29/19 at 3:55 PM with the Vice President of Patient Care Services, s/he stated that the hospital policy, "Hazard Communication Program"-effective 4/24/15 was used for storage of oxygen cylinders and that the policy directed staff to follow the Safety Data Sheet. Per review of the "Safety Data Sheet for Compressed Oxygen"-revised on 10/21/16 under section 7.2 it read, "Store only where temperature will not exceed 125 degrees Fahrenheit. Post 'No Smoking, No Open Flames' signs in storage and use areas .... Other precautions for handling, storage and use: Store and use with adequate ventilation."

Per review of the policy "ED-Nitrous Oxide (N2O) Administration" -effective 4/8/2018, it read, "A. The nitrous oxide machine will be kept in a locked area which has badge access. B. Nitrous oxide tanks will be stored and maintained by respiratory therapy...C. The nitrous oxide machine will be serviced by the manufacturer." There was no reference to the gas being hazardous and needing to follow the Safety Data Sheet measures per the "Hazard Communications Program Policy"-effective 4/24/15.