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Based on observations and interviews the facility failed to ensure emergency exits were continuously maintained free of all obstructions to full use in case of an emergency in accordance with the LSC, 2012 Edition Section 7.1.10.1, 19.2.1 and 19.2.3.4. This had the potential to affect all patients receiving services. The facility had a census of 112 patients.

Findings include:

Observations during the tour of the facility with Staff Y, Staff X and Staff R on 03/20/19 between 8:00 AM and 2:00 PM revealed an egress route not maintained properly. The identified egress route from the Laboratory corridor had storage shelves with 27 cardboard boxes full of combustible paper records permanently stored. Located in the same corridor a trash can and a cart stored in the corridor reducing the width of egress. Interview with Staff R revealed the shelves with combustibles were kept in the corridor.

Staff Y, Staff X and Staff R verified the above findings at the time of the observation.

Based on observation and interview, the facility failed to ensure all paths of egress were marked in accordance with 39.2.1 and 7.10, NFPA 101, 2012 edition. This had the potential to affect all patients receiving services. The facility had a census of 112 patients.

Findings:

On 02/26/19 between 7:58 AM and 8:55 AM, a tour was conducted with Staff Y and Staff Q. The path of egress (hallways) in the minor Emergency Department (ED) lacked exit signs in the path of egress where the path of exit was not readily apparent. Multiple rooms in these hallways were observed unlocked and could result in a delay of egress from the building.

The therapy rooms were observed with multiple rooms which were unlocked. There was a lack of exit signage in this area to indicate how to exit the suite of rooms.

This was confirmed on tour with Staff Y and Staff Q.

Based on observations and interviews the facility failed to ensure that all smoke barriers were able to resist the passage of smoke in accordance with the LSC, 2012 Edition 19.3.7.3 and 8.5.6.2. This had the potential to affect all patients receiving services. The facility had a census of 112 patients.

Findings include:

Observations during the tour of the facility and the interstitial space above ceiling tiles with Staff Y and Staff X on 03/19/19 between 8:00 AM and 4:00 PM revealed penetrations in smoke barrier walls. The smoke barrier wall on the third floor adjacent to the west lounge separating the corridor from B4 stairwell had a three-quarter inch hole with two speaker wires and a sprinkler pipe with no fire stop applied. Located above the door on the first floor separating 1B.1 from the hospital an untreated wood two by four filling the space between the block and corrugated metal ceiling. This was found in a two-hour rated wall. Interview with Staff Y indicated he was unaware of the located penetrations.

Staff Y and Staff X verified the above findings at the time of the observation.

Based on observations and interviews the facility failed to ensure that all corridor doors were able to resist the passage of smoke and provided with a means suitable for keeping the door closed in accordance with the LSC, 2012 Edition 19.3.6.3. This had the potential to affect all patients receiving services. The facility had a census of 112 patients.

Findings include:

Observations during tour of the facility with Staff Y and Staff X on 03/19/19 between 8:00 AM and 4:00 PM revealed doors to the corridor not maintained properly. Located the clean linen closet measuring 72 square feet in the service area across from the boiler room with double doors that open to the corridor. The doors were striking the top of the frame and the coordinator was broken not allowing the doors to self-close and latch as required. The double doors from central storage were magnetically held open and released on the fire alarm activation. The independent leaf of the door was equipped with a manual locking mechanism that was unlocked. When the doors released from the magnets they did not fully close and neither door had the capability to latch into the frame. The double doors entering the Ambulatory Care Center did not fully close and latch as required. The doors were released and did not strike the latch with enough force to secure the door on all three attempts. Interview with Staff Y revealed all the doors in the facility are checked quarterly.

Staff Y and Staff X verified the above findings at the time of the observation.

Based on observations and interviews the facility failed to ensure that all Heating Ventilation and Air Conditioning equipment in accordance with the LSC, 2012 Edition 19.5.2.1. This had the potential to affect all patients receiving services. The facility had a census of 112 patients.

Findings include:

Observations during tour of the facility and the interstitial space above ceiling tiles with Staff Y and Staff X on 03/19/19 between 8:00 AM and 4:00 PM revealed Heating Ventilation and Air Conditioning equipment not maintained properly. Located above the corridor between the Pharmacy and Ambulatory Care Center the return air ductwork was modified and was open to interstitial space between the ceiling tiles and hard capped ceiling. The system was designed as a fully ducted system and the open duct resulted in an open plenum return. Interview with Staff Y revealed that a renovation was completed in the area and the ductwork was left open at that time.

