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Based on observation, interview with staff and review of the fire alarm records , the facility failed to install, tested, and maintained the fire alarm system required for life safety in accordance with NFPA 70 National Electrical Code and NFPA 72. Findings include:

Exit doors on all exits except the Emergency Department (Ambulance Entrance) are not provided with manuel pull stations.

The facility failed to inspect annually the fire alarm sysem, last survey completed 9/17/2012 by Simplex Grinnell.

Based on observation and interview with staff, the facility failed to properly maintained automatic sprinkler system in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Findings include:

A) Automatic Sprinkler System did not have a annual inspection.

Based on observation and interview with staff the facility failed to provide Combustion and ventilation air for boiler, incinerator and heater rooms that is taken from and discharged to the outside air. 19.5.2.2

Findings include:

The combustion air window was blocked off, Facility must provide combustion air for Boiler and allow for sufficient air for the Emergency Generator.

1)Based on observation, interview with staff, the facility failed to provide Anesthetizing locations that are protected in accordance with NFPA 99, Standard for Health Care Facilities. Humidity was cited for being out of range and no means to regulate the humidity on the last survey.

Findings include:

a) The Operating Room is not provided with Humidity Control. NFPA 99 5-4.1.1

B) The Operating Room is not provided with Smoke Evacuation System or Equivalent.

c) Relative Humidity Logs depicted levels less than 35%. Facility logged those levels, however no corrective action taken.

d) Receptacles were not labeled to identify at least one circuit on Normal Power in the operating Room Suite.

e) Facility could not document air exchanges in the Operating Room, also at the time of the survey, 2pm on January 17, 2014, the HVAC System was turned off.

f) Operating Room did not have Battery Back up Emergency Lighting over the table.

Based on observation, interview with staff, and review of the last LSC Survey, the facility failed to provide a Type I Essential Electrical System powered by a generator with a transfer switch and separate power supply. The EES is in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4. These findings were on the last survey and are cited again.

Findings include:

(1) There is not a set of construction documents that reflect a single line diagram depicting the separation of power .
(2) The transfer switches and existing Generator do not have a 90 minute back up light installed over the equipment (NFPA 110).
(3) The generator is not separated from the boiler room by a two hour wall (3-4.1.1.6).
(4) There is not an Alarm Annunciator installed in a 24 hour manned station (3-4.1.1.15). (5) The emergency branches are not labeled and separated into Life Safety, and Critical Care branches (3-4.2.2.2).

1)Based on observation, review of Building Plans and interview with staff, the facility failed to use Performance-Based Design Option in accordance with NFPA 101 2000 Life Safety Code 5.8.14 .The Re-Design of the Operating Room Suite and Recovery or its use was not submitted for remodeling, modification, or renovation. The format and content of the documentation shall be acceptable to the authority having jurisdiction and submitted in accordance with Hospital Standards Chapter 667-47. Findings include:

a) Emergency Room 1 is also used as Recovery
b) Emergency Room 2 is also used as Recovery
c) Window Units were added in the Central Supply and Sterile Storage, Hospital Standards 667 Appendix A requires that reticulating room units shall not be used in areas marked "No."
d) Central Sterile was not provided with positive air movement.
e) Decontamination was not provided with negative air movement
f) The Line Isolation Monitor was located in a closet outside the OR suite with no audible alarm, Three circuits in the operating room were not connected to the LIM
g) The Hospital space located adjacent to the Out-Patient Surgery Center in Cushing, operated as a Clinic, is housing Intubation and Electro-cauterizing Equipment, used in a room not meeting requirements of a procedure room in accordance with Hospital Standards Chapter 667. The room does not have correct HVAC air exchanges, filtration, etc. The clinical practice setting shall be designed to facilitate movement of patients and personnel into, through, and out of defined areas within the suite and it is not. A functional narrative shall be submitted in conjunction with a Stamped set of plans.

