HospitalInspections.org

Based on observation and interview with staff, the facility failed to provide doors to rooms that protected corridors Doors are provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are permitted. 19.3.6.3

Roller latches are prohibited by CMS regulations in all health care facilities. Findings include:

The door to the X-Ray Procedure Room was not provided with latching hardware.

Based on observation and interview with staff, the facility failed to provide a fire alarm system required for life safety that is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. The system has an approved maintenance and testing program complying with applicable requirements of NFPA 70 and 72. 9.6.1.4 Findings include:

The combination fire and smoke damper located between the General Storage Room and Emergency Room opens and closes; however, it was not shown as tested on the annual inspection preformed by Simplex/Grinnell

Based on observation and interview with staff the facility failed to provide Heating, Ventilating, and Air- Conditioning that comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90 A, 19.5.2.2 Findings include:

1. The air flow to the rooms used for Endo Scope procedures in the existing Operating Room Suite is not designed for that procedure. Endo Scope procedure rooms requires a negative air flow in relationship to adjacent spaces.
The room requires movement of air in, 2 outside air exchanges, 6 changes per hour total, air may not be recirculated (Recirculating room HVAC units refers to those units that are used primarily for heating and cooling of air, and not disinfection of air. Because of cleaning difficulty and potential for build-up of contamination, recirculating room units shall not be used in areas marked "No". However, for airborne infection control, air may be re-circulated within individual isolation rooms if HEPA filters are used. Isolation and intensive care unit rooms may be ventilated by reheat induction units in which only the primary air supplied from a central system passes through the reheat unit. Gravity-type heating or cooling units such as radiators or convectors shall not be used in operating rooms and other special care areas, humidity controlled, with a temperature range of 68-73 degrees.
2. Currently the facility is cleaning scopes in the procedure rooms, the cleaning process requires two rooms as listed below on items 3 and 4 and fiscally separated.
3. The air flow in soiled work room requires to be negative.
4. The room for clean workroom and storage requires positive.
5. The facility failed to document Humidity Levels.
6. The fresh air to the Kitchen is from the boiler room and is being used as a plenum. The boiler room is
also being used as a storage room. Remove storage and take outside air from outside air intake for the
kitchen.
7. The use of fans on the second floor patient wing and interview with staff indicated that the unit
provided to supply cooling to the floor was not adequate and staff complained that staff and patients
were uncomfortable.

Based on observation and interview with staff, the facility failed to provide Means of egress that are continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects obstruct exits, access to, egress from, or visibility of exits. 7.1.10 Findings include:

1 The second floor patient wing was obstructed by equipment on rollers, fans and scales.
2 The first floor outside of x-ray was obstructed by chairs placed in the egress corridor.
3 The egress out of the dinning room (east doors) was blocked by chairs and a fan.

Based on observation and interview with staff, the facility failed to provide Qualification and Training program of Personnel in accordance with NFPA 99 1999 edition chapter 7-6.5 Findings include:
The facility failed to provide personnel concerned with the application and maintenance of electric appliances; including, physicians, nurses, nurse aides, engineers, technicians, and orderlies, shall all be cognizant of the risks associated with their use. To achieve this end, the hospital shall provide appropriate programs of continuing education and in-service training. This program shall include periodic review of manufacture safety guidelines and usage requirements for electro-Surgilase, electrocautery, and fiberoptics. The facility has a one time use battery controlled cauterizing tool used in the emergency room, the staff had never been trained for the hazard associated with its risks.

Based on observation, the facility failed to provide a Fire Loss Prevention program that deals with evaluation made of the hazards that could be encountered during procedures. The evaluation shall include hazards associated with electricity, other invasive equipment, and the nature of the environment. Periodic reviews shall be conducted and attention given to changes in materials, operation, and personnel, including Doctors and nurses, maintenance, etc. shall be taught general safety. Continuing education shall be reviewed monthly and procedures reviewed annually.

Based on observation and interview with Staff, the facility failed to provide a 90 minute battery back up light over the transfer switches located in the Boiler Room in accordance with NFPA 110 1999 edition chapter 5-3.1 Based on observation and interview with staff, the facility failed to provide Qualification and Training program of Personnel in accordance with NFPA 99 1999 edition chapter 7-6.5 Findings include:

The facility failed to provide personnel concerned with the application and maintenance of electric appliances, including physicians, nurses, nurse aides, 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 and in-service training. This program shall include periodic review of manufacture safety guidelines and usage requirements for electro-surgilasers, electrocautery, and fiberoptics. The facility has a one time use battery controlled cauterizing tool used in the emergency room, the staff had never been trained for the hazard associated with its risks.

Based on observation and interview with Staff, the facility failed to provide a 90 minute battery back-up light over the emergency power transfer switches located in the Boiler Room in accordance with NFPA 110 1999 edition chapter 5-3.1

Based on observation and interview with staff, the facility failed to ensure that Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2 Findings include:

1. The Line Isolation Monitors located in the two existing Operating Rooms were not on a preventive maintenance schedule in accordance with NFPA 99 1999 edition chapter 3-3.3.4.2. The LIM shall be tested at intervals not more than a month, or if self calibration the requirement is 12 months. A record shall be kept of repairs, modifications, which have met or failed to meet the performance of this chapter.

2. There were J-Boxes located in the Emergency Room that did not have covers.

3. The light over the stoop to the boiler room was about to fall to the ground. The roof over the stoop is rotten and has holes in it.

Based on observation and interview with staff, the facility was conducting Impedance Testing in the Hospital; however , the replacement receptacles in the ER had not been tested or the documentation was not provided on those outlets as was provided for all of the other outlets.

