HospitalInspections.org

Based on observation and interview with staff, the facility failed to ensure that doors to corridors were provided with a means suitable for keeping the door closed tightly in its frame. Roller latches are prohibited by CMS regulations in all health care facilities. Findings include:

1) Doors to Pharmacy and to Robins office were not provided with latching hardware.

Based on observation and interview with staff, the facility failed to install and maintain A fire alarm system with approved components, devices or equipment in accordance with NFPA 72. Findings include:

The powered assist device connected to the door separating the hospital from the clinic was not installed on the fire alarm system. Door devices shall drop out upon activation of the alarm.

1) Based on observation and interview with staff, the facility failed to install and maintain Heating, ventilating, and air conditioning equipment that comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2 Findings include:

The Performance-Based Design Option out of NFPA 101 2000 Life Safety Code chapter 5.8.14 requires that anyone involved in the ownership or management of the building notify and document the following upon remodeling, modification, renovation, change in use:
The building was approved as a performance-based design
with certain specified design criteria and assumptions.
a) Any remodeling, modification, renovation, change in use, or change in the established assumptions will require a re-evaluation and re-approval. HVAC units for Operating Rooms 1 and 2 were installed with out approval from the Authority Having Jurisdiction.
b) The fresh air intakes are not 3 feet above roof line.
c) Fresh air intakes are not 25 feet from any plumbing vent, powered exhaust, etc.
d) The facility failed to install a smoke control system for the operating rooms in accordance with NFPA 99 1999 edition chapter 5-4.1.2
e) Documentation for HEPA filter efficiencies was not conducted. Manometers shall be logged and used for determining life of HEPA filters.
f) Other HVAC Units scattered across the roof was less than 3 feet above roof line and less than 25 feet from exhausts, plumbing vents, etc.
g) Endoscope Room and Bronchoscope rooms was positive.
h) Humidifier for Operating Room number 1 would not maintain humidity levels greater than 30% on occations through out the year.
i) Facility failed to provide Temperature and Humidity Levels for all parts of the Hospital other than Operating Rooms. Sterile Processing and Endoscope/Procedure rooms was not provided or logged.

2) Based on observation and interview with staff the facility failed to provide design for cleaning of endoscope's Cleaning rooms shall allow for flow of instrumentation from the contaminated area to the clean area and, finally, to storage. The clean equipment rooms, including storage, shall protect the equipment from contamination.

Based on observation and interview with staff, the facility failed to provide Piped in medical gas systems that comply with NFPA 99, Chapter 4. Findings include:

There was no Dew Point Monitor for the Medical Air Pump.

Based on observation and interview with staff the facility failed to protect Anesthetizing locations in accordance with NFPA 99, Standard for Health Care Facilities. Findings include:

1) The Governing Body failed to identify Anesthesia Locations in accordance with NFPA 99 12- 2.7.
The Anesthesia Policy last updated 11/08/2012 is referencing anesthesia location that do not meet. The policy references Radiology Department, Special Procedure Areas including CT and MRI. These areas are not provided with physical plant requirements in accordance with NFPA 99 1999 edition, chapter 12-4.1.2 and chapter 5-4.1 through 5-6.1. for delivering Anesthesia
2) Roman Number V on the 14th page of the Policy states that Conscious (moderate) Sedation may be managed in any area where appropriate monitoring equipment, suction, and oxygen is available. The areas are not identified by room number.
3) The policy does not spell Rules and Regulation for control of personal concerned with anesthesia locations in accordance with 12-4.1.1.4 . For example and at a minimum ,the policy does not address what kind of endo tracheal tube to be used when working around the head in conjunction with a cauterizing tool.
4) Staff has had a Fire Loss Prevention Drill, however the training was not effective, staff as an example did not know what Line Isolation Monitor were or the protection it served.
5) Operating Room Humidifier number 1 could not maintain a level greater than 30%; logs reveal humidity levels less than 30% on numerous occasions with no corrective action , other than stating that maintenance was called.

Based on observation and interview with staff, the facility failed to provide and maintain equipment that is essential for the operation of the hospital and can be used in an emergency. Findings include:

1) The Boiler emergency supply connection used to heat and create steam for the Operating Rooms was rotten and could not be used.

2) Staff indicated that they had not been trained to fire the boiler off on alternative fuel (Diesel Fuel).

