HospitalInspections.org

Based on observation and interview, the facility does not ensure that the integrity of the rated smoke and fire walls is maintained or that the rated smoke and fire walls could be identified.

Findings include:

Observation of the rated fire walls on 4/6/11 revealed that penetrations were present in the 2-hour fire rated ceiling between the first and second floors and the walls between the three different buildings that were constructed in 1955, 1960 and 1969. These penetrations must be filled with a fire rated material that ensures the rating of the enclosure and does not jeopardize safety in the event of an actual emergency.

Interview with Staff #16 on 4/6/11 revealed that he was unaware of the location of the fire and smoke walls. Without knowing the location of the rated fire and smoke walls, it is not possible to determine if adequate separation and protection is provided throughout the facility, including patient care and non-regulated areas. This was discussed at the exit conference on 4/7/11 at 1:00 PM with Staff #1, 2 and 3.

Based on observation, document review and interview, the facility does not ensure that battery operated emergency lighting is tested monthly and annually, and that 2 of 4 battery operated emergency lights are operational. (procedure area and recovery area)

Findings include:

During tour of the operating room suite on 4/5/11, it was observed that the battery operated emergency light in the recovery area was not operational. When the light was tested, it did not illuminate and a buzzing noise was heard, which indicated the battery was insufficient.

During tour of the operating room suite on 4/5/11, it was observed that the battery operated emergency light in the procedure room area did not provide continuous illumination when pushing the test button. While this button was pushed, the light flickered, which indicated the unit required maintenance to ensure its proper operation.

Review on 4/6/11 of the Emergency Light testing log revealed that the date on which the battery operated emergency lights were tested was not indicated. Review of this log for the time frame from 01/10 through 03/11 showed only an "x" marked in the box indicating that the light was tested either monthly or annually.

Review on 4/6/11 of the Emergency Light testing log revealed that the log was not current as to the locations of all battery operated emergency lighting units. This log did not indicate the light in the recovery area or the light in the procedure area. The log also indicated that battery operated emergency light testing was performed on lighting units that are located in four operating rooms. However, it was noted during the walk through of the operating room suite on 4/5/11 that only two operating rooms were present.

These findings were verified with Staff #7 and 16 on 4/6/11.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 9/20/06.

Based on observation and interview, the facility does not ensure the 1 of 2 exit lights in the radiology area are illumined.

Findings include:

During facility tour on 4/6/11, it was observed that the exit light at Exit G was not illuminated. Exit lights must provide continuous illumination to ensure that staff, patients and visitors are aware of exit locations in the event of an emergency.

This finding was observed and confirmed by Staff #16 at that time.

Based on document review and interview, the facility does not ensure that 20 of 33 fire and smoke dampers are tested.

Findings include:

Review on 4/6/11 of the fire and smoke damper report revealed that 20 of 33 dampers were not tested during the 11/01/10 inspection, as follow:
-10 dampers were not tested because the fusible link was not replaceable or the damper had a motor driven or spring loaded fuse to operate;
-1 damper had the fusible link located on the opposite side of the access panel and could not be reached;
-1 damper did not close when the fusible link was removed;
-1 damper was not tested because the damper is located above the nurse's station and at the time the testing was performed, "the nurse's station was very busy" and access to the damper could not be achieved;
-4 dampers had access panels that were too small to allow access to the damper;
-3 dampers did not allow the testing company to reach the link to drop the damper or replace the fusible link.
These dampers must be routinely tested to ensure that they close properly and that fire and smoke would be contained in the event of an emergency.

This finding was verified with Staff #16 on 4/6/11.

Based on document review and interview, the facility does not ensure that the tamper alarm is tested quarterly, as evidenced for 2 of 4 sprinkler inspections during 2010. (first and third quarters of 2010)

Findings include:

Review on 4/6/11 of the 2010 sprinkler inspection reports revealed that the tamper switches were not tested during the first and third quarters of 2010. The reports indicated that the tamper alarm was disconnected during the test.

This finding was verified with Staff #16 on 4/7/11.

Based on observation and interview, the facility does not ensure the cleanliness of the facility in the operating suite.

Findings include:

During tour of the operating room suite on 4/5/11, it was observed that the mechanical exhaust grills in the sub-sterile area, between the operating rooms, had a significant amount of dust and debris present. This finding was observed and confirmed by Staff #17 and 18 at that time.


