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AIA, (American institute of Architects) Guidelines for Design and Construction of Health Care Facilities 2.1 General Hospitals 8.2 General Standards for Details and Finishes 8.2.3.4 Ceilings

(3) Semirestricted areas

(a) Ceiling finishes in semirestricted areas such as airborne infection isolation rooms, protective environment rooms, clean corridors, central sterile supply spaces, specialized radiographic rooms, and minor surgical procedure rooms shall be smooth, scrubbable, nonabsorptive, non perforated, capable of withstanding cleaning with chemicals, and without crevices that can harbor mold and bacterial growth.

(b) If lay-in ceiling is provided, it shall be gasketed or clipped down to prevent the passage of particles from the cavity above the ceiling plane into the semirestricted environment. Perforated, tegular, serrated, or highly textured tiles shall not be used.

Based on tour of the surgical suites on 9/1/11 with Staff A (Director of Surgical Services) it was observed that the facility failed to maintain an environment that is safe for the patients' well-being.

Findings include:

During tour of the surgical suite on 9/1/11 it was observed and shown to Staff A that the ceiling tiles located in the semi-restricted corridors between operating rooms 1, 2 and 3, along with central sterile supply, failed to have smooth, scrubbable, nonabsorptive, non perforated surfaces capable of withstanding cleaning with chemicals, and without crevices that can harbor mold and bacterial growth.

2010 Guidelines for the Design and Construction of Heath Care Facilities Chapter 2 Hospitals Section 2.1-8.6 Electronic Safety and Security Systems 2.1-8.6.2 Electronic Surveillance Systems "Electronic surveillance systems include but are not limited to patient elopement systems, door access/control systems, video/audio monitoring systems, patient location systems, and infant abduction prevention systems."

Based on tour of the facility on 9/2/11 it was found through observation and interview with staff that the facility fails to have proper security for the safety of patients and employees for the provisions of direct services.

Findings include:

During the facility tour with Staff C (Associate V.P. Organizational Improvement) it was found that the facility does not have adequate security for three areas of care. These three areas are as follows:

1) Pharmacy
2) Laboratory services
3) Emergency department

All three areas had turn key access or push button key pad with numerical access , with no ability to confirm who has or has not entered the areas written above. Each department head during tour was questioned that during different times of the day and night would they be able to know who has come into their work area. Each department confirmed that they would not be able to know since multiple people throughout the facility have access. All interviews were made with the director of each department along with Staff C.

Based on observation and interview on 9/2/11 it was observed that the facility failed to maintain laboratory equipment in a safe operating condition.

Finding include:

During tour on 9/2/11 of the laboratory services, it was observed that the rocker equipment in hematology was rusted. Staff B (Director of Laboratory Services) was shown this observation and stated on 9/2/11 that the equipment became rusty due to the cleanser being used and the unit should be replaced.

ANSI [Approved American National Standard Institute] /ASHRAE/ASHE [American Society for Healthcare Engineering] Standard 170-2008 Ventilation of Health Care Facilities. Page 11. 7.4 Surgery Rooms. 7.4.1 Class B and C Operating Rooms. Operating rooms shall be maintained at a positive pressure with respect to all adjoining spaces at all times. A pressure differential shall be maintained at a value of at least =0.01 in. wc (2.5Pa).


ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) Chapter 7 Health Care Facilities. Specific Design Criteria Surgery and Critical Care. 7.5 The following conditions are recommended for operating, catheterization, cystoscopic, and fracture rooms:

*Air pressure should be kept positive with respect to any adjoining rooms by supplying excess air.

*A differential-pressure-indication device should be installed to permit air pressure readings in the rooms. Thorough sealing of all wall, ceiling, and floor penetrations, and tight-fitting doors are essential to maintaining readable pressure.


Based on tour of the surgical suite on 9/1/11 with Staff A (Director of Surgical Services) it was observed that the facility failed to monitor the pressurization of the three surgical rooms.

Findings include:

During tour on 9/1/11 of the surgical suite it was observed and shown to Staff A that the surgical room failed to have visual air pressurization monitoring devices to show the appropriate air pressurization from the surgical suite to the sterile core.


AORN[Association of Peri-Operative Registered Nurses] Standards Recommended Practices, and Guidelines Recommended Practices for Selection and Use of Packaging Systems.

Packaging materials should be processed to maintain the properties required for sterilization.

1) "Packaging materials should be maintained at room temperature (ie, 18 C to 22 C [64 degrees Farenheit to 72 degrees Farenheit] and at a relative humidity of 35% to 70%. Maintaining room temperature and moisture content of packaging material..."

Based on tour of the surgical suite on 9/1/11 with Staff A (Director of Surgical Services) it was observed that two areas failed to have proper temperature and humidity monitoring.

Findings include:

On 9/1/11 during tour of the surgical suite it was observed and shown to Staff A (Director of Surgical Services) that the humidistat located on the wall in the central supply room failed to be working properly so Staff A used a handheld humidity unit to show the humidity level.

Also during tour it was observed and shown to Staff A that the Clean Sterile Storage area failed to have any temperature or humidity devices located in the room to read the humidity and temperature levels to confirm that packaged material were maintained at the proper temperature and humidity.