HospitalInspections.org

Based on record review and interview during the survey, it was determined through on-going dialog with the Facility Administrator CEO, Nurse Administrator and Maintenance Director that the facility failed to ensure that Heating, cooling, and ventilation are in accordance with ASHRAE 170. Medical supply and equipment manufacturer's instructions for use are considered before reducing humidity levels to those allowed by ASHRAE, per S&C 13-58. 18.3.2.3, 19.3.2.3 (LSC)
5.1.4.8.7, 5.1.4.8.7.2, 5.1.9.3, 5.1.9.3.4, 6.4.2.2.4.2 (NFPA 99)) This resulted in the potential for injury to patients during medical procedures. Findings include, but are not limited to:

On 03/39/2017, during record review between 10:00 hours - 13:00 hours., the humidity record that was presented to the surveyor showed a difference in ranges between a low of 18%RA to a high of 78%RA which is outside of the adopted/specified range of 30%-60% relative humidity for Anesthetizing / Operating areas by CMS. The facility's Humidity Policy showed their ranges between the adopted/specified range of 30%-60% relative humidity. A hand scribed correction of the facility's acceptable range of a lower 20% RA was found on the most recent humidity logs presented to the Surveyor, without evidence that the medical supplies and medical equipment used in the Anesthetizing / OR areas, could survive or be stored in the ranges recorded.


The Surveyor was accompanied by the Facility Administrator CEO and the Maintenance Director who acknowledged the existence and hazards of the finding(s).

Based on observations and interview during the survey, it was determined through on-going dialog with the Facility Administrator CEO and Maintenance Director that the facility failed to ensure that there was a complete sprinkler system installed in accordance with NFPA 13. This resulted in the potential for uncontrolled fire progression into the building in the event of a fire from the exterior. NFPA 13, Standard for Installation of Sprinkler Systems.
19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1). Findings include, but are not limited to:

On 03/29/2017 at 11:00 hours, the facility did not have adequate Fire Sprinkler coverage under the overhang of the buildings exterior. The overhang was approximately 4 foot in width or greater and supported by TYPE IV Heavy Timber Construction and combustible materials.

The Surveyor was accompanied by the Facility Administrator CEO and the Maintenance Director who acknowledged the existence and hazards of the finding(s)

Based on record review and interview during the survey, it was determined through on-going dialog with the Facility Administrator and Maintenance Director that the facility failed to ensure the sprinkler system was continuously maintained & in reliable operating condition. This resulted in the potential for system failure during fire emergencies (LSC9.7.5, 9.7.7, 9.7.8, and NFPA 25). Findings include, but are not limited to:

On 03/28/2017, during record review 10:00 - 13:00 hours., the facility was unable to show documentation regarding the most recent 5 Year IIIc internal pipe inspection report.

This Surveyor was accompanied by the Facility Administrator and Maintenance Director who acknowledged the existence of the finding(s).

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Facility Administrator CEO and Maintenance Director that the facility failed to maintain fire extinguishers in accordance with adopted standards for all extinguishers of the facility. This resulted in the potential for fires to progress beyond incipient stage ( NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10). Findings include, but are not limited to:

1. On 03/27/2017 at 11:43 hours, the facility had 2 type HFC-227 that were only inspected annually. These extinguishers need to be inspected on a semi-annual basis.

2. On 03/27/2017 at 11:54 hours, it was discovered that the facility's Fire Extinguisher Vendor had placed "HALOTRON" type extinguishers randomly throughout the hospital in inappropriate areas. This left areas with inadequate Fire Extinguisher coverage in the event of an emergency by wrong type and size.

3. On 03/29/2017 at 11:12 hours, it was discovered that the facility's Helicopter Landing Pad did not have any means of fire extinguishement for Hydrocarbon Fuel fires in the event of an incident or crash.

This Surveyor was accompanied by the Facility Administrator and Maintenance Director who acknowledged the existence of this condition.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facility Administrator CEO and Maintenance Director that the facility failed to provide safe storage for compressed gas in the OB/Nursery of the facility. This resulted in the potential for serious injury to neonatal patients, staff and visitors from a damaged compressed gas cylinder releasing unexpectedly. (5.1.3.3.2, 5.1.3.3.3, 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.2, 11.6.5 (NFPA 99)). Findings include, but were not limited to:

On 03/27/2017 at 13:04 hours, the facility had 23 Compressed Oxygen cylinders in a wooden rack, stored in the Nursery. There were electrical connections within the room below 60" without impact protective measures.

The Surveyor was accompanied by the Facility Administrator CEO and the Maintenance Director who acknowledged the existence and hazards of the finding(s)