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Based on observation and a staff interview, it was confirmed the facility failed to conduct one or more fire drills on each shift, during each quarter of the previous year. This deficient practice was not in accordance with the requirements at NFPA 101 (2000) Chapter 19, Section 19.7.1.2, and CMS policy. In a fire emergency, this deficient practice could adversely affect 15 of 15 patients.

FINDINGS INCLUDE:

On 07/29/2014 at 10:10 AM, while reviewing fire drill reports for the previous year, no documentation could be provided verifying that fire drills were conducted during October, November and December of 2013.

This deficient practice was confirmed with the chief building engineer.

Based on observation and a staff interview, the facility was storing medical gas cylinders in a manner not in conformance with the requirements at NFPA 99 (1999 edition) Chapter 4, Section 4-3.1.1.1. This deficient practice could adversely affect 1 patient and any staff in the vicinity of the unsecured cylinders.

FINDINGS INCLUDE:

On 07/29/2014 at 12:50 PM, observation revealed two (2) empty oxygen cylinders stored on the floor surface of the Operating Room anteroom. The oxygen cylinders were standing in an upright position, and were not secured and located to prevent tipping/falling. This free-standing storage arrangement was not in conformance with the requirements at NFPA 99 (1999), Chapter 4, Section 4-3.1.1.1 and Chapter 8, Section 8-3.1.1.

This finding was confirmed with the chief building engineer at the time of discovery.

Based on observation and a staff interview, the facility failed to provide line isolation monitoring at all anesthetizing locations, in accordance with the requirements at NFPA 101 (2000 edition) Chapter 19, Section 19.3.2.3 and NFPA 99 (1999 edition). This deficient practice could adversely affect the safety of an anesthetized patient and/or surgical staff.

FINDINGS INCLUDE:

On 07/29/2014 at 12:30 PM, observation revealed the sole Operating Room [OR] was a wet location where general anesthesia is administered, and no line isolation monitor could not be located. Further, no GFCI electrical outlets were present. In a discussion with staff, it could not be verified that a circuit interruption could be tolerated [See NFPA 70 (1999) article 517-20(a)]. If an interruption can be tolerated, GFCI protection may be permitted. If an interruption cannot be tolerated, an isolated power system is required [See NFPA 99 (1999) Chapter 3, Section 3-3.2.2.3]. Based upon observation, it could not be determined whether the electrical system within the OR would properly protect patients and staff from an electrical shock.

This finding was confirmed with the chief building engineer.

Based on observation and a staff interview, it was confirmed the facility failed to conduct one or more fire drills on each shift, during each quarter of the previous year. This deficient practice was not in accordance with the requirements at NFPA 101 (2000) Chapter 19, Section 19.7.1.2, and CMS policy. In a fire emergency, this deficient practice could adversely affect 15 of 15 patients.

FINDINGS INCLUDE:

On 07/29/2014 at 10:10 AM, while reviewing fire drill reports for the previous year, no documentation could be provided verifying that fire drills were conducted during October, November and December of 2013.

This deficient practice was confirmed with the chief building engineer.

Based on observation and a staff interview, the facility was storing medical gas cylinders in a manner not in conformance with the requirements at NFPA 99 (1999 edition) Chapter 4, Section 4-3.1.1.1. This deficient practice could adversely affect 1 patient and any staff in the vicinity of the unsecured cylinders.

FINDINGS INCLUDE:

On 07/29/2014 at 12:50 PM, observation revealed two (2) empty oxygen cylinders stored on the floor surface of the Operating Room anteroom. The oxygen cylinders were standing in an upright position, and were not secured and located to prevent tipping/falling. This free-standing storage arrangement was not in conformance with the requirements at NFPA 99 (1999), Chapter 4, Section 4-3.1.1.1 and Chapter 8, Section 8-3.1.1.

This finding was confirmed with the chief building engineer at the time of discovery.

Based on observation and a staff interview, the facility failed to provide line isolation monitoring at all anesthetizing locations, in accordance with the requirements at NFPA 101 (2000 edition) Chapter 19, Section 19.3.2.3 and NFPA 99 (1999 edition). This deficient practice could adversely affect the safety of an anesthetized patient and/or surgical staff.

FINDINGS INCLUDE:

On 07/29/2014 at 12:30 PM, observation revealed the sole Operating Room [OR] was a wet location where general anesthesia is administered, and no line isolation monitor could not be located. Further, no GFCI electrical outlets were present. In a discussion with staff, it could not be verified that a circuit interruption could be tolerated [See NFPA 70 (1999) article 517-20(a)]. If an interruption can be tolerated, GFCI protection may be permitted. If an interruption cannot be tolerated, an isolated power system is required [See NFPA 99 (1999) Chapter 3, Section 3-3.2.2.3]. Based upon observation, it could not be determined whether the electrical system within the OR would properly protect patients and staff from an electrical shock.

This finding was confirmed with the chief building engineer.