HospitalInspections.org

Based on observation it was determined the facility failed to ensure not using roller latches.

Findings:

On 9/27/2016 at 9:24 a.m., a roller latch was observed on the door of the soiled utility room in the surgical suite.

At 10:30 a.m., a roller latch was observed on the door leading to the room housing the fire alarm control panel.

The physical operations director acknowledged the roller latchs.


NFPA 101, 2000 Edition
Chapter 19 Existing Health Care Occupanices
19.3 Protection
19.3.6.3.2*
Roller latches are prohibited by CMS regulations in all health care facilities.

Based on observation it was determined the facility failed to ensure exit signage was installed.

Findings:

On 9/27/2016 at 15:05, a glass door exiting into the facility's enclosed courtyard had no signage indicating it was not an exit and in case of an emergency would likely be mistaken as an exit.


NFPA 101, 2000 Edition
Chapter 7.10 MARKING OF MEANS OF EGRESS
7.10.1 General.
7.10.1.1 Where Required.
Means of egress shall be marked in accordance with Section 7.10 where required in Chapters 11 through 42.

Chapter 19 Existing Health Care Occupancies
19.2 Means of Egress Requirements
19.2.10 Marking of Means of Egress
19.2.10.1
Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants. Doors, passages or stairways that are not a way of exit that are likely to be mistaken for an exit have a sign designating "No Exit".

Based on observation it was determined the facility failed to ensure smoke barriers were free from penetrations.

Findings:

On 9/27/2016 at 10:58 a.m., the corridor next to the clinic within the hospital was observed to have multiple penetrations that were not smoke resistant since the facility is fully sprinkled.

At 11:02 a.m., the physical operations director acknowledged the penetrations.

NFPA 101, 2000 Edition
8.3, 19.3.7.3, 19.3.7.5
Smoke barriers shall be constructed to provide at least a one half hour fire resistance rating and constructed in accordance with 8.3. Smoke barriers shall be permitted to terminate at an atrium wall. Windows shall be protected by fire-rated glazing or by wired glass panels and steel frames.

Based on observation it was determined the facility failed to ensure hazardous areas are protected.

Findings:

On 9/27/2016 at 8:58 a.m., 6 penetrations where observed in the eletrical room next to the boiler room.

The physical operations director acknowledged the penetrations.

NFPA 101, 2000 Edition
Chapter 19
19.3.2.1
One hour fire rated construction (with o hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protects hazardous areas. When the approved automatic fire extinguishing system option is used, the areas are separated from other spaces by smoke resisting partitions and doors. Doors are self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted.

Based on observation it was determined the facility failed to ensure emergency lighting is so arranged that failure of any single lighting fixture will not leave the area in darkness.

Findings:

On 09/27/2016 at 9:03 a.m., after touring throughout the facility on 9/26/2016 it was observed there were no identifiable existing secondary lighting arrangements to ensure that the failure of any single lighting fixture would not leave the facilitys' means of egress, including exit discharge in darkness.

Based on record review and staff intervivew it was determined the facility failed to ensure fire drills were completed as required.

Findings:

On 9/28/2016 at 9:15 a.m., on record review of the facility's fire drills revealed no 3rd shift fire drills were completed for 2016.

At 9:32 a.m., the safety officer was interviewed. He said that the facility HR Department had advised him there were only two staff shifts.


NFPA 101, 2000 Edition
Chapter 19 Existing Health Care Occupancies
19.7* Operating Features
19.7.1.2
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM a coded announcement may be used instead of audible alarms.

Based on observation and staff interview the facility failed to ensure air quality was being monitored and documented, and the facility failed to provide and ensure heating, ventilating, and air-conditioning systems complied with the manufacturer's specifications and recommendations.

Findings:

On 9/26/2016 at 11:57 a.m., the operating rooms air filter quality logs were not available when requested. Airflow manometer readings were not being recorded or documented. The airflow quality of the life of the final filters were not being documented or maintained.

At 12:00 p.m., the physical operations director was interviewed. The physical plant manager was asked for the documentation of airflow quality for the operating rooms. He said the HVAC filters that serve the operating rooms are changed periodically.

