HospitalInspections.org

Based on observation and interview, the facility failed to separate the new and existing construction in accordance with LCS (2000) Section 19.1.1.4.1. This deficient practice could affect all patients.

Findings include:

During facility tour between 01/07/2014 and 01/09/2014, observation revealed that the fire door separating the HVC Cardiotherapy area from the Main Hospital west mechanical room is 45-minute rated and not the required 90-minute for a occupancy separation.

This deficient practice was verified by the Hospital Engineering and Maintenance Staff at the time of the inspection.

Based on observation and interview, the facility had corridor doors that did not meet the requirements of NFPA 101 LSC (00) Section 19.3.6.3.2. This deficient practice could affect the operating room patients.

Findings include:

During facility tour between 01/07/2014 and 01/09/2014, observation revealed that the Brown Neighborhood outpatient cancer center infusion clinic, which is not part of the Park Nicollet Methodist Hospital provider number, has a roll down gate which is open to the hospital corridor system. This outpatient cancer infusion clinic is used for outpatient treatment only.

This deficient practice was verified by the Hospital Engineering and Maintenance Staff at the time of the inspection.

Based on observation and interview, the hazardous areas are not maintained in accordance with NFPA 101-2000, Section 19.3.2.1. This deficient practice could affect all patients.

Findings include:

During facility tour between 01/07/2014 and 01/09/2014, observation revealed that the doors to Room(s) 3-601, 408, 5th floor helicopter storage room and the traction room across from room 705 do not shut and/or latch closed.

This deficient practice was verified by the Hospital Engineering and Maintenance Staff at the time of the inspection.

Based on observation and interview, the facility failed to maintain the medical gas storage in accordance with NFPA 99. This deficient practice could affect all patients.

Findings include:

During facility tour between 01/07/2014 and 01/09/2014, observation revealed that the facility oxygen cylinders were not individually secured.

This deficient practice was verified by Engineering and Maintenance staff at the time of the inspection.

Based on observation and interview, the facility failed to maintain the medical gas storage in accordance with NFPA 99. This deficient practice could affect all patients.

Findings include:

During facility tour between 01/07/2014 and 01/19/2014, observation revealed that:
1. The "E" tank racking system located near the ground level recycling room contains oxygen, heliox, carbon dioxide, nitrous oxide, nitrogen and calibration gases, both full and empty cylinders, intermixed without clear separation of gases,
2. Room G-215 has "H" tanks contains multiple patient and support gases, both full and empty, intermixed without clear separation of gases.

This deficient practice was verified by the Hospital Engineering and Maintenance Staff at the time of the inspection.

Based on observation and staff interview, the medical gases are not in compliance with NFPA 99 Health Care Facilities (1999 edition), Chapter 4. The deficient practice could affect all patients.

Findings include:

On facility tour between 01/07/2014 and 01/09/2014, observation revealed that the oxygen line in Room G-214 feeding Meadowbrook is not labeled and the service valve is not of a 3-piece, serviceable design.

These deficient practices were verified by the Hospital Engineering and Maintenance Staff at the time of the inspection.

Based on observation and interview, the relative humidity for the anesthetizing locations is not being maintained in accordance with NFPA 99 and CMS S&C 13-25-LSC. This deficient practice could affect all surgical patients.

Findings include:

During facility tour between 01/07/2014 and 01/09/2014, observation revealed that operating room staff notify the Engineering Department whenever the relative humidity is out of range. There is no documentation for the daily checks of the relative humidity.

This deficient practice was verified by the Hospital Engineering and Maintenance Staff at the time of the inspection.

Based on record review and interview, the facility failed to maintain the medical gas system in accordance with NFPA 99, 4.3.1.2.2. This deficient practice could effect all patients.

Findings include:

During facility tour between 01/07/2014 and 01/09/2014, record review revealed that the facility could not provide documentation that the master alarms were tested monthly.

This deficient practice was verified by Engineering and Maintenance staff at the time of the inspection.

Based on observations, the facility has portable gaseous oxygen tanks not properly stored in compliance with the requirements of NFPA 99. This deficient practice could affect all patients.

Findings include:

On facility tour between 01/07/2014 and 01/09/2014, observation revealed that the 6th floor east storage room and Room 3-340 contains operational supply of "E" cylinders of oxygen without signage on doors.

This deficient practice was verified by the Hospital Engineering and Maintenance Staff at the time of the inspection.

Based on observations and interview, the facility's emergency generators do not comply with NFPA 99 Health Care Facilities (1999 edition) nor NFPA 110 Standard for Standby Power Systems (1998 edition). This deficient practice could affect all patients.

Findings include:

On facility tour between 01/07/2014 and 01/09/2014, observation revealed that there is no remote generator panel in a constantly attended location. The only remote generator panel is located in a physical plant office which is not staffed continuously.

This deficient practice was verified by the Hospital Engineering and Maintenance Staff at the time of the inspection.

Based on observation and interview, the facility failed to comply with NFPA 70, The National Electric Code. This deficient practice could affect all surgical patients.

Findings include:

On facility tour between 01/07/2014 and 01/09/2014, observation revealed that:
1. Powerstrips are being used in the operating room without documentation that the powerstrips are listed for hospital use,
2. The emergency power outlets in the operating rooms identified by the triangle are not NEC (National Electrical Code) compliant.

These deficient practices were verified by the Hospital Engineering and Maintenance Staff at the time of the inspection.

