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Based on observation and interview with staff, the facility failed to test and maintain the fire alarm system in accordance with NFPA 70 and NFPA 72. 9.6.1.4 Findings,

The facility failed to provide documentation that the combination fire and smoke dampers were connected to the fire alarm system, had been inspected on an annual basis or visually verified they will open and close upon activation of the fire alarm system.

Based upon observation and interview with staff, the facility failed to properly protect all anesthetizing locations in accordance with NFPA 99, Standard for Health care Facilities. NFPA 99, 4.3.1.2.3(n) and 5.4.1.1 Findings,

The facility had rooms that were used as an anesthetizing locations that were not constructed for that purpose; the rooms included an MRI, CT (3) and Endoscope/APC Rooms. Failure to comply in these locations included:
A. failure to have a shutoff valve located outside each location in each medical gas line located to be readily accessible at all times for use in an emergency.
B. Waste Anesthesia Disposal System (WAGD) inlets were not provided.
C. Means for humidity control is not provided.
D. Provisions for smoke removal is not provided.
E. Provisions for low returns is not provided.
F. Provisions for emergency power is not provided.

Based upon OR energy management data logs, the facility failed to consistently maintain humidity levels between 35% - 60% in the ORs of the surgery suite.

1) Based on observation, interview with staff and review of records, the facility failed to provide documentation of a Fire Loss Prevention Program for the OR staff of the Surgery Department, including the Physicians and Surgeons in accordance with NFPA 99 1999 edition 12-4.1.2.10. Findings,

While a committee is working on a policy for a Fire Loss Prevention Program for the surgery rooms in all of the St. John facilities, it will not be available for at least 2 months. The fire in the OR in 2011 that resulted in burn damage to a patient did result in an in-service for the physician, but not for the remainder of the staff.

2) The facility failed to provide emergency power to all locations required by NFPA 99 3-4.2.2.2 Emergency systems. Findings,

Staff commented that there are several patient care locations that do not have emergency power, specifically noted were the Angiographic Labs and Cardiac Catherization Labs.

3) Essential Electric System Requirements - Type 1 NFPA 99 3-4. While dual sources of normal power are provided, the facility failed to design a system to minimize the interruption of the electrical system to consider (e) "Stability and power capability of the prime mover during and after abnormal conditions". NFPA 99, 3-4.1.1.1 Design Considerations. Findings,

The staff failed to coordinate with the Prime Mover to have an automatic transfer system of normal power from one source to another after failure of one of the sources. With both the failure to have equipment in place to automatically transfer normal power and the equipment failure of the alternate source of power (generators), a catastrophic power failure occurred. Emergency battery lighting and equipment support were in many cases non-existent or inadequate for the 45 - 60 minutes required to restore normal power and alternative power that was compromised for providing essential power in a timely manner. The electric locking devices failed to reboot in a seamless manner, leaving doors and medication dispensers non-functional.

Based on observation, interview with staff and review of records, the facility failed to properly document required program to maintain and test the circuit breakers for the generators for proper operation in accordance with NFPA 99 3-4.4.1 Maintenance and Testing of EES. The facility failed to provide proper written records of inspection, performance, exercising period and repairs, NFPA 99 3-4.4.2 Record Keeping. Findings,

Following the June run test under load, the facility failed to properly inspect the breakers to verify they were in correct operating condition and positioned to the correct settings to function in the event of a future test or demand for emergency power. The points on the G 3 Breaker were improperly set, causing the catastrophic failure. Also, the facility failed to provide proper sequence of operation for the EES controls to continue to function after failure of the G 3 generator breaker.

The run log for the month of June was not signed by the technician witnessing the test. The data on the printed form differed from the electronic official copy.

Based on observation and interview with staff, the facility failed to test and maintain the fire alarm system in accordance with NFPA 70 and NFPA 72. 9.6.1.4 Findings,

The facility failed to provide documentation that the combination fire and smoke dampers were connected to the fire alarm system, had been inspected on an annual basis or visually verified they will open and close upon activation of the fire alarm system.

Based upon observation and interview with staff, the facility failed to properly protect all anesthetizing locations in accordance with NFPA 99, Standard for Health care Facilities. NFPA 99, 4.3.1.2.3(n) and 5.4.1.1 Findings,

The facility had rooms that were used as an anesthetizing locations that were not constructed for that purpose; the rooms included an MRI, CT (3) and Endoscope/APC Rooms. Failure to comply in these locations included:
A. failure to have a shutoff valve located outside each location in each medical gas line located to be readily accessible at all times for use in an emergency.
B. Waste Anesthesia Disposal System (WAGD) inlets were not provided.
C. Means for humidity control is not provided.
D. Provisions for smoke removal is not provided.
E. Provisions for low returns is not provided.
F. Provisions for emergency power is not provided.

Based upon OR energy management data logs, the facility failed to consistently maintain humidity levels between 35% - 60% in the ORs of the surgery suite.

1) Based on observation, interview with staff and review of records, the facility failed to provide documentation of a Fire Loss Prevention Program for the OR staff of the Surgery Department, including the Physicians and Surgeons in accordance with NFPA 99 1999 edition 12-4.1.2.10. Findings,

While a committee is working on a policy for a Fire Loss Prevention Program for the surgery rooms in all of the St. John facilities, it will not be available for at least 2 months. The fire in the OR in 2011 that resulted in burn damage to a patient did result in an in-service for the physician, but not for the remainder of the staff.

2) The facility failed to provide emergency power to all locations required by NFPA 99 3-4.2.2.2 Emergency systems. Findings,

Staff commented that there are several patient care locations that do not have emergency power, specifically noted were the Angiographic Labs and Cardiac Catherization Labs.

3) Essential Electric System Requirements - Type 1 NFPA 99 3-4. While dual sources of normal power are provided, the facility failed to design a system to minimize the interruption of the electrical system to consider (e) "Stability and power capability of the prime mover during and after abnormal conditions". NFPA 99, 3-4.1.1.1 Design Considerations. Findings,

The staff failed to coordinate with the Prime Mover to have an automatic transfer system of normal power from one source to another after failure of one of the sources. With both the failure to have equipment in place to automatically transfer normal power and the equipment failure of the alternate source of power (generators), a catastrophic power failure occurred. Emergency battery lighting and equipment support were in many cases non-existent or inadequate for the 45 - 60 minutes required to restore normal power and alternative power that was compromised for providing essential power in a timely manner. The electric locking devices failed to reboot in a seamless manner, leaving doors and medication dispensers non-functional.

Based on observation, interview with staff and review of records, the facility failed to properly document required program to maintain and test the circuit breakers for the generators for proper operation in accordance with NFPA 99 3-4.4.1 Maintenance and Testing of EES. The facility failed to provide proper written records of inspection, performance, exercising period and repairs, NFPA 99 3-4.4.2 Record Keeping. Findings,

Following the June run test under load, the facility failed to properly inspect the breakers to verify they were in correct operating condition and positioned to the correct settings to function in the event of a future test or demand for emergency power. The points on the G 3 Breaker were improperly set, causing the catastrophic failure. Also, the facility failed to provide proper sequence of operation for the EES controls to continue to function after failure of the G 3 generator breaker.

The run log for the month of June was not signed by the technician witnessing the test. The data on the printed form differed from the electronic official copy.