AIA Health Care Guidelines & ANI/ASHE Standard 170-208 Ventilation of Health Care Facilities requires the manometers to be used to determine the life of the filter. A 1.1 of ANI/ASHE Annex A states that filters shall be replaced on air pressure drop in accordance with the manometer readings.

Based on observation it was determined the facility failed to ensure protection from space heaters.

Findings:

On 9/27/2016 at 10:13 a.m., a space heater was observed in the payroll office under a desk.

At 10:20 a.m., a space heater was observed under the desk of the front lobby reception desk.

The physical operations director was interviewed. He was asked if the facility had documentation of the heating elements not eceeding 212 degrees farhenhiet. He said he would look. The documentation was not provided.

NFPA 101, 2000 Edition
Chapter 19
19.7.8
Portable space heating devices shall be prohibited in all health care occupancies. Except it shall be permitted to be used in non-sleeping staff and employee areas where the heating elements of such devices do not exceed 212 degrees F (100 degrees C).

Based on observation it was determined the faclity failed to ensure protection for trash receptacles exceeding 32 gallons.

Findings:

On 9/26/2016 at 11:55 a.m., a shredded paper receptacle over 32 gallons by medical records was observed stored open to the egress corridor.

On 9/27/2016 at 10:32 a.m., a shredded paper receptacle over 32 gallons was observed in a staff only closet near the main lobby front reception area.

At 14:07, a trash container of soiled linen was stored open to the egress corridor between paitent rooms 214 and 215.

The physical operations director acknowledged the over 32 gallon soiled linen container stored open to the egress corridor.


Soiled linen or trash collection receptacles do not exceed 32 gal (121 L) in capacity. The average density of container capacity in a room or space does not exceed .5 gal/sq ft (20.4 L/sq m). A capacity of 32 gal (121 L) is not exceeded within any 64 sq ft (5.9-sq m) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) are located in a room protected as a hazardous area when not attended. 19.7.5.5

Based on record review it was determined the facility failed to ensure anesthetizing locations were protected.

Findings:

On 9/28/2016 at 11:12 a.m., the facility temperature and humidity policy was reviewed. The facility humidity and temperature policy indicated the low-end range number for relative humidity was 20%.

At 13:38, on review of facility temperature and humidity logs revealed relative humidity levels exceeded 60%.

Facility relative humidity logs:

6-1-2016, procedure room - 84.6%
6-1-2016, decontam room - 61.4%
6-1-2016, sterilzer room - 60.2%
6-13-2016, dirty utility room - 67.4%

5-10-2016, PACU - 61.1%
5-11-2016, sterile supply 1 - 60.2%
5-11-2016, sterile supply 2 - 60.3%
5-11-2016, decontam room - 60.4%

Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.
(a) Shutoff valves are located outside each anesthetizing location and arranged so that shutting off one room or location will not affect others.
(b) Relative humidity is maintained equal to or great than 35% 4-3.1.2.3(n) and 5-4.1.1 (NFPA 99), 18.3.2.3, 19.3.2.3

Based on record review it was determined the facility failed to ensure safety procedures specfically developed for the laboratory.

Findings:

On 9/27/2016 at 9:24 a.m., while touring the laboratory the surveyors requested the established facility laboratory emergency procedures for controlling chemical spills. The labratory director showed the surveyors a stack of papers at her office in the laboratory that had been faxed from another facility. This paperwork reviewed had a different facility name at the top of the procedure sheets and did not have the Sequoyah County Hosptial name on it.

The laboratory director acknowledged the paperwork did not have their hosptial's name on it.


NFPA 99 Standard for Health Care Facilities, 1999 Edition
Chapter 10 Laboratories
10-2 Nature of Hazards
10-2.1.3.1
Procedures for laboratory emergencies shall be developed. Such procedures shall include alarm actuation, evacuation, and equipment shutdown procedures, and provisions for control of emergencies that could occur in the laboratory, including specific detailed plans for control operations by an emergency control group within the organization or a public fire department.
10-2.1.3.2
Emergency procedures shall be established for controlling chemical spills.

Based on observation and staff interview it was determined the facility failed to provide an emergency shower within the work area of the laboratory for immediate emergency use.