Based on observation and interview, the facility failed to separate the new and existing construction in accordance with LCS (2000) Section 19.1.1.4.1. This deficient practice could affect all patients.

Findings include:

During facility tour between 01/07/2014 and 01/09/2014, observation revealed that the fire door separating the HVC Cardiotherapy area from the Main Hospital west mechanical room is 45-minute rated and not the required 90-minute for a occupancy separation.

This deficient practice was verified by the Hospital Engineering and Maintenance Staff at the time of the inspection.

Based on observation and interview, the facility had corridor doors that did not meet the requirements of NFPA 101 LSC (00) Section 19.3.6.3.2. This deficient practice could affect the operating room patients.

Findings include:

During facility tour between 01/07/2014 and 01/09/2014, observation revealed that the Brown Neighborhood outpatient cancer center infusion clinic, which is not part of the Park Nicollet Methodist Hospital provider number, has a roll down gate which is open to the hospital corridor system. This outpatient cancer infusion clinic is used for outpatient treatment only.

This deficient practice was verified by the Hospital Engineering and Maintenance Staff at the time of the inspection.

Based on observation and interview, the hazardous areas are not maintained in accordance with NFPA 101-2000, Section 19.3.2.1. This deficient practice could affect all patients.

Findings include:

During facility tour between 01/07/2014 and 01/09/2014, observation revealed that the doors to Room(s) 3-601, 408, 5th floor helicopter storage room and the traction room across from room 705 do not shut and/or latch closed.

This deficient practice was verified by the Hospital Engineering and Maintenance Staff at the time of the inspection.

Based on observation and interview, the facility failed to maintain the medical gas storage in accordance with NFPA 99. This deficient practice could affect all patients.

Findings include:

During facility tour between 01/07/2014 and 01/09/2014, observation revealed that the facility oxygen cylinders were not individually secured.

This deficient practice was verified by Engineering and Maintenance staff at the time of the inspection.

Based on observation and interview, the facility failed to maintain the medical gas storage in accordance with NFPA 99. This deficient practice could affect all patients.

Findings include:

During facility tour between 01/07/2014 and 01/19/2014, observation revealed that:
1. The "E" tank racking system located near the ground level recycling room contains oxygen, heliox, carbon dioxide, nitrous oxide, nitrogen and calibration gases, both full and empty cylinders, intermixed without clear separation of gases,
2. Room G-215 has "H" tanks contains multiple patient and support gases, both full and empty, intermixed without clear separation of gases.

This deficient practice was verified by the Hospital Engineering and Maintenance Staff at the time of the inspection.

Based on observation and staff interview, the medical gases are not in compliance with NFPA 99 Health Care Facilities (1999 edition), Chapter 4. The deficient practice could affect all patients.

Findings include:

On facility tour between 01/07/2014 and 01/09/2014, observation revealed that the oxygen line in Room G-214 feeding Meadowbrook is not labeled and the service valve is not of a 3-piece, serviceable design.

These deficient practices were verified by the Hospital Engineering and Maintenance Staff at the time of the inspection.

Based on observation and interview, the relative humidity for the anesthetizing locations is not being maintained in accordance with NFPA 99 and CMS S&C 13-25-LSC. This deficient practice could affect all surgical patients.

Findings include:

During facility tour between 01/07/2014 and 01/09/2014, observation revealed that operating room staff notify the Engineering Department whenever the relative humidity is out of range. There is no documentation for the daily checks of the relative humidity.

This deficient practice was verified by the Hospital Engineering and Maintenance Staff at the time of the inspection.

Based on record review and interview, the facility failed to maintain the medical gas system in accordance with NFPA 99, 4.3.1.2.2. This deficient practice could effect all patients.

Findings include:

During facility tour between 01/07/2014 and 01/09/2014, record review revealed that the facility could not provide documentation that the master alarms were tested monthly.

This deficient practice was verified by Engineering and Maintenance staff at the time of the inspection.

Based on observations, the facility has portable gaseous oxygen tanks not properly stored in compliance with the requirements of NFPA 99. This deficient practice could affect all patients.

Findings include:

On facility tour between 01/07/2014 and 01/09/2014, observation revealed that the 6th floor east storage room and Room 3-340 contains operational supply of "E" cylinders of oxygen without signage on doors.

This deficient practice was verified by the Hospital Engineering and Maintenance Staff at the time of the inspection.

Based on observations and interview, the facility's emergency generators do not comply with NFPA 99 Health Care Facilities (1999 edition) nor NFPA 110 Standard for Standby Power Systems (1998 edition). This deficient practice could affect all patients.

Findings include:

On facility tour between 01/07/2014 and 01/09/2014, observation revealed that there is no remote generator panel in a constantly attended location. The only remote generator panel is located in a physical plant office which is not staffed continuously.

This deficient practice was verified by the Hospital Engineering and Maintenance Staff at the time of the inspection.

Based on observation and interview, the facility failed to comply with NFPA 70, The National Electric Code. This deficient practice could affect all surgical patients.

Findings include:

On facility tour between 01/07/2014 and 01/09/2014, observation revealed that:
1. Powerstrips are being used in the operating room without documentation that the powerstrips are listed for hospital use,
2. The emergency power outlets in the operating rooms identified by the triangle are not NEC (National Electrical Code) compliant.

These deficient practices were verified by the Hospital Engineering and Maintenance Staff at the time of the inspection.