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Based on observations the facility failed to provide testing for the operating room's emergency lighting and document the battery backup emergency lighting testing. Failure of these units during a power outage could cause harm to the patients by allowing the operating rooms to go dark during a surgery.

NFPA 101, Life Safety Code, 2012, Chapter 19, Section 19.2.9.1 "Emergency lighting shall be provided in accordance with Section 7.9". Section 7.9.3 " Periodic Testing of Emergency Lighting Equipment" " Section 7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows: (1) Functional Testing shall be conducted monthly with a minimum of 3 weeks and a maximum of 5 weeks between tests. , for not less than 30 seconds except as otherwise permitted by 7.9.3.1.1. (2) The Test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.(3) Functional testing shall be conducted annually for a minimum of 1/1/2 hours if the emergency lighting system is battery powered. (4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1 (1) and (3). (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings include:

Observations while on tour January 4-6, 2022 revealed that the facility was not conducting testing of the operating rooms emergency lights for monthly or yearly requirements.

Employees # 2, #5, and #6 confirmed during the walk down and at the exit conference on January 4-6, 2022 that the facility was not conducting the required testing of the operating room's emergency lights.

Based on observations and staff interviews, the facility failed to test the fire alarm system for the monthly requirements for the facility. Failure to test the fire alarm system could cause harm to staff and residents during an emergency.

NFPA 101, Life Safety Code, 2012 Edition, Chapter 9, Section 9.6.1.3 "A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use". NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition, Chapter 14, Section 14.2.2.1, "The property or building or system owner or the owner ' s designated representative shall be responsible for inspection, testing, and maintenance of the system and for alterations or additions to this system". Chapter 26, Section 26.3.5.2.2 "The subsidiary facility shall be inspected at least monthly by central station personnel for the purpose of verifying the operation of all supervised equipment, all telephones, all battery conditions, and all fluid levels of batteries and generators". NFPA 72, National Fire Alarm and Signaling Code, Section14.6.2.1, Records shall be retained until the next test and for 1 year thereafter. CMS requires 3 years.
NFPA 72 Chapter 14, section 14.2.5 Releasing Systems.
Requirements pertinent to testing the fire alarm systems initiating fire suppression system releasing functions shall be covered by 14.2.5.1 through 14.2.5.6. and must be inspected in accordance with section 14.3 Inspection which requires Monthly and Annual inspection and service.

Findings include:

During the review of the facility's documentation on January 4-6, 2022, the facility was not able to provide documentation of the monthly testing of the fire alarm system for review.

Employees #2, #5, and #6 acknowledged during the exit conference that the facility failed to provide the required documentation of a monthly inspection of the fire alarm system.

Based on record review and staff interviews it was determined that the facility failed to perform the monthly inspection of the facility's sprinklers systems. Failure to perform the required inspections may cause harm to patients and staff.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.1. "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, 2011 Edition, "Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems." NFPA 25, 2011 Edition, "Water Based Extinguishment Systems," requires monthly, quarterly and annual testing of automatic sprinkler systems.
Findings Include:

Observations while on tour January 4-6, 2022 revealed that the facility failed to show proof of the monthly testing of the sprinkler systems in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems.

Employees #2, #5, and #6 confirmed during the exit conference that the facility failed to conduct the required monthly testing of the sprinklers systems.

Based on record review and staff interviews, it was determined that the facility failed to document humidity testing for the hospital operating rooms. Failing to document humidity testing in all operating rooms could result in harm to the patients.

CFR 416.44(a) Standard: Physical Environment, (a)(1) Temperature, humidity and airflow in ORs must be maintained within acceptable standards to inhibit microbial growth, reduce risk of infection, control odor, and promote patient comfort, ASCs must maintain records that demonstrate they have maintained acceptable standards. CMS S&C: 15-27 ASC states that ASCs need to ensure they comply with the instructions for use for their Operating Room supplies and equipment.