Based on documentation and interview, the facility does not ensure that documentation is maintained for maintenance performed on 7 of 7 heating, ventilation and air conditioning (HVAC) units. (units 1-7)

Findings include:

Review on 4/7/11 of the provided documentation revealed that documentation was not provided to verify that preventative maintenance had been performed on the 7 HVAC units. During interview on 4/7/11, Staff #16 stated that maintenance is performed on the HVAC units, but documentation is not maintained.

Based on observation and interview, the facility does not ensure that 2 of 2 medical gas shut-off valves are unobstructed in the operating room suite.

Findings include:

During the tour of the operating rooms on 4/5/11, it was observed that the medical gas shut-off valves were not accessible in the operating room suite. The shut-off valves for operating room #1 were obstructed by a malignant hypothermia cart, and the shut-off valves for operating room #2 were obstructed by an exchange cart. This finding was also observed and confirmed by Staff #17 at that time.


Based on observation and interview, the facility does not ensure that 2 of 2 medical gas area alarms are labeled to indicate the area that is associated with these alarms. (in the operating room suite)

Findings include:

Observation on 4/5/11 of the medical gas alarm panels behind the information desk of the operating room suite revealed that the medical gas area alarms, which were for oxygen and vacuum, were not labeled.

This finding was verified with Staff #17 on 4/5/11.

Based on observation, document review and interview, the facility does not ensure that the humidity levels in 2 of 2 operating rooms are documented daily.

Findings include:

During tour of the operating rooms on 4/5/11, Staff #17 indicated that the daily humidity readings of the two operating rooms are performed by Staff #16, who maintains the humidity records.

Review on 4/6/11 of the provided documentation did not reveal any logs for the daily humidity readings of the two operating rooms.

Interview on 4/6/11 with Staff #16 revealed that the daily humidity readings were not documented.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 9/20/06.

Based on observation and interview, the facility does not ensure that operating room staff are familiar with the location of the medical gas shut-off valves for 2 of 2 procedure rooms.

Findings include:

During tour of the procedure rooms on 4/5/11, it was observed that medical gas shut-off valves were not located in the procedure area. During interview at that time, Staff #17 revealed that she was unsure of the location of the shut-off valves for this area. Later that day, Staff #17 reported that the shut-off valves were located in the adjacent critical care area.

Based on observation and interview, the facility does not ensure that the medical gas room located in the operating room suite is maintained in a safe manner.

Findings include:

During tour of the operating room suite on 4/5/11, it was observed that a large tank of liquid oxygen was present in the medical gas room. Interview with Staff #17 revealed that respiratory staff utilize this liquid oxygen tank to transfer oxygen into smaller "B" tanks that were located in the same room. It was noted that this room is not sprinklered and the door does not provide an operational locking mechanism, which was confirmed by Staff #17. Without a positive latching mechanism, the one-hour fire rating is jeopardized around this room.

During tour of the operating room suite on 4/5/11, it was observed that medical gas room in the operating room suite was not maintained safely, as it was noted that the door could not be fully opened due to the presence of an empty rack that would be utilized for an "H" tank. Six empty racks utilized for securing individual "E" tanks had been placed haphazardly in this room for storage.

Based on document review and interview, the facility does not ensure that weekly testing is performed on 2 of 2 emergency generators. (CAT and ONAN)

Findings include:

Review on 4/4/11 of the generator logs for the time frame from 4/8/10 through 3/31/11 did not reveal evidence that routine weekly maintenance was conducted. The only documented weekly maintenance was performed on 2/14/11, 3/15/11 and 3/29/11.

This finding was verified with Staff #3 on 4/4/11, and Staff #16 on 4/5/11.

Based on observation, the facility does not ensure that 2 of 2 alcohol based hand rub (ABHR) dispensing stations are properly located. (operating rooms #1 and 2)

Findings include:

During tour of the operating room suite on 4/5/11, it was observed that an ABHR dispensing station was present in each operating room proper. The operating rooms are not sprinklered and do not have smoke detection devices present. The ABHR contents are 70% alcohol, and the stations are located immediately inside the operating room doors.

These findings were verified with Staff #17 on 4/5/11.