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Based on tests to equipment and observations made during the survey for Life Safety from fire with the facility's Physical Plant Manager, it was determined that the facility does not meet some applicable provision of the 2000 edition of Life Safety Code of the NFPA 101.

Findings include:

The Life Safety from Fire survey was performed on 2/10/10 and 2/11/10 from 8:00 am till 4:00 pm; for deficiencies related to Life Safety from fire (form 2786R) please see tags with letter K on the 2567 form (K0046, K0051, K0108 and K0130).

Based on the review of licenses, certificates and endorsements during the physical environment survey with the facility's Physical Plant Manager, it was determined that the facility failed to ensure that its Fire Department Endorsement is updated and current.

Findings include:

Review of the facility's Fire Department Endorsement on 2/11/10 at 11:00 am, provided evidence that it expired on January 23, 2010.

Based on tests performed on equipment and observations made during the survey for the physical environment with the facility's Physical Plant Manager, it was determined that this facility's physical structure is not designed in accordance with Federal and State laws to provide protection of patients and staff related to bathrooms in the emergency room and pre-anesthesia area, the operating room department is not appropriately designed related to traffic, recovery room emergency call systems do not emit an auditory alarm, Cidex OPA is not used in an appropriate area, the emergency rooms' decontamination room is not properly designed and there is only one crash cart for the adult and pediatric emergency room.

Findings include:

1. The waiting area of the emergency room was visited on 2/10/10 at 8:30 am and provided evidence that this area has two handicapped accessible patient's bathrooms. In order to comply with "Americans with Disabilities Act" (Ley ADA) the device to roll out the paper from the paper dispensers for front access, shall not exceed 48 inches above the floor, however the device used to roll out the paper from the dispensers in these bathrooms were measured at 54 inches above the floor.

2. The bathrooms (male and female) located in the pre-anesthesia area were visited on 2/11/10 at 8:00 am with the Physical Plant Manager and provided evidence that they do not comply with "Americans with Disabilities Act" (Ley ADA). The height of toilets in the male and female bathrooms were measured at 15 inches high, in order for these bathroom to comply with Americans with Disabilities Act (Ley ADA) requirements for toilet heights, the toilet seat must be between 17 and 19 inches in height. Also needed at these bathrooms are handrails in back of and on one side of the toilets. These bathrooms are handicapped accessible, however the symbol recognized by "Americans with Disabilities Act" (Ley ADA) is needed on these bathroom doors for handicapped persons recognition.

3. The operating room department was visited on 2/11/10 from 7:30 am till 9:00 am with the Physical Plant Manager and nursing supervisor and provided evidence of the following:

a. The pre-anesthesia area is located in the semi-restrictive area and is before the recovery room area. The recovery room (with 10 cubicles and 1 isolation room) has been designated an unrestricted area and persons were observed in street clothes. When staff take patients to the operating suites they have to pass through the recovery room (that has been designated unrestricted). Staff in scrubs who enter the operating rooms and persons in street clothes occupying the same area (recovery room) increases the risk of cross contamination.
b. Operating suite #1 does not have a hands free intercom system within the suite connected to the nursing station and recovery room.
c. The hands free intercom system in operating suites #2, #3 and #4 were tested and provided evidence that they do not function.
d. The front doors of operating suites #1, #2, #3 and #4 were found with locks, permitting those inside to lock the doors, limiting access from the outside in the event of an emergency.
e. A handsink located in the pre-anesthesia area was found without a paper dispenser or soap dispenser.
f. The facility performs outpatient surgeries, however they do not have a designated phase II area as defined in the Guidelines for Design and Construction of Health Care facilities (GDCHCF) for the 2006 edition in chapter 2.1, section 5.3.3.3 on pages 79 and 80 (and the 2001 edition, section 7.7.C14 "Phase II Recovery" on pages 37 and 38). This area shall have lounge chairs with a minimum of 50 square feet each, with additional space for equipment, a bathroom, hand sink, designated space for family members, privacy curtains and area for nurse supervision with a desk or counter placed in a manner to have direct visual contact of the patients.
g. The operating department does not have an ice machine as described in the GDCHCF for the 2006 edition in chapter 2.1, section 5.3.5.5 on page 81 (and the 2001 edition, section 7.7.C21 "Ice Machine" on page 38).
h. Two pails and four mops were found to clean four operating suites, instead of one mop and one pail per suite and each pail and mop need to be label with the number of the operating suite that they serve. One designated mop and pail are needed for the hallways, recovery and phase II areas. Also, another mop and pail are needed exclusively for contaminated cases.