Findings Include:

During review of the facility's documentation conducted on January 4-6, 2022, revealed that the facility has humidity displays in two places for the operating rooms. However, the facility cannot provide daily logs for review of the relative humidity testing conducted by staff in a daily basis.

In addition, during the exit conference, employee's #2, #5, and #6 confirmed that the relative humidity testing in the operating rooms was not being conducted or recorded.

Based on observation and staff interviews, the facility failed to ensure a remote stop or kill switch for the generator was installed, and failed to perform the required weekly testing of the generator batteries. This affected the entire facility and could result in a loss of power due to a generator malfunction during an emergency power outage. Failure to have an emergency stop on the generator could cause a fire or harm to the residents and/or staff.

Code reference: NFPA 110 2010 Edition; Standard for Emergency and Standby Power Systems 5.6.5.6 All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation, located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building. A.5.6.5.6 For systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.

NFPA 101 Life Safety Code, 2012, Chapter19, Section 19.7.6 "Maintenance and Testing (See 4.6.12) Section 4.6.12.2 " Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 99 "HEALTH CARE FACILITIES" 2012 Edition, Chapter 3, Section 3-5.4.1.1 (a) and Section 3-4.4.1.1 (b) "Generator sets shall be tested twelve (12) times a year... Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Chapter 6, Section 8.4.1 "Level 1 and Level 2 EPSSs, including all appurtenant components shall be inspected weekly and shall be exercised under load at least monthly. NFPA 110, Chapter 8, Section 8.4.2 "Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes...

Findings include:

Observations while on tour conducted on January 4-6, 2022, revealed two violations of the Life Safety Code 2012 edition and as follows:
1. The hospitals' generator did not have the required remote stop or kill switch.
2. The hospital failed to document the weekly continuity or conductivity tests of the generator batteries.

Employees #2, #5, and #6 confirmed during the exit conference that the facility failed to install a remote stop switch for the emergency diesel generator. The facility also failed to conduct the required weekly continuity or conductivity tests on the generator batteries.

Based on observations during the facility tour, it was determined the facility allowed the use of non-UL 1363A or UL 60601-1 power strips in patient care areas of the hospital. Failure to properly use power strips and outlets could lead to electrical overload or fire which could cause harm to the patients and staff.

NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2, "All Patient Care Areas," Sections 6.3.2.2.6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

State Operations Manual Appendix A Interpretive Guidelines §482.41(a)
The hospital must ensure that the condition of the physical plant and overall hospital environment is developed and maintained in a manner to ensure the safety and well-being
of patients. This includes ensuring that routine and preventive maintenance and testing activities are performed as necessary, in accordance with Federal and State laws, regulations, guidelines, and manufacturer's recommendations, by establishing maintenance schedules and conducting ongoing maintenance inspections to identify areas or equipment in need of repair. The routine and preventive maintenance and testing activities should be incorporated into the hospital's QAPI plan.
The hospital must be constructed and maintained to ensure risks are minimized for patients as well as for employees and visitors. Hospitals are expected to demonstrate how they are addressing important safety features in accordance with nationally recognized standards. Although the following items are expected to be addressed when applicable, the list is not all-inclusive.
Accessibility
o A hospital must ensure all buildings at all locations of the certified hospital meet State and Federal accessibility standards (e.g. Office of Civil Rights requirements). The requirements apply to the interior and exterior of all buildings.
Life Safety Code surveyors assess the use of power strips in healthcare facilities. However, the following guidance is provided as a reference for healthcare surveyors as they survey the physical environment along with other CoP requirements. Any observed power strip deficiencies should be conveyed to the LSC surveyors for citation.
If line-operated medical equipment is used in a patient care room/area, inside the patient care vicinity:
o UL power strips would have to be a permanent component of a rack-, table-, pedestal-, or cart-mounted & tested medical equipment assembly
o Power strips providing power to medical equipment in a patient care room/area must be UL 1363A or UL 60601-1
o Power strips cannot be used for non-medical equipment
If line-operated medical equipment is used in a patient care room/area, outside the patient care vicinity:
o UL power strips could be used for medical & non-medical equipment with precautions as described in the memo
o Power strips providing power to medical equipment in a patient care room/area must be UL 1363A or UL 60601-1
o Power strips providing power to non-medical equipment in a patient care room/area must be UL 1363
If line-operated medical equipment is not used in a patient care room/area, inside and outside the patient care vicinity:
o UL power strips could be used with precautions
Power strips providing power to non-medical equipment in a patient care room/area must be UL 1363. In non-patient care areas/rooms, other UL strips could be used with the general precautions.