3) The emergency Plan was provide to supply continuous service for an disaster or emergency, however the effectiveness of the plan, equipment, and training was not provided too or evaluated so, the continuity of all essential building systems would operate. Show how water for the boiler is supplied/maintained in an emergency along with sufficient amount of fuel. This is one part of the emergency plan, show all elements of the plan, with an over view of the training and components that make the facility self supporting in an emergency.

Based on observation and interview with staff, the facility failed to store Flammable and Combustible liquids that are used from and stored in approved containers in accordance with NFPA 30, Flammable and Combustible Liquids Code, and NFPA 45, Standard on Fire Protection for Laboratories Using Chemicals. Storage cabinets for flammable and combustible liquids shall be constructed in accordance with NFPA 30, Flammable and Combustible Liquids Code, NFPA 99. 4.3, 10.7.2.1. Findings included:

1) There was 6 gallons of alcohol, in plastic containers, located under the counter top in the lab. This condition was verified by the Lab Director.

Based on observation and interview with staff, the facility failed to provide an Type I EES that is divided into the critical branch, life safety branch and the emergency system in accordance with NFPA 99. 3.4.2.2.2. Findings include:

There was no battery back up lighting installed over the transfer switch that would supply an effective amount of lighting for diagnosing or repairing the transfer switch that could failed during an emergency. This is another part of the emergency or disaster planing that did not meet minimum requirements and was not planned for.

Based on observation and interview with staff,the facility failed to installed and maintained Electrical wiring and equipment in accordance with NFPA 70, National Electrical Code. 9.1.2 and NFPA 99 1999 edition. Findings include:

1) Line Isolation Monitors located in the Operating Rooms, Procedure Rooms and in the area once labeled ICU, rooms 118-121 were not on a preventive maintenance program.

2) The Audible Alarm on the Line Isolation Monitor located in the operating room OR number 1, was not working.

3) The fuse was removed from the Line Isolation Monitor located in the operating room OR number 2.

4) The fuse was removed from the Line Isolation Monitor located in the Endoscope Procedure room.

5) Bio Medical equipment Site Rite IV, Ultrasound had not receiving initial safety checks and was in a patient location ready for use.
6) Facility failed to remove Site Rite IV, Ultrasound equipment from patient location that had not received required Life Safety Electrical Test. Test are identified by a sticker of which this piece of equipment did not have.

Based on observation and interview with staff, the facility failed to ensure that doors to corridors were provided with a means suitable for keeping the door closed tightly in its frame. Roller latches are prohibited by CMS regulations in all health care facilities. Findings include:

1) Doors to Pharmacy and to Robins office were not provided with latching hardware.

Based on observation and interview with staff, the facility failed to install and maintain A fire alarm system with approved components, devices or equipment in accordance with NFPA 72. Findings include:

The powered assist device connected to the door separating the hospital from the clinic was not installed on the fire alarm system. Door devices shall drop out upon activation of the alarm.

1) Based on observation and interview with staff, the facility failed to install and maintain Heating, ventilating, and air conditioning equipment that comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2 Findings include:

The Performance-Based Design Option out of NFPA 101 2000 Life Safety Code chapter 5.8.14 requires that anyone involved in the ownership or management of the building notify and document the following upon remodeling, modification, renovation, change in use:
The building was approved as a performance-based design
with certain specified design criteria and assumptions.
a) Any remodeling, modification, renovation, change in use, or change in the established assumptions will require a re-evaluation and re-approval. HVAC units for Operating Rooms 1 and 2 were installed with out approval from the Authority Having Jurisdiction.
b) The fresh air intakes are not 3 feet above roof line.
c) Fresh air intakes are not 25 feet from any plumbing vent, powered exhaust, etc.
d) The facility failed to install a smoke control system for the operating rooms in accordance with NFPA 99 1999 edition chapter 5-4.1.2
e) Documentation for HEPA filter efficiencies was not conducted. Manometers shall be logged and used for determining life of HEPA filters.
f) Other HVAC Units scattered across the roof was less than 3 feet above roof line and less than 25 feet from exhausts, plumbing vents, etc.
g) Endoscope Room and Bronchoscope rooms was positive.
h) Humidifier for Operating Room number 1 would not maintain humidity levels greater than 30% on occations through out the year.
i) Facility failed to provide Temperature and Humidity Levels for all parts of the Hospital other than Operating Rooms. Sterile Processing and Endoscope/Procedure rooms was not provided or logged.