Based on observation and interview with staff, the facility failed to provide doors to rooms that protected corridors Doors are provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are permitted. 19.3.6.3

Roller latches are prohibited by CMS regulations in all health care facilities. Findings include:

The door to the X-Ray Procedure Room was not provided with latching hardware.

Based on observation and interview with staff, the facility failed to provide a fire alarm system required for life safety that is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. The system has an approved maintenance and testing program complying with applicable requirements of NFPA 70 and 72. 9.6.1.4 Findings include:

The combination fire and smoke damper located between the General Storage Room and Emergency Room opens and closes; however, it was not shown as tested on the annual inspection preformed by Simplex/Grinnell

Based on observation and interview with staff the facility failed to provide Heating, Ventilating, and Air- Conditioning that comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90 A, 19.5.2.2 Findings include:

1. The air flow to the rooms used for Endo Scope procedures in the existing Operating Room Suite is not designed for that procedure. Endo Scope procedure rooms requires a negative air flow in relationship to adjacent spaces.
The room requires movement of air in, 2 outside air exchanges, 6 changes per hour total, air may not be recirculated (Recirculating room HVAC units refers to those units that are used primarily for heating and cooling of air, and not disinfection of air. Because of cleaning difficulty and potential for build-up of contamination, recirculating room units shall not be used in areas marked "No". However, for airborne infection control, air may be re-circulated within individual isolation rooms if HEPA filters are used. Isolation and intensive care unit rooms may be ventilated by reheat induction units in which only the primary air supplied from a central system passes through the reheat unit. Gravity-type heating or cooling units such as radiators or convectors shall not be used in operating rooms and other special care areas, humidity controlled, with a temperature range of 68-73 degrees.
2. Currently the facility is cleaning scopes in the procedure rooms, the cleaning process requires two rooms as listed below on items 3 and 4 and fiscally separated.
3. The air flow in soiled work room requires to be negative.
4. The room for clean workroom and storage requires positive.
5. The facility failed to document Humidity Levels.
6. The fresh air to the Kitchen is from the boiler room and is being used as a plenum. The boiler room is
also being used as a storage room. Remove storage and take outside air from outside air intake for the
kitchen.
7. The use of fans on the second floor patient wing and interview with staff indicated that the unit
provided to supply cooling to the floor was not adequate and staff complained that staff and patients
were uncomfortable.

Based on observation and interview with staff, the facility failed to provide Means of egress that are continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects obstruct exits, access to, egress from, or visibility of exits. 7.1.10 Findings include:

1 The second floor patient wing was obstructed by equipment on rollers, fans and scales.
2 The first floor outside of x-ray was obstructed by chairs placed in the egress corridor.
3 The egress out of the dinning room (east doors) was blocked by chairs and a fan.

Based on observation and interview with staff, the facility failed to provide Qualification and Training program of Personnel in accordance with NFPA 99 1999 edition chapter 7-6.5 Findings include:
The facility failed to provide personnel concerned with the application and maintenance of electric appliances; including, physicians, nurses, nurse aides, engineers, technicians, and orderlies, shall all be cognizant of the risks associated with their use. To achieve this end, the hospital shall provide appropriate programs of continuing education and in-service training. This program shall include periodic review of manufacture safety guidelines and usage requirements for electro-Surgilase, electrocautery, and fiberoptics. The facility has a one time use battery controlled cauterizing tool used in the emergency room, the staff had never been trained for the hazard associated with its risks.

Based on observation, the facility failed to provide a Fire Loss Prevention program that deals with evaluation made of the hazards that could be encountered during procedures. The evaluation shall include hazards associated with electricity, other invasive equipment, and the nature of the environment. Periodic reviews shall be conducted and attention given to changes in materials, operation, and personnel, including Doctors and nurses, maintenance, etc. shall be taught general safety. Continuing education shall be reviewed monthly and procedures reviewed annually.

Based on observation and interview with Staff, the facility failed to provide a 90 minute battery back up light over the transfer switches located in the Boiler Room in accordance with NFPA 110 1999 edition chapter 5-3.1 Based on observation and interview with staff, the facility failed to provide Qualification and Training program of Personnel in accordance with NFPA 99 1999 edition chapter 7-6.5 Findings include:

The facility failed to provide personnel concerned with the application and maintenance of electric appliances, including physicians, nurses, nurse aides, 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 and in-service training. This program shall include periodic review of manufacture safety guidelines and usage requirements for electro-surgilasers, electrocautery, and fiberoptics. The facility has a one time use battery controlled cauterizing tool used in the emergency room, the staff had never been trained for the hazard associated with its risks.

Based on observation and interview with Staff, the facility failed to provide a 90 minute battery back-up light over the emergency power transfer switches located in the Boiler Room in accordance with NFPA 110 1999 edition chapter 5-3.1

Based on observation and interview with staff, the facility failed to ensure that Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2 Findings include:

1. The Line Isolation Monitors located in the two existing Operating Rooms were not on a preventive maintenance schedule in accordance with NFPA 99 1999 edition chapter 3-3.3.4.2. The LIM shall be tested at intervals not more than a month, or if self calibration the requirement is 12 months. A record shall be kept of repairs, modifications, which have met or failed to meet the performance of this chapter.

2. There were J-Boxes located in the Emergency Room that did not have covers.

3. The light over the stoop to the boiler room was about to fall to the ground. The roof over the stoop is rotten and has holes in it.

Based on observation and interview with staff, the facility was conducting Impedance Testing in the Hospital; however , the replacement receptacles in the ER had not been tested or the documentation was not provided on those outlets as was provided for all of the other outlets.