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ALLEGHENY GENERAL HOSPITAL
INFECTION CONTROL PROGRAM
Tag No.: A0749
Based on review of the facility documents, and staff interview (EMP), it was determined the facility failed to ensure maintenance of a sanitary physical environment.
Findings include:
1) On March 19, 2015, at approximately 1:00 PM, review of facility document, "Room Ventilation Test Sheet," dated January 2015, revealed OR8 = 13 air changes per hour, OR14 = 12 air changes per hour, Surgical Suite #3 = 11 air changes per hour, Surgical Suite #6 = 11 air changes per hour. OR 16 = neutral airflow, GI Labs 13, 17, and 23 = negative airflow.
2) Interview with EMP6 revealed, "We don't have PM (Preventative Maintenance) or a policy for ventilation. We are in the process of changing our policies."