Findings:

On 9/27/2016 at 9:25 a.m., on a tour of the laboratory an eye wash station was observed with in the laboratory but the laboratory contained no emergency body shower.

At 9:27 a.m., the laboratory director was interviewed. She was asked where the laboratory emergency body shower was. She said that if one is needed laboratory staff go to a patient room that is not being used or to the emergency room if they need to use an emergency shower.



NFPA 99 Standard for Health Care Facilities, 1999 Edition
Chapter 10 Laboratories
10-6* Emergency Shower.
Where the eyes or body of any person can be exposed to injurious corrosive materials, suitable fixed facilities for quick drenching or flushing of the eyes and body shall be provided within the work area for immediate emergency use. Fixed eye baths shall be designed and installed to avoid injurious water pressure.

Based on observation, staff interview, and record review, it was determined the facility failed to ensure protection of electrical wiring and equipment as required.

Findings:

On 9/26/2016 at 11:43 a.m., a portable air conditioning unit was observed to be plugged into an extension cord in the CT room.

At 9/26/2016 at 11:50 a.m., a multiplug was observed to be in use in the x-ray viewing room.

At 11:57 a.m., a power tap was observed to be in use at the reception desk near the medical records department.

On 9/27/2016 at 8:58 a.m., an open junction box was observed in the boiler room.

At 9:43 a.m., on tour of the emergency room no red plugs could be identified, and eletrical receptacles where not labeled.

At 10:13 a.m., a patient light in procedure room #2 did not have an inspection label.

At 10:30 a.m., an open junction box was observed in the area where the fire alarm control panel was installed.

On 9/27/2016 at 10:58 a.m., 7 open junction boxes were observed in the plenum space located in the corridor next to the clinic within the facility.

At 15:29, a protable air conditioning unit in the emergency room was observed to be plugged into a power tap.

At 15:11, an extension cord was observed to be in use in the blood bank room in the facility laboratory.

On 9/27/2016 at 15:15, a countertop sink next to the laboratory office had a strip of eletrcial outlets that where observed to not be GFCI.

At 15:32, isolation rooms #211 and #214 were observed to have countertop electrical receptacles within 6 feet of a water source.

On 9/28/2016 at 8:59 a.m., at the physical therapy building, a hydroculator was observed to be plugged into a non-GFCI receptacle.

Based on observation it was determined the facility failed to ensure alcohol based hand rub dispensers (ABHR) were not installed over an ignition source.

Findings:

On 9/26/2016 at 11:31 a.m., an ABHR was observed to be installed over an ignition source in the facility clean room.

On 9/27/2016 at 15:19, two ABHR's in the laboratory were observed to be installed over electrical light switches.

The physcial operations director acknowledged the ABHR dispensers installed over ignition sources in the laboratory.

NFPA 101, 2000 Edition, 18.3.2.7
CFR 403.744, 418.110, 460.72, 482.41, 483.70, 485.623

Based on observation it was determined the facility failed to ensure not using roller latches.

Findings:

On 9/27/2016 at 9:24 a.m., a roller latch was observed on the door of the soiled utility room in the surgical suite.

At 10:30 a.m., a roller latch was observed on the door leading to the room housing the fire alarm control panel.

The physical operations director acknowledged the roller latchs.


NFPA 101, 2000 Edition
Chapter 19 Existing Health Care Occupanices
19.3 Protection
19.3.6.3.2*
Roller latches are prohibited by CMS regulations in all health care facilities.

Based on observation it was determined the facility failed to ensure exit signage was installed.

Findings:

On 9/27/2016 at 15:05, a glass door exiting into the facility's enclosed courtyard had no signage indicating it was not an exit and in case of an emergency would likely be mistaken as an exit.


NFPA 101, 2000 Edition
Chapter 7.10 MARKING OF MEANS OF EGRESS
7.10.1 General.
7.10.1.1 Where Required.
Means of egress shall be marked in accordance with Section 7.10 where required in Chapters 11 through 42.

Chapter 19 Existing Health Care Occupancies
19.2 Means of Egress Requirements
19.2.10 Marking of Means of Egress
19.2.10.1
Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants. Doors, passages or stairways that are not a way of exit that are likely to be mistaken for an exit have a sign designating "No Exit".