2) Based on observation and interview with staff the facility failed to provide design for cleaning of endoscope's Cleaning rooms shall allow for flow of instrumentation from the contaminated area to the clean area and, finally, to storage. The clean equipment rooms, including storage, shall protect the equipment from contamination.

Based on observation and interview with staff, the facility failed to provide Piped in medical gas systems that comply with NFPA 99, Chapter 4. Findings include:

There was no Dew Point Monitor for the Medical Air Pump.

Based on observation and interview with staff the facility failed to protect Anesthetizing locations in accordance with NFPA 99, Standard for Health Care Facilities. Findings include:

1) The Governing Body failed to identify Anesthesia Locations in accordance with NFPA 99 12- 2.7.
The Anesthesia Policy last updated 11/08/2012 is referencing anesthesia location that do not meet. The policy references Radiology Department, Special Procedure Areas including CT and MRI. These areas are not provided with physical plant requirements in accordance with NFPA 99 1999 edition, chapter 12-4.1.2 and chapter 5-4.1 through 5-6.1. for delivering Anesthesia
2) Roman Number V on the 14th page of the Policy states that Conscious (moderate) Sedation may be managed in any area where appropriate monitoring equipment, suction, and oxygen is available. The areas are not identified by room number.
3) The policy does not spell Rules and Regulation for control of personal concerned with anesthesia locations in accordance with 12-4.1.1.4 . For example and at a minimum ,the policy does not address what kind of endo tracheal tube to be used when working around the head in conjunction with a cauterizing tool.
4) Staff has had a Fire Loss Prevention Drill, however the training was not effective, staff as an example did not know what Line Isolation Monitor were or the protection it served.
5) Operating Room Humidifier number 1 could not maintain a level greater than 30%; logs reveal humidity levels less than 30% on numerous occasions with no corrective action , other than stating that maintenance was called.

Based on observation and interview with staff, the facility failed to provide and maintain equipment that is essential for the operation of the hospital and can be used in an emergency. Findings include:

1) The Boiler emergency supply connection used to heat and create steam for the Operating Rooms was rotten and could not be used.

2) Staff indicated that they had not been trained to fire the boiler off on alternative fuel (Diesel Fuel).

3) The emergency Plan was provide to supply continuous service for an disaster or emergency, however the effectiveness of the plan, equipment, and training was not provided too or evaluated so, the continuity of all essential building systems would operate. Show how water for the boiler is supplied/maintained in an emergency along with sufficient amount of fuel. This is one part of the emergency plan, show all elements of the plan, with an over view of the training and components that make the facility self supporting in an emergency.

Based on observation and interview with staff, the facility failed to store Flammable and Combustible liquids that are used from and stored in approved containers in accordance with NFPA 30, Flammable and Combustible Liquids Code, and NFPA 45, Standard on Fire Protection for Laboratories Using Chemicals. Storage cabinets for flammable and combustible liquids shall be constructed in accordance with NFPA 30, Flammable and Combustible Liquids Code, NFPA 99. 4.3, 10.7.2.1. Findings included:

1) There was 6 gallons of alcohol, in plastic containers, located under the counter top in the lab. This condition was verified by the Lab Director.

Based on observation and interview with staff, the facility failed to provide an Type I EES that is divided into the critical branch, life safety branch and the emergency system in accordance with NFPA 99. 3.4.2.2.2. Findings include:

There was no battery back up lighting installed over the transfer switch that would supply an effective amount of lighting for diagnosing or repairing the transfer switch that could failed during an emergency. This is another part of the emergency or disaster planing that did not meet minimum requirements and was not planned for.

Based on observation and interview with staff,the facility failed to installed and maintained Electrical wiring and equipment in accordance with NFPA 70, National Electrical Code. 9.1.2 and NFPA 99 1999 edition. Findings include:

1) Line Isolation Monitors located in the Operating Rooms, Procedure Rooms and in the area once labeled ICU, rooms 118-121 were not on a preventive maintenance program.

2) The Audible Alarm on the Line Isolation Monitor located in the operating room OR number 1, was not working.

3) The fuse was removed from the Line Isolation Monitor located in the operating room OR number 2.

4) The fuse was removed from the Line Isolation Monitor located in the Endoscope Procedure room.

5) Bio Medical equipment Site Rite IV, Ultrasound had not receiving initial safety checks and was in a patient location ready for use.
6) Facility failed to remove Site Rite IV, Ultrasound equipment from patient location that had not received required Life Safety Electrical Test. Test are identified by a sticker of which this piece of equipment did not have.