HospitalInspections.org

Based on observation, interview and document review, the critical access hospital (CAH) was found to be out of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital.

Findings include:

Please refer to the Life Safety Code inspection tags: K0223, K0225, K0281, K0291, K0324, K0353, L0361, K0372, K0712, K0781, K0914, K0918, K0920.

Based on observation, interview and document review, the facility failed to protect and secure the biohazard and sharps containers within the clinics.

Findings include:

During observation on 4/30/24 at 8:00 a.m., the Silver Bay clinic laboratory department, which contained a patient laboratory draw chair, contained opened and unsecured biohazard containers next to laboratory equipment and machines. Inside each biohazard container were multiple vials of vacuum tubes and used test stripes with visible dark tinged red liquid.

During interview on 4/30/24 at 8:30 a.m., the technical consultant and lab manager (TCLM) stated that he does not expect staff to have the biohazard containers within the lab, with vacuum tubes containing reddish brown liquid and used test strips to be protected from spilling onto the counter or floor. TCLM stated he does not feel there is any potential harm if an opened biohazard bin with used biomedical waste were to fall onto the counter or floor.

During observation and interview on 4/30/24 at 8:42 a.m., the Silver Bay clinic radiology room contained one sharps container with used needles. The sharps container had a locked lid, however, the opening to drop the sharps material was visible open and the container was not secured to prevent it from falling on the counter or floor. The CEO acknowledged the sharps container was not protected from falling and agreed that facility needs to assure all sharps and biohazard containers be covered and protected from tipping or falling over onto the ground.

During observation on 4/30/24 at 9:03 a.m., the Silver Bay clinic medication room contained two sharps containers, each with a locked lid. However, the opening to drop sharps material was visible open and contained two lancets and one medication vial. The sharps container was not secured from falling on the counter or floor.

During observation and interview on 4/30/24 at 1:34 p.m., the clinic within the hospital, med room, contained a sharps container with visible needles and vials 3/4 full. The sharps containers had a locked lid, however the opening to the lid had a visible opening. The sharps containers were on a counter next to a sink with a raised basin, making the sharps container visibly uneven with the surface of the counter. Additionally, the sharps container was not secured or protected from falling over on the counter or ground. The director of the medical clinic and outpatient services (DMCOS) stated that the sharps container should be secured from falling and tipping over and agrees that if the sharps container were to fall or spill, it could cause harm or exposure to infectious diseases.

During interview on 5/2/24 at approximately 8:30 a.m., the director of environment services/ imaging, and materials (DESIM) stated she expected housekeeping to place biohazard bins and sharps containers in a secured location from tipping over and spilling onto the floor or counters. Additionally, she expected biohazard bins to have a lid. She stated that if a biohazard bin or sharps containers that was open and/or not secured from falling, that a patient or staff could be injured and potentially exposed to infectious diseases.

During an interview on 5/2/24 at approximately 9:00 a.m., the director of nursing (DON) and infection prevention manager (IPM) stated that they would expect the biohazard bins and sharps containers should be covered and protected from falling and/ or spilling onto the ground. The DON and IPM agree, if uncovered and not secured, there is a potential for patients and staff harm from any sharps within the containers and infectious disease exposure.

The pharmaceutical and waste stream pharmacy policy dated 2023 directed all pharmaceutical waste shall be disposed of according to state and federal regulations. This waste includes expired drugs, waste materials containing excess drug (syringes, IV bags, tubing, vials, etc.), and any other drugs that cannot be used or are intended to be discarded. All pharmaceutical waste is to be assumed hazardous and managed accordingly, unless evaluated and documented to be non-hazardous. For ease of determining waste streams and to protect the environment to the greatest extent possible, all pharmaceutical waste at Lake View Hospital will be deemed hazardous, with the exception of maintenance IV fluids (e.g. NS, D5W, LR, KCL).

Based on interview and document review, the facility failed to provide evidence it had created a policy and procedure that outlined the business continuity operations program.

Findings include:

During document review and interview, on 4/30/24 between 2:54 p.m. and 4:11 p.m., the emergency preparedness coordinator (EPC) and the director of nursing (DON) stated and acknowledged the facility had not created or implement a business continuity operation policy or procedure.

The emergency incident/multiple casualty or over capacity policy and procedure last revised 12/21/23 indicated the facility under [the] emergency operations, Lake View will do its utmost to preserve its basic service and facilities for prompt and maximum use.

Based on documentation review and interview, the facility failed to provide evidence it had completed an 1135 waiver policy and procedure as part of the emergency preparedness program.

Findings include:

During document review and interview, on 4/30/24 between 3:36 p.m. and 4:11 p.m., the EPC and DON stated and acknowledged the facility had not implemented or created an 1135 policy or procedure.

The emergency incident/multiple casualty or over capacity policy and procedure last revised 12/21/23, indicated the facility under [the] emergency operations, Lake View will do its utmost to preserve its basic service and facilities for prompt and maximum use.