HospitalInspections.org

1) Based on observation and interview with staff, the facility failed to store quantities of flammable, combustible, or hazardous materials that are considered a severe hazard that are protected in accordance with NFPA 99. Findings include:

a) Two gallons of alcohol was found stored in the lab on a shelf and not in a Flammable Storage Cabinet.

( Based on observation and interview with staff, the facility failed to provide Exit accesses that are arranged so that exits are readily accessible at all times in accordance with section 7.1. 19.2.1 Findings include:

a) Magnetic Locks installed on the Egress doors out of Surgery did not have devices that meet requirements of 7.2.1.6 Special Locking Arrangements. 7.2.1.6.1 Delayed-Egress Locks. Approved, listed, delayed egress locks shall be permitted to be installed on doors serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 12 through 42, provided that the following criteria are met. (a1) The doors shall unlock upon actuation of an approved, supervised automatic sprinkler system in accordance with Section 9.7 or upon the activation of any heat detector or activation of not more than two smoke detectors of an approved, supervised automatic fire detection system in accordance with Section 9.6. (b1) The doors shall unlock upon loss of power controlling
the lock or locking mechanism.(c1) An irreversible process shall release the lock within 15 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lb. (67 N) nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate
an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the
releasing device, relocking shall be by manual means only. Exception: Where approved by the authority having jurisdiction, a delay not exceeding 30 seconds shall be permitted. (d1) *On the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than.

1) Based on observation and interview with staff, the facility failed to provide piped in medical gas systems that comply with NFPA 99, Chapter 4.

a) The Bottled reserve is not covered.

b) The Zone Valve and Medical Gas Alarms for the Pre-op/ Post-Op. unit west of the Surgery Suite was not installed Immediately outside the unit.

c) The facility just recently installed a new Med Gas System. The facility could not provide a Medical Gas Certification for the New work . Also NFPA 101 chapter 5.8.14, Performance-Based Design Option, requires that the change in design for any part of the hospital requires that the ownership or management of the building, will have a re-evaluation and re-approval for any remodeling, modification, renovation, or change in use. The building was approved with performance-based design and certain specified design criteria and assumptions, the Medical Gas System upgrade was not submitted for review.

1) Based on observation, interview with staff, the facility failed to protect Anesthetizing locations in accordance with NFPA 99, Standard for Health Care Facilities. Findings include:

a) The facility failed to adopt and post NFPA 99 12-4.1.1 Rules and Regulations that requires authorities and professional staff to jointly consider and agree upon necessary rules and regulations for the control of personnel concerned with anesthetizing locations. Upon adoption of rules and regulations, these rules shall be prominently posted in the operating room suite, there was no rules posted for Fire Loss Prevention . These positive measures are necessary to acquaint all personnel with the rules and regulations established and to ensure enforcement. The governing body of the hospital failed to correlate regulations and standard operating procedures to ensure that both the physical qualities and the operating maintenance methods pertaining to anesthetizing locations meet the standards set in chapter 12. The controls adopted shall cover the conduct of professional personnel in anesthetizing locations, periodic inspection to ensure the proper grounding of dead metal (see 3-3.3.2), and inspection of all electrical equipment, including testing of line isolation monitors. Line Isolation Monitors were not on a Preventive Maintenance program. Staff was unable to identify zone valves in all areas.

b) Based on observation and interview with staff, the facility failed to provide a program that includes periodic review of manufacturers' safety guidelines and usage requirements for electrosurgical units and similar appliances with all personnel concerned with the application and maintenance of electric appliances, including physicians, nurses, nurse aids, engineers, technicians, and orderlies, shall be cognizant of the risks associated with their use. To achieve this end the hospital shall provide appropriate programs of continuing education for its personnel in accordance with Qualification and Training of Personnel NFPA 99 chapter 7-6.5. As an example a one-time use battery cautery device was found in the ER. No documentation was available for review that shows staff was in-serviced or cognizant of the potential for fire in the Emergency Room Department with its use.

c) The facility failed to provide a smoke evacuation system installed in accordance with NFPA chapter 12-4.1.2 and chapter 5-4.1 through 5-6.1 5-4.1* Ventilation-Anesthetizing Locations Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion. If the system is installed it is not documented on the annual inspection report of the Fire Alarm System.

1) Based on observation and interview with Staff, the facility failed to maintain Fume hoods that are in accordance with NFPA 99. 5.4.3, 5.6.2 Findings include:

a) Conoco Hood was not calibrated and documentation was not available in the Lab.

