HospitalInspections.org

Based on observation and interview with staff, the facility failed to have doors that are 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. 19.3.6.3
Findings include:

1. Roller Latches were installed on patient room doors on the Lindsay Side of the facility. Roller latches will have to be removed and Latching hardware installed.

Based on observation, interview with staff, the facility failed to conduct Fire Drills that are held at unexpected times under varying conditions, at least quarterly on each shift. The staff shall be familiar with procedures and be aware that drills are part of established routine. The responsibility for planning and conducting drills shall be assigned to competent persons who are qualified to exercise leadership. Where drills are conducted between 9 PM and 6 AM a coded announcement may be used instead of audible alarms. Findings include:

1. The facility failed to conduct Facility Wide Drills at unexpected times. The Department of Corrections and Lindsay Hospital was conducting Fire Drills unilaterally; Drills shall be conducted jointly and be arranged to address and conform to all of the requirements in chapter 19.7.1.2*. (Staff member from DOC was not on the Lindsay Safety Committee, participating in, and reporting at all meetings.)

Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.

When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms. Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

19.7.1.3 Employees of health care occupancies shall be
instructed in life safety procedures and devices.

19.7.2 Procedure in Case of Fire.

19.7.2.1* For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff
shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon
staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy ' s fire safety plan.

19.7.2.2 A written health care occupancy fire safety plan shall provide for the following:

(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire


19.7.2.3 All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under the following conditions:

(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm
box and then shall execute immediately their duties as outlined in the fire safety plan.

Based on observation and interview with staff, the facility failed provide testing of the fire alarm system required for life safety that is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. Findings include:

The smoke evacuation system unique to the Operating Room was not tested on the annual test conducted on March 3, 2013.

Based on observation and interview with staff, the facility failed to insure that the means of egress is continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects shall obstruct exits, access to, egress from, or visibility of exits. 7.1.10 Findings include:

1. Four computers on wheels were staged in the main corridor 1147 of the DOC side of the facility.

2. The blue 4-wheeled soiled holding cart was continuously staged in corridor 1122.

Based on observation and interview with staff, the facility failed to maintain design features constructed for the building. To continue to meet the performance goals and objectives of this Code, the Building shall be maintained in accordance with performance goals and objectives that include complying with all documented assumptions and design specifications. Any variations shall require the approval of the authority having jurisdiction prior to the actual change in accordance with NFPA 101, 2000 edition, chapter 5.1.7. Findings include:

1. The soiled work room (room 1132 in accordance with 2002 drawing from Rees Architecture) between the Operating Room and the Endoscope Room is now being used as a scope processing room. This room does not meet the requirements for processing of scopes. The dirty side of a scope processing requires a negative air flow in relationship to adjacent area, with two sinks, etc.; the clean side requires a positive air flow, sinks , etc. Both rooms, dirty and clean, require physical separation (The Cleaning process requires the flow of instruments from the contaminated area to the clean area and, finally, to storage).

2. The soiled utility room (1137) adjacent to the Operating Room has been changed into an IT Server Room. The bagged waste was to be placed in this room, however it is now being staged in a blue receptacle on wheels, approximately 50 gallon in size, located in corridor 1122.

3 Surgery Supply Room 1140 is now a combined dirty instrument cleaning room and sterile supply room . Dirty instruments and clean supply cannot be combined. Again as stated in item number one, dirty rooms require a negative flow and clean requires a positive flow, also these rooms are required to be separated.



Based on observation and interview with staff, the facility failed to provide a complete evaluation of hazards that could be encountered during surgical procedures. The evaluation shall include hazards associated with the properties of electricity, hazards associated with the operation of surgical equipment, and hazards associated with the nature of the environment. New operating room/surgical suite personnel, including physicians and surgeons, shall be taught general safety practices for the area and specific safety practices for the equipment and procedures they will use. Fire exit drills shall be conducted periodically in accordance with NFPA 99, 1999 edition, chapter 12-4.1.2.10. Findings include:

1 The new orthopedic surgeon had not been in serviced.

2 The Time Out Form "Special Invasive Procedure" did not have a time out requirement documentation for drying time of newly introduced combustible alcohol/Hibiclens Surgery Prep, or the existing Dura Prep.

3 The facility failed to conduct a fire drill in the operating room.

Based on observation , interview with staff, the facility failed to provide qualification and training of personnel concerned with the application and maintenance of electric appliances, including physicians, nurses, nurse aids, engineers, technicians, and orderlies. Staff shall be cognizant of the risks associated with their use and to achieve the end results the hospital shall provide appropriate programs of continuing education for its personnel. This program shall include periodic review of manufacturers ' safety guidelines and usage requirements for electrosurgical units and similar appliances in accordance with NFPA 99, 1999 edition, chapter 7-6.5.1. Findings include:

1 Facility could not produce documentation that the new Orthopedic Physician had any area specific inservice of hospitals equipment . Also, the facility could not provide documentation of a continuing education program for periodic training of staff that also included Physicians.