Staff Y and Staff X verified the above findings at the time of the observation.

Based on review of fire drills and staff interview, the facility failed to sound the fire drills for three of the past four drills, and failed to ensure the offsite central monitoring stations received the fire alarm signs in accordance with NFPA 101, 2012 edition, 21.7.2.1.2 (2) and 21.7.1.4. This could potentially affect all patients receiving services in the facility. A total of 5,044 procedures were conducted between 03/01/18 and 02/28/19. The facility had a census of 112 patients.

Findings include:

On 03/21/19 at 10:20 AM a review was conducted of fire drills with Staff T. The drills were conducted quarterly for the past 12 months on 11/19/18, 09/18/18, 05/24/18 and 03/19/18. Only one of these four drills (on 11/19/18)included sounding of the fire alarm and signal transmission to the central monitoring stations. This was confirmed with Staff T at the time of the review. Staff T stated the facility currently has surgical services and only sounds the fire alarm and checks the signal transmission one time a year.

Based on observations, staff interviews and review of the oxygen maintenance records, the facility failed to ensure repairs were performed timely after a medical gas inspection identified issues that required correction in accordance with NFPA 99, 2012 edition, 5.1.14.3.2. This could potentially affect all patients receiving services in the facility. A total of 5,044 procedures were conducted between 03/01/18 and 02/28/19. The facility had a census of 112 patients.

Findings include:

On 03/21/19 observation of the facility at 9:30 AM revealed a piped in medical gas system with a manifold, zone valves and alarms. At 10:20 AM a review of facility maintenance documentation of the medical gas system was conducted with Staff T. An outside service contractor conducted an annual category 1 inspection of the medical gas system on 11/13/18. Per this inspection, three priority 2 areas (repair action) items were identified as requiring correction. At the time of the review in the ambulatory surgery facility, Staff T was unable to provide documented evidence of the repairs. Staff T, Z and Y were present at the time of the review and all three staff confirmed the untimely repair of the medical gas system.

At 3:20 PM on 03/21/19 at the main hospital building, Staff Z provided documentation of the repairs and confirmed the repairs were completed as follows:

a) Station 2 & 3 and Outlet 2 & 3 in Operating Room (OR) 1's vacuum was below 85 lpm. The recommendation was for Flowzyme inlet to remove debris in check valve/repair additional items as required or replace latch. The date assigned for completion was 12/15/18. The date of completion was 03/14/19.

b) Station 1, Outlet 1 in OR 4's oxygen outlet was below 100 lpm. The recommendation was for repair or replace latch valve assembly. The date assigned for completion was 12/15/18. The date of completion was 03/14/19. The front latch was rebuilt on that date and passed 170 lpm.

c) The oxygen manifold in the manifold room was identified with a top left #2 check valve which was leaking. A recommendation was for replacement of the check valve. The date assigned for completion was 12/15/18. The date of replacement check valve being shipped to the facility was 02/19/19 and replaced on 02/22/19.

Based on staff interviews, observations and review of facility maintenance documentation, the facility failed to timely conduct a risk assessment for wet locations. This could potentially affect all patients receiving services in the facility. A total of 5,044 procedures were conducted between 03/01/18 and 02/28/19. The facility had a census of 112 patients.

Findings include:

On 03/21/19 at 10:20 AM a review of facility maintenance documentation was conducted with Staff T. Tour of the facility between 9:20 AM and 10:17 AM revealed the facility has four operating rooms. When asked about the type of surgical procedures conducted, Staff T replied the facility does orthopedic surgery at which time a large volume of fluids are used during certain orthopedic procedures.

The maintenance review lacked evidence of a risk assessment of the operating rooms. After leaving the ambulatory surgery center, while at the main hospital building on 03/21/19, a risk assessment was provided for the ambulatory surgery center by Staff Z. The risk assessment was dated the same date (03/21/19). This was confirmed with Staff Z on 03/21/19 at 3:40 PM.

Based on observation, review of facility maintenance records, and staff interview, the facility failed to comply with National Fire Protection Association (NFPA) 99, 6.3.4 to initially test hospital grade electrical receptacles at patient bed locations and areas where deep sedation or general anesthesia is administered. This had the potential to affect all patients receiving services. The facility had a census of 112 patients in the hospital building and conducted 5,044 procedures in the ambulatory surgery center from 03/01/18 through 02/28/19.

Findings include:

On 03/21/19 with Staff Y at 10:20 AM, during facility maintenance records review with Staff Y, there was lack of documented evidence of initial hospital grade receptacle testing. Staff Z confirmed hospital grade receptacles are present in the facility, and stated they are tested only when they have to be replaced.

