HospitalInspections.org

Based on interviews with staff, tour of departments, and review of policies the facility failed to review, approve, and designate appropriate spaces for anesthetizing locations.

1. During a tour of the radiology department on 7/24/2012 surveyors observed anesthesia machines present in magnetic resonance imaging (MRI), computed tomography (CT), and interventional radiology room utilized for endoscopic retrograde cholangiopancreatography (ERCP). At the time of the tour Staff G told surveyors anesthesia was provided in these locations occasionally. There was no documentation these locations had been reviewed and approved through governance as anesthetizing locations. There was no documentation the anesthetizing locations met the room requirements as specified in the Life Safety Code, and Oklahoma Hospital Standards 667 310:667-25-2, (b) 7 and (h) 1-5. Also see Life Safety Survey.
2. During the tour of the radiology department on 7/24/2012, a surveyor asked staff about medical gas shut off locations. Staff members were unable to identify locations of medical gas shutoff valves. Staff could not verbalize how the valves shut off or why the valves would need to be shut off.
3. On the afternoon of 7/24/2012, Staff C told surveyors she was unaware anesthesia was provided in CT, MRI, and the ERCP room. This finding was also verified with multiple members of the facilities maintenance department on the afternoon of 7/24/2012.
4. This information was provided during the exit conference on 7/26/2012 with administration. No further documentation was provided.