Based on observation and interview with staff, the facility failed to have doors that are 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. 19.3.6.3
Findings include:

1. Roller Latches were installed on patient room doors on the Lindsay Side of the facility. Roller latches will have to be removed and Latching hardware installed.

Based on observation, interview with staff, the facility failed to conduct Fire Drills that are held at unexpected times under varying conditions, at least quarterly on each shift. The staff shall be familiar with procedures and be aware that drills are part of established routine. The responsibility for planning and conducting drills shall be assigned to competent persons who are qualified to exercise leadership. Where drills are conducted between 9 PM and 6 AM a coded announcement may be used instead of audible alarms. Findings include:

1. The facility failed to conduct Facility Wide Drills at unexpected times. The Department of Corrections and Lindsay Hospital was conducting Fire Drills unilaterally; Drills shall be conducted jointly and be arranged to address and conform to all of the requirements in chapter 19.7.1.2*. (Staff member from DOC was not on the Lindsay Safety Committee, participating in, and reporting at all meetings.)

Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.

When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms. Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

19.7.1.3 Employees of health care occupancies shall be
instructed in life safety procedures and devices.

19.7.2 Procedure in Case of Fire.

19.7.2.1* For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff
shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon
staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy ' s fire safety plan.

19.7.2.2 A written health care occupancy fire safety plan shall provide for the following:

(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire


19.7.2.3 All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under the following conditions:

(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm
box and then shall execute immediately their duties as outlined in the fire safety plan.

Based on observation and interview with staff, the facility failed provide testing of the fire alarm system required for life safety that is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. Findings include:

The smoke evacuation system unique to the Operating Room was not tested on the annual test conducted on March 3, 2013.

Based on observation and interview with staff, the facility failed to insure that the means of egress is continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects shall obstruct exits, access to, egress from, or visibility of exits. 7.1.10 Findings include:

1. Four computers on wheels were staged in the main corridor 1147 of the DOC side of the facility.

2. The blue 4-wheeled soiled holding cart was continuously staged in corridor 1122.

Based on observation and interview with staff, the facility failed to maintain design features constructed for the building. To continue to meet the performance goals and objectives of this Code, the Building shall be maintained in accordance with performance goals and objectives that include complying with all documented assumptions and design specifications. Any variations shall require the approval of the authority having jurisdiction prior to the actual change in accordance with NFPA 101, 2000 edition, chapter 5.1.7. Findings include:

1. The soiled work room (room 1132 in accordance with 2002 drawing from Rees Architecture) between the Operating Room and the Endoscope Room is now being used as a scope processing room. This room does not meet the requirements for processing of scopes. The dirty side of a scope processing requires a negative air flow in relationship to adjacent area, with two sinks, etc.; the clean side requires a positive air flow, sinks , etc. Both rooms, dirty and clean, require physical separation (The Cleaning process requires the flow of instruments from the contaminated area to the clean area and, finally, to storage).

2. The soiled utility room (1137) adjacent to the Operating Room has been changed into an IT Server Room. The bagged waste was to be placed in this room, however it is now being staged in a blue receptacle on wheels, approximately 50 gallon in size, located in corridor 1122.

3 Surgery Supply Room 1140 is now a combined dirty instrument cleaning room and sterile supply room . Dirty instruments and clean supply cannot be combined. Again as stated in item number one, dirty rooms require a negative flow and clean requires a positive flow, also these rooms are required to be separated.



Based on observation and interview with staff, the facility failed to provide a complete evaluation of hazards that could be encountered during surgical procedures. The evaluation shall include hazards associated with the properties of electricity, hazards associated with the operation of surgical equipment, and hazards associated with the nature of the environment. New operating room/surgical suite personnel, including physicians and surgeons, shall be taught general safety practices for the area and specific safety practices for the equipment and procedures they will use. Fire exit drills shall be conducted periodically in accordance with NFPA 99, 1999 edition, chapter 12-4.1.2.10. Findings include:

1 The new orthopedic surgeon had not been in serviced.

2 The Time Out Form "Special Invasive Procedure" did not have a time out requirement documentation for drying time of newly introduced combustible alcohol/Hibiclens Surgery Prep, or the existing Dura Prep.

3 The facility failed to conduct a fire drill in the operating room.

Based on observation , interview with staff, the facility failed to provide qualification and training of personnel concerned with the application and maintenance of electric appliances, including physicians, nurses, nurse aids, engineers, technicians, and orderlies. Staff shall be cognizant of the risks associated with their use and to achieve the end results the hospital shall provide appropriate programs of continuing education for its personnel. This program shall include periodic review of manufacturers ' safety guidelines and usage requirements for electrosurgical units and similar appliances in accordance with NFPA 99, 1999 edition, chapter 7-6.5.1. Findings include:

1 Facility could not produce documentation that the new Orthopedic Physician had any area specific inservice of hospitals equipment . Also, the facility could not provide documentation of a continuing education program for periodic training of staff that also included Physicians.