1) Based on observation and interview with staff, the facility failed to provide a quick drenching or flushing Fixed eye bath maintained and installed to avoid injurious water pressure in accordance with NFPA 99. 10.6 Findings include:

a) The eye wash and shower was not logged monthly and presented to the Safety Committee for review.

1) Based on observation and interview with staff, the facility failed to inspect weekly and exercise the Generator under load for 30 minutes per month in accordance with NFPA 99. 3.4.4.1. Findings include:

a) The Emergency Generator Testing Record adopted by the facility did not log Load, Length of Time of Run, Fuel Level and when to call for more fuel.

1) Based on observation and interview with staff, the facility failed to provide a Type I EES that is divided into the critical branch, life safety branch and the emergency system in accordance with NFPA 99. 3.4.2.2.2.Findings include:

a) The generator and automatic transfer switch do not have separation of the life safety and critical branch panels labeled, staff does not have the knowledge of separation of Branches of the Emergency Power System in the Hospital

1) Based on observation and interview with staff, the facility did not have Electrical wiring and equipment that is in accordance with NFPA 70, National Electrical Code. 9.1.2

a) Impedance testing of patient care areas is not a part of a Preventive Maintenance Program. 3-3.3.2.5. Measurements plus or minus of +/- 20% shall be made in patient Care Areas

b) The hospital was designed with Performance-Based Design that requires that any change in design for any part of the hospital ,the ownership or management of the building shall have a re-evaluation and re-approval for any remodeling, modification, renovation, or change in use. The building was approved with performance-based design and certain specified design criteria and assumptions, any room that is re-purposed will be submitted for approval. The room being used for recovery does not meet wiring requirements found in NFPA 99 and NFPA 70. The room did not have dedicated circuits supplied from the Emergency Critical Care Branch. Staff could not identify the circuit that fed recovery room located west of the Surgery Suite.

c) The hospital failed to adopt regulations and practices concerning the use of electric appliances and failed to establish programs for the training of physicians, nurses, and other personnel who might be involved in the procurement, application, use inspection, testing, and maintenance of electrical appliances for the care and use around patients NFPA 99 7-6.5.
The governing body failed to document or ensure that the services performed under a contract are provided in a safe and effective manner. No documentation of assessment, performance improvement, or evaluation of services provided by the BIO-Medical Contractor. Space Lab Anesthesia Machine was not stickered with an up to date Bio-Medical Sticker. Staff failed to recognize the sticker and did not take machine out of use.

1) Based on observation and interview with staff, the facility failed to store quantities of flammable, combustible, or hazardous materials that are considered a severe hazard that are protected in accordance with NFPA 99. Findings include:

a) Two gallons of alcohol was found stored in the lab on a shelf and not in a Flammable Storage Cabinet.

( Based on observation and interview with staff, the facility failed to provide Exit accesses that are arranged so that exits are readily accessible at all times in accordance with section 7.1. 19.2.1 Findings include:

a) Magnetic Locks installed on the Egress doors out of Surgery did not have devices that meet requirements of 7.2.1.6 Special Locking Arrangements. 7.2.1.6.1 Delayed-Egress Locks. Approved, listed, delayed egress locks shall be permitted to be installed on doors serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 12 through 42, provided that the following criteria are met. (a1) The doors shall unlock upon actuation of an approved, supervised automatic sprinkler system in accordance with Section 9.7 or upon the activation of any heat detector or activation of not more than two smoke detectors of an approved, supervised automatic fire detection system in accordance with Section 9.6. (b1) The doors shall unlock upon loss of power controlling
the lock or locking mechanism.(c1) An irreversible process shall release the lock within 15 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lb. (67 N) nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate
an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the
releasing device, relocking shall be by manual means only. Exception: Where approved by the authority having jurisdiction, a delay not exceeding 30 seconds shall be permitted. (d1) *On the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than.

1) Based on observation and interview with staff, the facility failed to provide piped in medical gas systems that comply with NFPA 99, Chapter 4.

a) The Bottled reserve is not covered.

b) The Zone Valve and Medical Gas Alarms for the Pre-op/ Post-Op. unit west of the Surgery Suite was not installed Immediately outside the unit.

c) The facility just recently installed a new Med Gas System. The facility could not provide a Medical Gas Certification for the New work . Also NFPA 101 chapter 5.8.14, Performance-Based Design Option, requires that the change in design for any part of the hospital requires that the ownership or management of the building, will have a re-evaluation and re-approval for any remodeling, modification, renovation, or change in use. The building was approved with performance-based design and certain specified design criteria and assumptions, the Medical Gas System upgrade was not submitted for review.