2)Based on observation and interview with staff, the facility failed to establish performance and maintenance criteria for anesthetizing locations and for equipment to safeguard patients and health care personnel from fire, explosion, electrical, and related hazards associated with the administration of inhalation anesthetics. Findings include:

a) Operating Room Staff R,AA,CC did not know what the function of the Line Isolation Monitor was or were it was located. LIM is not located outside the OR suite. At or around 11 am on January 17, 2014 , Staff E was paged Stat to the Operating Room, a breaker was tripped and Operating room staff did not know location of tripped breaker. Staff member E found the breaker and reset it. After surgery, Operating Room Staff as a group was asked if they knew the location of the breaker and what would happen if Staff E was not available. Staff indicated that had never happened before, however OR staff did not know location of breakers, nor did staff indicate that there had been any training for locations of equipment and its use.

b) Operating Room Nurse Anesthetists covering for the first time at this facility did not receive Rules and Regulation agreed upon and Adopted by governing body for the control of personnel concerned with anesthetizing locations, this was the first time the person was ever at Bristow Hospital. Staff also has not had complete training for Rules and Regulation including Physicians concerned with Anesthetizing Location. There is no Fire Loss Prevention Policy in accordance with NFPA 99 1999 edition chapter 12-4.1.2.10 which includes Hazard Assessment, Fire Prevention Procedures, Orientation and Training of Personal, also the facility failed to conduct a Fire Drill that was area specific to the Operating Room Suite.

Based on observation and interview with staff, the facility failed to provide Electrical wiring and equipment that is Maintained, Tested, and Inserviced in accordance with NFPA 70, National Electrical Code. 9.1.2, and NFPA 99 Findings include:

The Defibrillator located in the Urgent Care Center was not tested Daily.

The facility failed to provide Personnel concerned with the application and maintenance of electric appliances, including physicians, nurses, nurse aids, engineers, technicians, and orderlies, trained and cognizant of the risks associated with their use. To achieve this end result, the hospital shall provide appropriate programs of continuing education for its personnel in accordance with NFPA 99 1999 edition chapter 7-6.5 Qualification and Training of Personnel.

Personnel at the clinic were using cauterizing equipment without documented training, the use of cauterizing tool in combination with combustibles (alcohol) and an Oxidizer (oxygen) in an area without equipment. HVAC design parameters creates a space for the potential for a fire hazard, also the main hospital could not provide a documented training program for the entire staff.

Based on observation, interview with staff and review of the fire alarm records , the facility failed to install, tested, and maintained the fire alarm system required for life safety in accordance with NFPA 70 National Electrical Code and NFPA 72. Findings include:

Exit doors on all exits except the Emergency Department (Ambulance Entrance) are not provided with manuel pull stations.

The facility failed to inspect annually the fire alarm sysem, last survey completed 9/17/2012 by Simplex Grinnell.

Based on observation and interview with staff, the facility failed to properly maintained automatic sprinkler system in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Findings include:

A) Automatic Sprinkler System did not have a annual inspection.

Based on observation and interview with staff the facility failed to provide Combustion and ventilation air for boiler, incinerator and heater rooms that is taken from and discharged to the outside air. 19.5.2.2

Findings include:

The combustion air window was blocked off, Facility must provide combustion air for Boiler and allow for sufficient air for the Emergency Generator.

1)Based on observation, interview with staff, the facility failed to provide Anesthetizing locations that are protected in accordance with NFPA 99, Standard for Health Care Facilities. Humidity was cited for being out of range and no means to regulate the humidity on the last survey.

Findings include:

a) The Operating Room is not provided with Humidity Control. NFPA 99 5-4.1.1

B) The Operating Room is not provided with Smoke Evacuation System or Equivalent.

c) Relative Humidity Logs depicted levels less than 35%. Facility logged those levels, however no corrective action taken.

d) Receptacles were not labeled to identify at least one circuit on Normal Power in the operating Room Suite.

e) Facility could not document air exchanges in the Operating Room, also at the time of the survey, 2pm on January 17, 2014, the HVAC System was turned off.

f) Operating Room did not have Battery Back up Emergency Lighting over the table.

Based on observation, interview with staff, and review of the last LSC Survey, the facility failed to provide a Type I Essential Electrical System powered by a generator with a transfer switch and separate power supply. The EES is in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4. These findings were on the last survey and are cited again.