4. The front door of the isolation room on the third floor was observed on 2/10/10 at 1:30 pm with a window (approximately 3 feet by 3 feet). This door with the window is located in the hallway and does not allow for privacy for the patient in this room; the patient can be seen from the hallway when lying in bed.

5. The emergency call system of the recovery room cubicles (cubicles #1 through #10) and the isolation room were tested on 2/11/10 at 8:20 am and they do not emit an auditory alarm when activated.

6. Two Cidex OPA trays were observed with the Physical Plant Manager on 2/11/10 at 8:45 am in an anteroom of the autoclave room near the operating room suites. Manufacturers' recommendations suggests that the solution is used in a well-ventilated area and in closed containers with tight fitting lids, and the user must use gloves, eye protection and fluid-resistant gowns. The use of Cidex OPA should be in an area that is ventilated with a local exhaust hood which contains a filter media or provide a certification from an engineer of the amount of air exchange in this anteroom per hour by the ceiling extractor and it must be in accordance with the Manufacturers' recommendations.

7. The emergency room was visited on 2/10/10 at 8:15 am with the Physical Plant Manager and provided evidence that the facility has a decontamination room that does not comply completely with the Guidelines for Design and Construction of Health Care facilities (GDCHCF) for the 2006 edition in chapter 2.1, section 5.1.3.7, number 5 (and the 2001 edition, section 7.9.D.25 "Decontamination Area" page 45 and appendix A7.9.D25 on page 46 "Decontamination room within the facility"). This decontamination room does not have two duplex receptacles, a curtain for privacy, and does not have a contained water drainage system to safely dispose of the used water to ensure that it does not enter into the hospital or community drainage systems.

8. The emergency room was visited on 2/10/10 at 8:00 am with the Physical Plant Manager and provided evidence that there are seven adult cubicles and one adult isolation room and in a separate area there are three pediatric cubicles and one pediatric isolation room. However there is only one crash cart with a defibrillator and monitor. Pediatric and adult emergency room areas shall have independent crash carts with defibrillator and monitor and equipped appropriately depending on the patient (adult or pediatric).

Based on observations made during the survey for the physical environment with the facility's Physical Plant Manager, it was determined that the physical structure and care areas failed to provide proper ventilation in the emergency rooms' waiting area, triage area and observation areas, these areas are not equipped with an air disinfection system.

Findings include:

The emergency room was visited on 2/10/10 from 8:00 am till 10:00 am and provided evidence that the waiting area, triage area and the observation area of the emergency room are not equipped with an air disinfection system (for example: Ultraviolet lights). According to the "Guidelines for Design and Construction of Health Care Facilities" (GDCHCF) the triage area is the point of entry of undiagnosed and untreated airborne infections and should be designed and ventilated to reduce exposure of staff, patients and families to airborne infectious diseases. Through the facility's infection control program, determinations must be made related to general ventilation and air disinfection similar to inpatient requirements for airborne infection isolation rooms according to the CDC "Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health Care Facilities". The waiting area and observation area are other areas to provide protection with an air disinfection system. (This finding was brought to the attention of administrative staff and they found a vender who arrived at the facility on 2/11/10 and he evaluated the ventilation system and gave the facility his recommendation. On 2/11/10 an ultraviolet lamp purchase order was signed and will be delivered within a week and installed by the facility's electrician).