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Based on facility design records, interview and observation it was determined that two rooms in the Diagnostic Unit, presently unfinished shell space and designed for future diagnostic imaging, were being used as storage rooms.

The findings, on a tour of the facility with the Director of Plant Operations/Safety Officer on 04/26/11 at 1400, revealed that the two rooms in the Diagnostic Unit were being used as Storage Rooms. The rooms were found to be in excess of 100 square feet storing a quantity of miscellaneous materials of unknown fire hazard and was not enclosed with a fire barrier.

The failed practice had the potential to affect all patients, staff and visitors. A review of facility design plans revealed the rooms were not designed as storage rooms and therefore were not enclosed with fire rated barrier construction to contain fire hazards. Findings follow:

1. A room provided for future Magnetic Resonance Imaging (MRI), in excess of 100 square feet located in the Diagnostic Imaging Unit, was being used to store a quantity of miscellaneous materials of unknown fire hazard that was not enclosed with fire rated barrier construction.

2. A room provided for future Radiography/Fluoroscopy (R/F) in excess of 100 square feet located in the Diagnostic Imaging Unit, was being used to store a quantity of miscellaneous materials of unknown fire hazard that was not enclosed with fire rated barrier construction.

Based on observation during a tour of the Operating Room, it was determined that a Isolated Power System - Line Isolation Monitor was in use.

The findings, based on interview with the Director of Plant Operations/Safety Officer on 04/26/11 at 1300, revealed there were no records of monthly testing of the Isolated Power System - Line Isolation Monitor.

The failed practice had the potential to affect all surgical patients and staff in the Operating Room coming in contact with electrical equipment.

Monthly verification that the Line Isolation Monitor is functional and would alarm properly in the event of an electrical problem is required if the system does not have automated self-test and self-calibration capabilities. Based on interview it was unknown if the system had self-test and self-calibration capabilities.

National Fire Protection Association, NFPA 99, 1999 Edition, Section 3-3.3.4.2 Line Isolation Monitor Tests.

Based on facility design records, interview and observation it was determined that two rooms in the Diagnostic Unit, presently unfinished shell space and designed for future diagnostic imaging, were being used as storage rooms.

The findings, on a tour of the facility with the Director of Plant Operations/Safety Officer on 04/26/11 at 1400, revealed that the two rooms in the Diagnostic Unit were being used as Storage Rooms. The rooms were found to be in excess of 100 square feet storing a quantity of miscellaneous materials of unknown fire hazard and was not enclosed with a fire barrier.

The failed practice had the potential to affect all patients, staff and visitors. A review of facility design plans revealed the rooms were not designed as storage rooms and therefore were not enclosed with fire rated barrier construction to contain fire hazards. Findings follow:

1. A room provided for future Magnetic Resonance Imaging (MRI), in excess of 100 square feet located in the Diagnostic Imaging Unit, was being used to store a quantity of miscellaneous materials of unknown fire hazard that was not enclosed with fire rated barrier construction.

2. A room provided for future Radiography/Fluoroscopy (R/F) in excess of 100 square feet located in the Diagnostic Imaging Unit, was being used to store a quantity of miscellaneous materials of unknown fire hazard that was not enclosed with fire rated barrier construction.

Based on observation during a tour of the Operating Room, it was determined that a Isolated Power System - Line Isolation Monitor was in use.

The findings, based on interview with the Director of Plant Operations/Safety Officer on 04/26/11 at 1300, revealed there were no records of monthly testing of the Isolated Power System - Line Isolation Monitor.

The failed practice had the potential to affect all surgical patients and staff in the Operating Room coming in contact with electrical equipment.

Monthly verification that the Line Isolation Monitor is functional and would alarm properly in the event of an electrical problem is required if the system does not have automated self-test and self-calibration capabilities. Based on interview it was unknown if the system had self-test and self-calibration capabilities.

National Fire Protection Association, NFPA 99, 1999 Edition, Section 3-3.3.4.2 Line Isolation Monitor Tests.