Based on observation it was determined the facility failed to ensure smoke barriers were free from penetrations.

Findings:

On 9/27/2016 at 10:58 a.m., the corridor next to the clinic within the hospital was observed to have multiple penetrations that were not smoke resistant since the facility is fully sprinkled.

At 11:02 a.m., the physical operations director acknowledged the penetrations.

NFPA 101, 2000 Edition
8.3, 19.3.7.3, 19.3.7.5
Smoke barriers shall be constructed to provide at least a one half hour fire resistance rating and constructed in accordance with 8.3. Smoke barriers shall be permitted to terminate at an atrium wall. Windows shall be protected by fire-rated glazing or by wired glass panels and steel frames.

Based on observation it was determined the facility failed to ensure hazardous areas are protected.

Findings:

On 9/27/2016 at 8:58 a.m., 6 penetrations where observed in the eletrical room next to the boiler room.

The physical operations director acknowledged the penetrations.

NFPA 101, 2000 Edition
Chapter 19
19.3.2.1
One hour fire rated construction (with o hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protects hazardous areas. When the approved automatic fire extinguishing system option is used, the areas are separated from other spaces by smoke resisting partitions and doors. Doors are self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted.

Based on observation it was determined the facility failed to ensure emergency lighting is so arranged that failure of any single lighting fixture will not leave the area in darkness.

Findings:

On 09/27/2016 at 9:03 a.m., after touring throughout the facility on 9/26/2016 it was observed there were no identifiable existing secondary lighting arrangements to ensure that the failure of any single lighting fixture would not leave the facilitys' means of egress, including exit discharge in darkness.

Based on record review and staff intervivew it was determined the facility failed to ensure fire drills were completed as required.

Findings:

On 9/28/2016 at 9:15 a.m., on record review of the facility's fire drills revealed no 3rd shift fire drills were completed for 2016.

At 9:32 a.m., the safety officer was interviewed. He said that the facility HR Department had advised him there were only two staff shifts.


NFPA 101, 2000 Edition
Chapter 19 Existing Health Care Occupancies
19.7* Operating Features
19.7.1.2
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM a coded announcement may be used instead of audible alarms.

Based on observation and staff interview the facility failed to ensure air quality was being monitored and documented, and the facility failed to provide and ensure heating, ventilating, and air-conditioning systems complied with the manufacturer's specifications and recommendations.

Findings:

On 9/26/2016 at 11:57 a.m., the operating rooms air filter quality logs were not available when requested. Airflow manometer readings were not being recorded or documented. The airflow quality of the life of the final filters were not being documented or maintained.

At 12:00 p.m., the physical operations director was interviewed. The physical plant manager was asked for the documentation of airflow quality for the operating rooms. He said the HVAC filters that serve the operating rooms are changed periodically.

AIA Health Care Guidelines & ANI/ASHE Standard 170-208 Ventilation of Health Care Facilities requires the manometers to be used to determine the life of the filter. A 1.1 of ANI/ASHE Annex A states that filters shall be replaced on air pressure drop in accordance with the manometer readings.

Based on observation it was determined the facility failed to ensure protection from space heaters.

Findings:

On 9/27/2016 at 10:13 a.m., a space heater was observed in the payroll office under a desk.

At 10:20 a.m., a space heater was observed under the desk of the front lobby reception desk.

The physical operations director was interviewed. He was asked if the facility had documentation of the heating elements not eceeding 212 degrees farhenhiet. He said he would look. The documentation was not provided.

NFPA 101, 2000 Edition
Chapter 19
19.7.8
Portable space heating devices shall be prohibited in all health care occupancies. Except it shall be permitted to be used in non-sleeping staff and employee areas where the heating elements of such devices do not exceed 212 degrees F (100 degrees C).

Based on observation it was determined the faclity failed to ensure protection for trash receptacles exceeding 32 gallons.

Findings:

On 9/26/2016 at 11:55 a.m., a shredded paper receptacle over 32 gallons by medical records was observed stored open to the egress corridor.