Findings include:

(1) There is not a set of construction documents that reflect a single line diagram depicting the separation of power .
(2) The transfer switches and existing Generator do not have a 90 minute back up light installed over the equipment (NFPA 110).
(3) The generator is not separated from the boiler room by a two hour wall (3-4.1.1.6).
(4) There is not an Alarm Annunciator installed in a 24 hour manned station (3-4.1.1.15). (5) The emergency branches are not labeled and separated into Life Safety, and Critical Care branches (3-4.2.2.2).

1)Based on observation, review of Building Plans and interview with staff, the facility failed to use Performance-Based Design Option in accordance with NFPA 101 2000 Life Safety Code 5.8.14 .The Re-Design of the Operating Room Suite and Recovery or its use was not submitted for remodeling, modification, or renovation. The format and content of the documentation shall be acceptable to the authority having jurisdiction and submitted in accordance with Hospital Standards Chapter 667-47. Findings include:

a) Emergency Room 1 is also used as Recovery
b) Emergency Room 2 is also used as Recovery
c) Window Units were added in the Central Supply and Sterile Storage, Hospital Standards 667 Appendix A requires that reticulating room units shall not be used in areas marked "No."
d) Central Sterile was not provided with positive air movement.
e) Decontamination was not provided with negative air movement
f) The Line Isolation Monitor was located in a closet outside the OR suite with no audible alarm, Three circuits in the operating room were not connected to the LIM
g) The Hospital space located adjacent to the Out-Patient Surgery Center in Cushing, operated as a Clinic, is housing Intubation and Electro-cauterizing Equipment, used in a room not meeting requirements of a procedure room in accordance with Hospital Standards Chapter 667. The room does not have correct HVAC air exchanges, filtration, etc. The clinical practice setting shall be designed to facilitate movement of patients and personnel into, through, and out of defined areas within the suite and it is not. A functional narrative shall be submitted in conjunction with a Stamped set of plans.

2)Based on observation and interview with staff, the facility failed to establish performance and maintenance criteria for anesthetizing locations and for equipment to safeguard patients and health care personnel from fire, explosion, electrical, and related hazards associated with the administration of inhalation anesthetics. Findings include:

a) Operating Room Staff R,AA,CC did not know what the function of the Line Isolation Monitor was or were it was located. LIM is not located outside the OR suite. At or around 11 am on January 17, 2014 , Staff E was paged Stat to the Operating Room, a breaker was tripped and Operating room staff did not know location of tripped breaker. Staff member E found the breaker and reset it. After surgery, Operating Room Staff as a group was asked if they knew the location of the breaker and what would happen if Staff E was not available. Staff indicated that had never happened before, however OR staff did not know location of breakers, nor did staff indicate that there had been any training for locations of equipment and its use.

b) Operating Room Nurse Anesthetists covering for the first time at this facility did not receive Rules and Regulation agreed upon and Adopted by governing body for the control of personnel concerned with anesthetizing locations, this was the first time the person was ever at Bristow Hospital. Staff also has not had complete training for Rules and Regulation including Physicians concerned with Anesthetizing Location. There is no Fire Loss Prevention Policy in accordance with NFPA 99 1999 edition chapter 12-4.1.2.10 which includes Hazard Assessment, Fire Prevention Procedures, Orientation and Training of Personal, also the facility failed to conduct a Fire Drill that was area specific to the Operating Room Suite.

Based on observation and interview with staff, the facility failed to provide Electrical wiring and equipment that is Maintained, Tested, and Inserviced in accordance with NFPA 70, National Electrical Code. 9.1.2, and NFPA 99 Findings include:

The Defibrillator located in the Urgent Care Center was not tested Daily.

The facility failed to provide Personnel concerned with the application and maintenance of electric appliances, including physicians, nurses, nurse aids, engineers, technicians, and orderlies, trained and cognizant of the risks associated with their use. To achieve this end result, the hospital shall provide appropriate programs of continuing education for its personnel in accordance with NFPA 99 1999 edition chapter 7-6.5 Qualification and Training of Personnel.

Personnel at the clinic were using cauterizing equipment without documented training, the use of cauterizing tool in combination with combustibles (alcohol) and an Oxidizer (oxygen) in an area without equipment. HVAC design parameters creates a space for the potential for a fire hazard, also the main hospital could not provide a documented training program for the entire staff.