HospitalInspections.org

Based on document review and staff interview the Critical Access Hospital (CAH) failed to provide appropriate orientation and training for the use of fire extinguishers one new employee and annual fire extinguisher training for two surgical registered nurses, staff C, D, and G.

Findings include:

- Review of staff G's employee file on 1/27/10 at 9:45am revealed a hire date of 10/26/09. Review of staff G's surgical orientation checklist lacked orientation for fire hazard or fire extinguisher training. Review of staff G's central supply/OR (operating room) technician job description revealed under "Safety: C. Demonstrates understanding of emergency procedures."
Interview with staff G on 1/27/10 at 10:10am confirmed they had not completed a hospital orientation and lacked orientation on how to operate the fire extinguisher. Interview with staff B on 1/27/10 at 10:20am confirmed that staff G had not completed the hospital wide orientation that would include fire hazard and fire extinguisher training.

Interview with staff C on 1/26/10 at 3:30pm revealed staff G responded to the surgical fire on 1/8/10 but failed to demonstrate knowledge of how to secure the nozzle of the fire extinguisher after the pin on the handle was pulled. Staff C stated they did not know how to operate the fire extinguisher and when they released the pin the nozzle whipped all over the room. Staff C confirmed they failed to attend the annual fire extinguisher in-service the past two years on 10/16/08 and 10/15/09.

Document review the CAH's Nurse Manager- Surgery job description revealed under "Safety: A. "Demonstrates knowledge and understanding of Emergency Preparedness Plans,...B...eliminate safety hazards." Under, "Professional Development:...C. Encourages other employees to participate in in-service education and suggests programs to the in-service director according to the needs of the staff..."

Based on document review and staff interview the Critical Access Hospital (CAH) failed to assure the CAH's Operating Room Policies and Procedures were evaluated, reviewed, and/or revised at least once a year as part of the annual program evaluation.

Findings included:

- Review of the CAH's Operating Room (Surgery) Policies and Procedures on 1/26/10 at 3:45pm revealed the Chief of Surgery reviewed and approved the policies on 4/27/06. Review of policies with a revised date of 2008 lacked approval from the Chief of Surgery or the Medical Staff.

Interview with staff C on 1/26/10 at 3:45pm confirmed the revised policies and procedures lacked the approval of the Chief of Surgery or the Medical Staff. Staff C confirmed the CAH failed to review and evaluate the policies annually as required by regulation.