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Based on observation and interview the facility failed to ensure egress access to corridors were continuously maintained free of all obstructions to full use in case of emergency as required in NFPA 101, 2012 Edition, Chapter 7.1.10.1 and 19.2.1.

Findings:

On 01/04/18 at 12:04 pm the surveyor observed three wheelchairs stored in the emergency egress corridor pathway near the office labeled Dr. Eck's office.

On 01/04/18 at 12:08 pm the facility manager was asked why the wheelchairs were stored in the emergency egress pathway. He stated they have made prior attempts to remove the wheelchairs from the egress pathway but staff continue to keep placing the wheelchairs back into the emergency egress pathway. He stated they will find another area for storage for the three wheelchairs.

Based on observation and interview the facility failed to ensure doors in a required means of egress were not equipped with a lock that required the use of a key from the egress side and egress corridor access door(s) required only one action to open as required by NFPA 101, 2012 Edition, Chapter 19.2.2.2.4.

Findings:

On 01/04/18 at 12:58 pm a deadbolt lock was observed to be on the laboratory corridor access door which would require two actions to open instead of only one action to open as required by fire code.

On 01/04/18 at 12:58 pm the surveyor asked the facility manager why a deadbolt keyed lock was installed on the laboratory corridor access door and he stated he did not know the reason it was installed. He stated the deadbolt would be removed.

Based on observation and interview, the facility failed to ensure each emergency exit discharge area was provided with emergency powered lighting as required in NFPA 101, 2012 Edition, Chapter 7.8 and 19.2.8.

Findings:

On 01/04/18 at 1:16 pm the surveyor observed each of the five exit discharges from the facility; main front entrance/exit, outpatient pickup exit, patient care east exit, pain three exit, ER main exit, to not have identifiable lighting fixtures on emergency power or battery backed up lighting as required by fire code.

On 01/04/18 at 1:16 pm the facility manager was asked to identify the emergency powered lighting at each exit discharge. He stated the existing light fixtures at each exit discharge were not on emergency generator power and did not have emergency battery backed up power. He stated he would get emergency battery backed up lighting installed or existing lighting circuits rewired to the emergency generator.

Based on record review and interview the facility failed to ensure the facility ventilation within the surgical suite was in accordance with ASHRAE 170-2013.

Findings:

On 01/04/18 at 12:37 pm five four shelf metal wheeled nylon covered storage racks were observed to be stored in the substerile corridor within the surgical suite. Blue wrapped sterile supplies were observed to be stored on the racks.

On 01/04/18 at 12:37 pm the facility manager was asked why the five metal shelves were stored within the substerile corridor. He stated they did not have enough room and they will relocate the shelves when they finish remodeling construction with their central sterile area. The surveyor asked if they submitted their plans to OSDH Plan Review for their review and he stated yes. The facility manager was asked if the substerile space where the five shelves are stored was included on the annual test and balance to ensure it was positively ventilated with the appropriate minimum number of air exchanges per hour. He stated no it was not included on the inspection test.

Based on record review and interview the facility failed to ensure completing building systems risk assessments for the medical gas system as required by NFPA 99, 2012 Edition, Chapters 5.1.1.1, 5.2.1, 5.3.1.1, 5.3.1.5.

Findings:

During record review the facility manager was asked for the building systems medical gas systems risk assessment documentation. He did not provide the medical gas system risk assessment as it did not exist.

On 01/04/18 at 11:17 am the facility manager was asked for the building systems risk assessment for the medical gas system. The facility manager stated the building systems risk assessment was not completed for their medical gas system.

Based on record review and interview the facility failed to ensure the facility's building system risk assessments for their essential electric system (EES) as required by NFPA 99, 2012 Edition, Chapters 3.3.138, 6.3.2.2.10, 6.6.2.2.2, and TIA 12-3.

Findings:

During record review the facility manager was asked for the building systems medical gas systems risk assessment documentation. He did not provide the EES system risk assessment as it did not exist.

On 01/04/18 at 11:17 am the facility manager was asked for the building systems risk assessment for their essential electrical systems. The facility manager stated the building systems risk assessment was not completed for their essential electrical system.