1) Based on observation, interview with staff, the facility failed to protect Anesthetizing locations in accordance with NFPA 99, Standard for Health Care Facilities. Findings include:

a) The facility failed to adopt and post NFPA 99 12-4.1.1 Rules and Regulations that requires authorities and professional staff to jointly consider and agree upon necessary rules and regulations for the control of personnel concerned with anesthetizing locations. Upon adoption of rules and regulations, these rules shall be prominently posted in the operating room suite, there was no rules posted for Fire Loss Prevention . These positive measures are necessary to acquaint all personnel with the rules and regulations established and to ensure enforcement. The governing body of the hospital failed to correlate regulations and standard operating procedures to ensure that both the physical qualities and the operating maintenance methods pertaining to anesthetizing locations meet the standards set in chapter 12. The controls adopted shall cover the conduct of professional personnel in anesthetizing locations, periodic inspection to ensure the proper grounding of dead metal (see 3-3.3.2), and inspection of all electrical equipment, including testing of line isolation monitors. Line Isolation Monitors were not on a Preventive Maintenance program. Staff was unable to identify zone valves in all areas.

b) Based on observation and interview with staff, the facility failed to provide a program that includes periodic review of manufacturers' safety guidelines and usage requirements for electrosurgical units and similar appliances with all personnel concerned with the application and maintenance of electric appliances, including physicians, nurses, nurse aids, engineers, technicians, and orderlies, shall be cognizant of the risks associated with their use. To achieve this end the hospital shall provide appropriate programs of continuing education for its personnel in accordance with Qualification and Training of Personnel NFPA 99 chapter 7-6.5. As an example a one-time use battery cautery device was found in the ER. No documentation was available for review that shows staff was in-serviced or cognizant of the potential for fire in the Emergency Room Department with its use.

c) The facility failed to provide a smoke evacuation system installed in accordance with NFPA chapter 12-4.1.2 and chapter 5-4.1 through 5-6.1 5-4.1* Ventilation-Anesthetizing Locations Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion. If the system is installed it is not documented on the annual inspection report of the Fire Alarm System.

1) Based on observation and interview with staff, the facility failed to provide a quick drenching or flushing Fixed eye bath maintained and installed to avoid injurious water pressure in accordance with NFPA 99. 10.6 Findings include:

a) The eye wash and shower was not logged monthly and presented to the Safety Committee for review.

1) Based on observation and interview with staff, the facility failed to inspect weekly and exercise the Generator under load for 30 minutes per month in accordance with NFPA 99. 3.4.4.1. Findings include:

a) The Emergency Generator Testing Record adopted by the facility did not log Load, Length of Time of Run, Fuel Level and when to call for more fuel.

1) Based on observation and interview with staff, the facility failed to provide a Type I EES that is divided into the critical branch, life safety branch and the emergency system in accordance with NFPA 99. 3.4.2.2.2.Findings include:

a) The generator and automatic transfer switch do not have separation of the life safety and critical branch panels labeled, staff does not have the knowledge of separation of Branches of the Emergency Power System in the Hospital

1) Based on observation and interview with staff, the facility did not have Electrical wiring and equipment that is in accordance with NFPA 70, National Electrical Code. 9.1.2

a) Impedance testing of patient care areas is not a part of a Preventive Maintenance Program. 3-3.3.2.5. Measurements plus or minus of +/- 20% shall be made in patient Care Areas

b) The hospital was designed with Performance-Based Design that requires that any change in design for any part of the hospital ,the ownership or management of the building shall have a re-evaluation and re-approval for any remodeling, modification, renovation, or change in use. The building was approved with performance-based design and certain specified design criteria and assumptions, any room that is re-purposed will be submitted for approval. The room being used for recovery does not meet wiring requirements found in NFPA 99 and NFPA 70. The room did not have dedicated circuits supplied from the Emergency Critical Care Branch. Staff could not identify the circuit that fed recovery room located west of the Surgery Suite.

c) The hospital failed to adopt regulations and practices concerning the use of electric appliances and failed to establish programs for the training of physicians, nurses, and other personnel who might be involved in the procurement, application, use inspection, testing, and maintenance of electrical appliances for the care and use around patients NFPA 99 7-6.5.
The governing body failed to document or ensure that the services performed under a contract are provided in a safe and effective manner. No documentation of assessment, performance improvement, or evaluation of services provided by the BIO-Medical Contractor. Space Lab Anesthesia Machine was not stickered with an up to date Bio-Medical Sticker. Staff failed to recognize the sticker and did not take machine out of use.