Findings include:

Observations while on tour January 4-6, 2022 revealed the following locations with non-UL 1363A or UL 60601-1 power strips were used in the following patient care areas:
1. 6 non-hospital grade power strips in the Pre-Op area of the surgical unit.
2. 2 non-hospital grade power strips in the Ultrasound area of the Radiology unit

During the exit conference conducted on January 6th, 2022 Employees # 2, #5, and #6 confirmed the improper use of power strips in the identified areas (pre-op area of the surgical unit and ultrasound area of the radiology unit).

Based on observation, record review, and staff interviews the facility failed to provide a record of electrical equipment tests, repairs, and modifications. Failure to conduct maintenance on patient care appliances could cause harm to the patient if the appliance malfunctions.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 10, Section 10.5.6 Record Keeping-Patient Appliances Electrical Equipment - Testing and Maintenance Requirements
"The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training."

Findings include:

Observations, record review, and staff interviews conducted on Jan 4-6, 2022, revealed that the facility was unable to produce policies, protocols, or documentation to identify some electrical equipment tests, repairs, and modifications were performed on these equipment. The facility provided documentation for all equipment except for the following items:

1. 1 Blood pressure/vitals machine in the X-ray area
2. Ultrasound machine in the Operating room pre-op area
3. Ultrasound machine in the radiology X-Ray area

Employee #2, #5, and #6 Confirmed during the exit conference on Jan 6, 2022, the facility failed to provide Preventive Maintenance on some of its electrical equipment (1 Blood pressure/vitals machine in the X-ray area, Ultrasound machine in the Operating room pre-op area, and Ultrasound machine in the radiology X-Ray area).

Based on observation during the facility tour, the facility failed to secure two medical gas Nitrous Oxide and Oxygen cylinders in a stand or cart. Failure to secure compressed medical gas cylinders could cause harm to the patients and staff.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 11 Section 11.6.2.3 (11) Free standing cylinders shall be properly chained or supported in a proper cylinder stand or cart."

Findings include:

Observations while on tour January 4-6, 2022 revealed two (2) unsecured Nitrous Oxide cylinders in the storage area of the surgical med gas room and 1 oxygen tank in the X-Ray area in radiology.

During the exit conference conducted on January 6th, 2022, Employees #2, #5, and #6 acknowledged and confirmed the existence of the unsecured Nitrous Oxide cylinders in the Medical Gas storage and oxygen tank in the X-ray area.

Based on staff interviews and program review it was determined that the facility failed to provide programs for continuing education and periodic review of safety guidelines and usage requirements for medical gases and oxygen cylinders. Failure to provide programs and periodic reviews of safety guidelines of oxygen cylinders or liquid oxygen could cause harm to the patients and staff.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 11 Section 11.5.2.1" Gas Equipment - Qualifications and Training of Personnel concerned with the application, maintenance and handling of medical gases and cylinders are trained on the risk. Facilities provide continuing education, including safety guidelines and usage requirements. Equipment is serviced only by personnel trained in the maintenance and operation of equipment.

Findings include:

The review of the facility's documentation on oxygen risk training conducted on January 4-6, 2022 revealed that the facility does not provide an ongoing educational program for oxygen risk to existing and was confirmed during staff interview. However, initial training on the oxygen risk is provided by the facility to new employees.

Employees # 2, #5, and #6 confirmed during the exit conference on January 6, 2022, that the facility does not have an ongoing oxygen risk training program provided to existing employees. However, initial training on oxygen risk is provided by the facility to new employees.