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Based on observation, policy review, and staff interview, facility staff failed to secure 5 of 5 medium compressed gas storage cylinders and 2 of 7 large compressed gas storage cylinders in the Gas Storage Room. The administrative staff identified a census of 7 patients.

All compressed gases, including oxygen, are hazardous because of the high pressures inside the cylinders. Gas can be released deliberately by opening the cylinder valve, or accidentally from a broken or leaking valve or from a safety device. Escaping gas will propel the cylinder with enough force to penetrate cinder block walls. To prevent ballistic missile type injury all cylinders, even empty ones, should be handled as if they are pressurized.

Failure to secure oxygen cylinders increases the risk of knocking over the cylinder causing the valve to break and the cylinder becoming an uncontrolled rocket or pinwheel inflicting severe damage and/or injury.

Findings include:

1. During the environmental tour on 3/6/13 beginning at 1:30 PM, observation revealed 5 of 5 medium and 2 of 7 large unsecured compressed gas cylinders in the Gas Storage Room.

During an interview, at the time of the observation, the Director of Facilities acknowledged the 2 large gas cylinders should be secured and that they were full. The Director was uncertain if the 5 medium tanks were empty or not.

2. During a follow up interview on 3/6/13 at 3:00 PM, the Director of Facilities confirmed the 5 medium gas cylinders were full and should be secured. The Director acknowledged the risks an unsecured compressed gas cylinder presented to patients.


3. Review of facility policy titled "Oxygen Safety," effective 9/19/12, revealed the following in part "... Oxygen cylinders should always be placed on a cart or strapped to some firm object to prevent accidental falling. If the cylinder would fall and shear the valve it could result in a jet reaction spinning the cylinder at great speed ..."

Based on document review and staff interview, the facility failed to have a current emergency water agreement, consider the facility's usual supply on hand, and quantities needed for water and fuel during an interruption in service, as part of the planning for emergency fuel and water agreements. The administrative staff identified a census of 7 patients.

Failure to ensure emergency water and fuel are available to meet the facility's critical functions during an emergency/crisis situation inhibits the facility ' s ability to ensure patient safety and quality of care while responding to and recovering from a situation that resulted in disruption of water and/or fuel service.

Findings include:

1. Review of a document dated 10/3/08, from Culligan Water Conditioning, revealed an agreement to provide the facility with potable water in the event of an interruption in their current water supply. The agreement failed to identify the quantity of water needed and the timeframe in which delivery would occur. In addition, the document identified the agreement was only good through 12/31/10.

Review of a document, dated 10/7/08 from the Cresco Fire Department, revealed an agreement to provide the facility with water for non-food related services, in the event of an emergency. The agreement failed to identify the quantity of water needed and the timeframe in which delivery would occur.

Review of a document, dated 10/16/08 from the Lime Springs Fire Department, revealed an agreement to provide the facility with water for non-food related services, in the event of an emergency. The agreement failed to identify the quantity of water needed and the timeframe in which delivery would occur.

Review of a document, dated 10/29/12 from Fencl Oil and L.P. Company, revealed an agreement to provide the facility with fuel, in the event of an emergency, not to exceed 4 hours after being contacted. The agreement failed to identify the quantity of fuel needed.

2. During an interview on 3/6/13, on the environmental tour beginning at 1:30 PM, the Director of Facilities reported the facility had 2 emergency generators and 250 gallons of fuel on hand to power the generators. He was unsure how long this would provide emergency power, but reported he could make that calculation. During a follow-up interview, the Director of Facilities reported the facility had 275 gallon of fuel for the generators, rather than 250 gallons, and estimated the fuel would power the generators for approximately 15 hours.

During an interview on 3/6/13 at 2:50 PM, the Director of Facilities reported the facility had not considered their daily needs for potable and non-potable water or fuel, as part of the emergency planning process.

During an interview on 3/6/13 at 4:15 PM, the Director of Nursing Support/Quality reported she was only able to locate one policy that addressed disaster/emergency planning, and it did not include details regarding the planning for emergency fuel and water. Review of the policy titled "During a Disaster," revised 10/00, revealed it failed to include the determination of the quantity of fuel and water to meet the facility's needs.

Based on observation, staff interview, and document review, the facility failed to ensure surgical services staff wrote a shortened expiration date on 3 of 3 vials of Succinylcholine Chloride and 1 of 1 vial of Rocuronium Bromide located in a small tray used to hold the vials during surgical procedures involving general anesthesia. The facility identified an average of 1 surgical procedure per month involving general anesthesia.

Failure to write a shortened expiration date on the vials of succinylcholine chloride and Rocuronium bromide could result in the anesthesiologist or CRNA using the drugs past the date the manufacturer guaranteed the drugs would remain potent, potentially resulting in the patient not receiving the intended effect of the drugs.

Findings include:

1. Observations, during a tour of the surgical services department, on 3/6/13 at 9:00 AM revealed 1 (of 1) medication refrigerator in the Certified Registered Nurse Anesthetist's (CRNA, a nurse with advanced training in the administration of anesthesia medications) office. Further observations of the refrigerator revealed a small tray approximately 5 inches by 5 inches where the CRNA had placed 3 vials of succinylcholine chloride (a medication to relax a patient's muscles for a short time during surgery) and 1 vial of rocuronium bromide (a medication to relax a patient's muscles for a longer time during surgery).