On 9/27/2016 at 10:32 a.m., a shredded paper receptacle over 32 gallons was observed in a staff only closet near the main lobby front reception area.

At 14:07, a trash container of soiled linen was stored open to the egress corridor between paitent rooms 214 and 215.

The physical operations director acknowledged the over 32 gallon soiled linen container stored open to the egress corridor.


Soiled linen or trash collection receptacles do not exceed 32 gal (121 L) in capacity. The average density of container capacity in a room or space does not exceed .5 gal/sq ft (20.4 L/sq m). A capacity of 32 gal (121 L) is not exceeded within any 64 sq ft (5.9-sq m) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) are located in a room protected as a hazardous area when not attended. 19.7.5.5

Based on record review it was determined the facility failed to ensure anesthetizing locations were protected.

Findings:

On 9/28/2016 at 11:12 a.m., the facility temperature and humidity policy was reviewed. The facility humidity and temperature policy indicated the low-end range number for relative humidity was 20%.

At 13:38, on review of facility temperature and humidity logs revealed relative humidity levels exceeded 60%.

Facility relative humidity logs:

6-1-2016, procedure room - 84.6%
6-1-2016, decontam room - 61.4%
6-1-2016, sterilzer room - 60.2%
6-13-2016, dirty utility room - 67.4%

5-10-2016, PACU - 61.1%
5-11-2016, sterile supply 1 - 60.2%
5-11-2016, sterile supply 2 - 60.3%
5-11-2016, decontam room - 60.4%

Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.
(a) Shutoff valves are located outside each anesthetizing location and arranged so that shutting off one room or location will not affect others.
(b) Relative humidity is maintained equal to or great than 35% 4-3.1.2.3(n) and 5-4.1.1 (NFPA 99), 18.3.2.3, 19.3.2.3

Based on observation and staff interview it was determined the facility failed to provide an emergency shower within the work area of the laboratory for immediate emergency use.

Findings:

On 9/27/2016 at 9:25 a.m., on a tour of the laboratory an eye wash station was observed with in the laboratory but the laboratory contained no emergency body shower.

At 9:27 a.m., the laboratory director was interviewed. She was asked where the laboratory emergency body shower was. She said that if one is needed laboratory staff go to a patient room that is not being used or to the emergency room if they need to use an emergency shower.



NFPA 99 Standard for Health Care Facilities, 1999 Edition
Chapter 10 Laboratories
10-6* Emergency Shower.
Where the eyes or body of any person can be exposed to injurious corrosive materials, suitable fixed facilities for quick drenching or flushing of the eyes and body shall be provided within the work area for immediate emergency use. Fixed eye baths shall be designed and installed to avoid injurious water pressure.

Based on observation, staff interview, and record review, it was determined the facility failed to ensure protection of electrical wiring and equipment as required.

Findings:

On 9/26/2016 at 11:43 a.m., a portable air conditioning unit was observed to be plugged into an extension cord in the CT room.

At 9/26/2016 at 11:50 a.m., a multiplug was observed to be in use in the x-ray viewing room.

At 11:57 a.m., a power tap was observed to be in use at the reception desk near the medical records department.

On 9/27/2016 at 8:58 a.m., an open junction box was observed in the boiler room.

At 9:43 a.m., on tour of the emergency room no red plugs could be identified, and eletrical receptacles where not labeled.

At 10:13 a.m., a patient light in procedure room #2 did not have an inspection label.

At 10:30 a.m., an open junction box was observed in the area where the fire alarm control panel was installed.

On 9/27/2016 at 10:58 a.m., 7 open junction boxes were observed in the plenum space located in the corridor next to the clinic within the facility.

At 15:29, a protable air conditioning unit in the emergency room was observed to be plugged into a power tap.

At 15:11, an extension cord was observed to be in use in the blood bank room in the facility laboratory.

On 9/27/2016 at 15:15, a countertop sink next to the laboratory office had a strip of eletrcial outlets that where observed to not be GFCI.

At 15:32, isolation rooms #211 and #214 were observed to have countertop electrical receptacles within 6 feet of a water source.

On 9/28/2016 at 8:59 a.m., at the physical therapy building, a hydroculator was observed to be plugged into a non-GFCI receptacle.