During tour of the facility on 03/21/19 between 9:20 AM and 10:12 AM with Staff T, hospital grade receptacles were observed in the four operating rooms and post operative areas of the facility.

Based on observation, review of facility maintenance records, and staff interview, the facility failed to comply with National Fire Protection Association (NFPA) 99, 6.3.4 to initially test hospital grade electrical receptacles at patient bed locations and areas where deep sedation or general anesthesia is administered. This had the potential to affect all patients receiving services. The facility had a census of 112 patients.

Findings include:

On 03/19/18 beginning at 8:32 AM, during facility maintenance records review with Staff Z, there was lack of documented evidence of initial hospital grade receptacle testing. Staff Z confirmed hospital grade receptacles are present in the facility, and stated they are tested only when they have to be replaced.

Observations and staff interviews with Staff Z and Y during tour of the facility on 03/19/19 through 03/20/19 confirmed the use of hospital grade receptacles in patient bed locations, in the operating rooms and post operative areas of the facility.

Based on observations and interviews the facility failed to ensure that all routine storage areas for medical gas oxygen cylinders were provided with a precautionary sign per NFPA 99, 2012, 11.3.4.2, failed to ensure oxygen cylinders were stored more than 5 feet from combustibles per NFPA 99, 2012 edition, 11.3.2.3 (2), and failed to ensure medical gas cylinders of oxygen greater than 300 but less than 3,000 cubit feet were stored in accordance with NFPA 99, 2012 edition. This had the potential to affect all patients receiving services. The facility had a census of 112 patients.

Findings include:

Tour and observations were conducted with Staff Z and Staff V on 03/19/19 between 2:30 PM and 3:37 PM for the fourth and sixth floors, and on 03/20/19 between 8:57 AM and 1:50 PM with Staff Z, V, and Y on the first, second and third floors.

Routine medical gas storage rooms were observed with up to 12 e cylinders of oxygen in the following rooms and lacked a precautionary sign readable from 5 feet which includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING" on the storage room doors as follows:

a) The sixth floor patient care area was observed with a clean supply room in section 6.1 which contained 4 e tanks of oxygen in a 12 compartment rack which were located within five feet of combustibles. Interview with the nurse manager, Staff AA, confirmed this room was routinely used for oxygen cylinder storage up to 12 e sized cylinders.

b) The fourth floor patient care area was observed with a clean supply room in section 4.1 which contained ten e tanks of oxygen in a 12 compartment rack which were located within five feet of combustibles. Interview with the nurse manager, Staff BB, confirmed this room was routinely used for oxygen cylinder storage up to 12 e sized cylinders.

c) The third floor intensive care unit (ICU) was observed with 11 e tanks of oxygen in a clean utility room behind the nurses' station. The cylinders were located within 5 feet of combustibles.

On the first floor:

d) The first floor radiology department section 1.4 was observed with four e tanks of oxygen in the x-ray room. An interview with Staff CC confirmed a lack of precautionary signage on the door and confirmed this is a routine storage area for oxygen cylinders.

e) The emergency department central supply room was observed with four e size cylinders of oxygen. Interview with Staff DD confirmed this was a routine oxygen storage area, could store up to six e tanks and lacked precautionary signage.

f) The wellness center was observed with 11 e cylinders of oxygen in the exercise area. Interview with Staff EE revealed the cylinders were in use as it was a respiratory therapy day. However, observation revealed less than 11 patients in this room at the time of tour. An additional closet located in the same smoke compartment was observed with 16 e cylinders of oxygen. The door of the storage room lacked precautionary signage. The smoke compartment was observed containing greater than 300 cubit feet of oxygen.

Staff Z, V and Y confirmed the oxygen storage areas at the time of tour.

Based on observations and interviews the facility failed to ensure that one routine storage areas of medical gas was provided with a precautionary sign per NFPA 99, 2012, 11.3.4.2. This had the potential to affect all patients receiving services. The facility had a census of 112 patients.

Findings include:

Tour and observations were conducted on 03/21/19 between 2:05 PM and 2:40 PM with Staff Z, Y, V and FF.
A medical gas storage room was observed located near the radiation treatment area of the building in the main corridor. This room contained large cylinders of oxygen along with a manifold.

The door to the room lacked a precautionary sign readable from 5 feet which included the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."

Staff FF confirmed this was the main medical gas room which was used for the piped in oxygen in the building and confirmed the lack of precautionary signage.