2. During an interview at the time of the tour, the CRNA stated he stored the medications in in a tray in the refrigerator when he was not using them. When the CRNA needed to provide general anesthesia to a patient, he removed the tray of medications from the refrigerator, and kept the tray in the operating room while he administered general anesthesia (medications to render a patient unconscious and unable to feel pain during surgery) to the patient. The CRNA stated he stored the medications at room temperature for an hour or more during the surgical procedure. After the CRNA finished administering general anesthesia to the patient, he returned the tray with any unused medications to the refrigerator for storage until the next time he needed them.

3. Additional observations of the vials of succinylcholine chloride and rocuronium bromide at the time of the tour revealed 3 of 3 vials of succinylcholine chloride and 1 of 1 vial of rocuronium bromide lacked documentation of the date the surgical services staff first removed the vials from refrigerated storage.

4. Review of the manufacturer's instructions for succinylcholine chloride, revised 9/10, revealed in part, "Store in refrigerator ... The ... vials are stable for up to 14 days at room temperature without significant loss of potency." The manufacturer's instructions for storage did not address allowing the medication to warm to room temperature then return to refrigeration during the 14 days.

Review of succinylcholine chloride manufacturer information, in the form of an email, solicited by the facility, revealed the manufacturer did not have stability information that showed how long the product would be good after returning it to the refrigerator following exposure to room temperature storage. According to the manufacturer, their in-house testing only showed stability exposure to room temperature storage; the testing did not include stability once staff placed the drug back in the refrigerator. The information did not support the facility ' s practice.

5. Review of the manufacturer's instructions for rocuronium bromide, revised 7/11, revealed in part, "Store refrigerated ... Upon removal from refrigeration to room temperature storage conditions ... use Rocuronium Bromide Injection within 60 days."

Review of Rocuronium manufacturer information, in the form of an email, solicited by the facility, revealed the manufacturer did not have stability testing with removing the drug from refrigeration for short durations then returning the drug to refrigeration. According to the manufacturer, studies of removal from refrigeration for extended periods of time revealed certain impurities that definitely increased and cautioned the facility about the time the drug remains at room temperature. The information did not support the facility ' s practice.

6. During an interview at the time of the tour, the CRNA acknowledged he did not document the date he first removed the vials from the refrigerator, and acknowledged the vials could warm to room temperature during the time he was administering general anesthesia to a patient.

Based on observation, document review, and staff interview, the facility failed to ensure 3 of 3 observed nurses in the operating room allowed the disinfectant solution (3M HB Quat) to remain wet on the surfaces cleaned for the manufacturer recommended 10 minutes to kill all micro-organisms. The facility performed an average of 35 surgical procedures per month.

Failure to allow the disinfectant to remain wet on a surface for the full manufacturer recommended time could potentially result in the disinfectant failing to kill all the micro-organisms (bacteria, fungi, and viruses) on the surface. If micro-organisms remained on the surface, the staff could potentially spread the micro-organisms to another patient, and potentially result in the other patient developing an infection.

Findings include:

1. Observations during a tour of the operating rooms on 3/6/13 at 10:21 AM revealed the Director of Surgical Services used a mop to clean the floor of the main operating room. As the Director of Surgical Services mopped the floor, the liquid from the mop remained wet for approximately 3 minutes after she wiped the area.

During an interview, at the time of the observation, the Director of Surgical Services stated the mop contained HB Quat as the liquid used to disinfect the floor of the operating room.

2. Review of the manufacturer's instructions for 3M HB Quat, revised 1/13, revealed in part, "The contact time for the viruses, fungi, and bacterial listed on the label is 10 minutes ..."

3. During an interview on 3/6/13 at 4:00 PM, the Infection Control Nurse stated the manufacturer required the Surgical Services staff members to allow the 3M HB Quat to remain wet on a surface for 10 minutes in order to fully kill all the micro-organisms the manufacturer stated the liquid would kill.

4. Additional observations with the Director of Surgical Services in the main operating room on 3/6/13 revealed:

At 1:04 PM, Registered Nurse (RN) A wiped down a portable table with a rag soaked in 3M HB Quat solution. RN A left a layer of liquid on the surface of the portable table. At 1:07 PM, the liquid had air dried off the surface of the table.

At 1:05 PM, RN A wiped down a piece of equipment used to warm a patient with a rag soaked in 3M HB Quat solution. RN A left a layer of liquid on the surface of the warming equipment. At 1:06 PM, RN A brushed against the front of the warming equipment, and her jacket wiped off the liquid on the front of the warming equipment. At 1:07 PM, the liquid had air dried off the surface of the warming equipment.

At 1:09 PM, RN A wiped down the Striker Power Supply (a device used to power tools used by the surgeon) with a rag soaked in 3M HB Quat solution. RN A left a layer of liquid on the surface of the power supply. At 1:11 PM, the liquid had air dried off the surface of the power supply.

At 1:12 PM, RN A wiped down the tourniquet machine (a machine used to stop the blood flow to a patient's limb during surgery) with a rag soaked in 3M HB Quat. RN A left a layer of liquid on the surface of the tourniquet. At 1:13 PM, the liquid had air dried off the surface of the tourniquet machine.

5. During an interview on 3/6/13 at 4:15 PM, the Director of Surgical Services acknowledged the surgical services staff had not allowed the 3M HB Quat to remain wet on the surfaces they wanted to disinfect for the 10 minutes as required by the manufacturer.