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Based on observation, review of facility policy, and staff interview, the Critical Access Hospital (CAH) failed to ensure the safety of patients, staff, and the public by not securely storing oxygen tanks in 1 of 1 oxygen storage area at the CAH's off-site clinic location #1. Failure to secure oxygen tanks places any person in the vicinity at risk for injury should the tank fall or become damaged.

Findings include:

Review of the facility policy titled "Oxygen Use and Storage" occurred on 11/16/22. This policy, dated October 2014, stated, ". . . All cylinders shall be secured in place by appropriately designed storage racks and stands. . . ."

Observation on the morning of 11/16/22 at the CAH's off-site clinic location #1 showed an unsecured oxygen tank sitting on the floor of the clinic's patient procedure room.

During interview, the morning of 11/16/22, a clinic staff member (#6) verified the tank lacked placement in a rack or stand.

Based on observation, policy review, and staff interview, the Critical Access Hospital (CAH) failed to store medication in a manner that prevented unauthorized access for 1 of 2 medication rooms (acute medication room). Failure to store controlled medications securely (double locked) may result in unauthorized access to medications.

Findings include:

Review of the policy titled, "Pharmacy Use by Nursing Personnel" occurred on 11/15/22. This policy, revised 07/10/13, stated, ". . . Access to the Pharmacy and Medication room shall be limited and authorized only to: . . . Pharmacist, Hospital employed pharmacy technician, Director of Nursing, Assistant Director of Nursing, Registered Nurse/Charge Nurse . . . Authorized Nursing staff are to enter the medication room when in need of controlled substances . . ."

Review of the policy titled, "Pharmacy Policy Manual" occurred on 11/15/22. This undated policy, stated, ". . . Operation Policy . . . Controlled substances shall be stored in locked cabinets. . . . Controlled Substances . . . All controlled substances stored outside of the pharmacy should be stored in double locked cabinets. . . ."

Observation of the locked acute medication room identified the CAH did not store controlled substances in a locked cabinet (double locked) for the following:
* 11/14/22 at 8:45 a.m. observation with a charge nurse (#1) showed a double door narcotic cabinet with a key present in both door locks.
* 11/15/22 at 8:45 a.m. observation with charge nurse (#1) showed a double door narcotic cabinet with a key present in both door locks.
* 11/15/22 at 10:00 a.m. observation with an administrative nurse (#2) showed a double door narcotic cabinet with a key present in both door locks.

Medications stored in the acute medication room narcotic cabinet included the following:
Fentanyl patches (analgesic opioid), injectable medications including Midazolam (sedative/anticonvulsant), Ketamine (anesthetic), Fentanyl, Diazepam (antianxiety), Morphine (analgesic opioid), Hydromorphone (analgesic opioid), and oral medications including Gabapentin (anticonvulsant), Hydrocodone (analgesic opioid), Tylenol/Codeine (analgesic opioid), Alprazolam (antianxiety), Oxycodone (analgesic opioid), Pregabalin (anticonvulsant), Lorazepam (antianxiety), Clonazepam (antianxiety), Temazepam (sedative/hypnotic), Carisoprodol (muscle relaxant), MS Contin [morphine sulfate controlled-release] (analgesic opioid), and Ritalin (stimulant).

During interview on 11/15/22 at 7:45 a.m., an Information Technologist (#3) stated she assigns security badge access and confirmed nurses, providers, central supply, and paramedics have badge access to the acute medication room.

During interview on 11/15/22 at 8:40 a.m., a facility provider (#4) confirmed providers have badge access to the acute medication room.

During interview on 11/15/22 at 10:30 a.m., a facility paramedic (#5) confirmed his security badge allows access to the acute medication room.

During interview on 11/15/22 at 10:00 a.m., an administrative nurse (#2) confirmed staff should not store the narcotic keys in the cabinet door locks.

Based on observation, review of facility policy, and staff interview, the Critical Access Hospital (CAH) failed to ensure the removal of outdated medications and glucose testing strips in 2 of 2 medication storage areas (procedure room crash cart and laboratory/medication room) at the CAH's off-site clinic location #1. Failure to remove outdated medications and glucose test strips may result in patients receiving ineffective medications and inaccurate test results.

Findings include:

Review of the facility policy titled "Pharmacy Policies" occurred on 11/16/22. This undated policy stated, ". . . Outdates: Drugs and biologicals that are outdated, deteriorated, or adulterated are removed from the shelf and taken to the [CAH] for the consultant pharmacist for disposal. . . ."

Observations on the morning of 11/16/22 at the CAH's off-site clinic location #1 showed the following:
- Crash cart in patient procedure room: a 1000 milliliter bag of Dextrose 0.45% expired February 2022
- Laboratory/medication room: 2 bottles of glucometer test strips expired 07/02/22

During interview, the morning of 11/16/22, a clinic staff member (#6) verified the Dextrose bag and test strips as expired.