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Based on staff interview and review of fifteen minute observation flow sheets which are part of the clinical medical record, the hospital failed to ensure that the observation flow sheets were dated for 8 of 9 patients on the P3N Unit at the North College Hill Unit on 12/02/2010. (Patient #'s 32, 33, 34, 35, 36, 37, 38 and 39). The patient census on the unit was 9.

Findings include:

On 12/2/2010 in the PM, review of the clinical records for the patients on the P3N Unit at the North College Hill in patient unit revealed that 8 of the 9 patient's clinical record contained 15 minute flow sheeets that were not dated. These flow sheets were used as a monitoring tool of the patient's status and behaviors.
The above findings were verified with the Director of the unit during the record reviews on the unit at 4:00PM on 12/2/2010.

Based on observation and staff interview, the hospital failed to ensure the facility was in compliance with the requirements of the life safety code for safety from fire and failed to ensure equipment in the kitchen was clean and well maintained.

Findings included;

The hospital failed to comply with the requirements of the life safety code. This affected three of five buildings reviewed (Building 1, 2 and 3). Please refer to A709 and A710.


Equipment in the kitchen was not maintained to ensure safety. This includes a fan in the area of where the clean dishes come out of the automatic dishwasher and the large can openers used to open cans in the food preparation area. The current hospital census was 365 at the time of the survey. Please refer to K724.

Based on observation and staff interview, the hospital failed to comply with the requirements of the life safety code. This affected three of five buildings reviewed (Building 1, 2 and 3).

Findings included;

Main Building, 1 of 5
2000 Existing Code
3333 Burnet Avenue,
Cincinnati, 45229-4200

One smoke barrier in the B building contained non-rated sliding glass. Please refer to K25

Egress lighting at three discharge exits did not meet the Code requirements. Please refer to K45.

One trash chute discharge fire door was held open by bags of trash. Please refer to K71

One medical gas room was observed with and electrical outlet/receptacle less than 5 feet above the floor. Please refer to K76.

Four operating rooms had relative humidity levels less than 35% in November and December 2010. At one time, the humidity level was 15%. Please refer to K78.

The fire watch plan for the sprinkler system lacked notification of the authority having jurisdication (AHJ), the person assigned to do the fire watch, and the frequency of the fire watch rounds. Please refer to K154.

The fire watch plan for the fire alarm system lacked notification of the authority having jurisdiction, the person assigned to do the fire watch, and the frequency of the fire watch rounds. Please refer to K155.

Building 2 of 5
2000 New Code
Cincinnati Children's Liberty Campus
7777 Yankee Road
Liberty Township, Ohio 45044

Medical gas storage area was observed with electrical outlets/receptacles less than 5 feet above the floor. Please refer to K76.

Operating room logs revealed relative humidity readings were less than 35%. Please refer to K78.

Building 3 of 5:
2000 Existing Code
Cincinnati Children's College Hill Campus
5642 Hamilton Avenue
Cincinnati, Ohio 45224

One exit discharge lacked a continuous exit to the public way. Please refer to K38.

Exit discharges lacked required discharge lighting. Please refer to K45.

Based on observation and staff interview, the hospital failed to comply with the requirements of the life safety code. This affected three of five buildings reviewed (Building 1, 2 and 3).

Findings included;

Main Building, 1 of 5
2000 Existing Code
3333 Burnet Avenue,
Cincinnati, 45229-4200

One smoke barrier in the B building contained non-rated sliding glass. Please refer to K25

Egress lighting at three discharge exits did not meet the Code requirements. Please refer to K45.

One trash chute discharge fire door was held open by bags of trash. Please refer to K71

One medical gas room was observed with and electrical outlet/receptacle less than 5 feet above the floor. Please refer to K76.

Four operating rooms had relative humidity levels less than 35% in November and December 2010. At one time, the humidity level was 15%. Please refer to K78.

The fire watch plan for the sprinkler system lacked notification of the authority having jurisdication (AHJ), the person assigned to do the fire watch, and the frequency of the fire watch rounds. Please refer to K154.

The fire watch plan for the fire alarm system lacked notification of the authority having jurisdiction, the person assigned to do the fire watch, and the frequency of the fire watch rounds. Please refer to K155.

Building 2 of 5
2000 New Code
Cincinnati Children's Liberty Campus
7777 Yankee Road
Liberty Township, Ohio 45044

Medical gas storage area was observed with electrical outlets/receptacles less than 5 feet above the floor. Please refer to K76.

Operating room logs revealed relative humidity readings were less than 35%. Please refer to K78.

Building 3 of 5:
2000 Existing Code
Cincinnati Children's College Hill Campus
5642 Hamilton Avenue
Cincinnati, Ohio 45224

One exit discharge lacked a continuous exit to the public way. Please refer to K38.

Exit discharges lacked required discharge lighting. Please refer to K45.

Based on observation and staff interview, equipment in the kitchen was not maintained to ensure safety. This includes a fan in the area of where the clean dishes come out of the automatic dishwasher and the large can openers used to open cans in the food preparation area. The current hospital census was 365 at the time of the survey.

Findings include:

Per kitchen observation on 12/02/10 at 11:25 AM in the presence of Employee A and B, the suspended fan had built up dust on the two blades of the fan and the outside metal blade cover. When observed, the fan was blowing toward the end of the automatic dish washer where the clean dishes are exposed on racks. Per review of the maintenance tag hanging from the fan, preventive maintenance was provided on 01/21/10, 03/25/10 and most recently on 08/16/10. This was confirmed by Staff A and B.

Per kitchen observation on 12/02/10 at 11:25 AM two large can openers were observed with the surface missing from the points which penetrate the can of food when being opened. The metal plating was missing from these points and could not be appropriately cleaned to ensure an acceptable level of safety.