HospitalInspections.org

1) Basad on observation and interview with staff, the facility failed to provide Exit components (such as stairways) are enclosed with construction having a fire resistance rating of at least one hour, are arranged to provide a continuous path of escape, and provide protection against fire or smoke from other parts of the building. 8.2.5.2, 19.3.1.1 Findings include:

a) Based on observation and interview with staff, construction work from the ambulatory center , located from the floor below, provided a hazard and allowed the exit compromised. . The door to the construction site of the ambulatory center was blocked open, trash was stacked to the ceiling, exits were trashed out.

1) Based on observation and interview with staff, the facility failed to provide a fire alarm that is tested and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. The system shall have a maintenance and testing program that complies with applicable requirements of NFPA 70 and 72. 9.6.1.4 Findings include:

a) Dampers located in smoke compartment walls and magnetic locks installed to prevent access were not a part of the annual testing program. All equipment connected to the system shall be tested annually.

b) Annual alarm test performed was e-mailed or faxed. The facility failed to have the original signed and explained so that equipment as explained above could be tested.

c) Smoke Detector adjacent to the HVAC Supply Grill was not at least 3 feet away from the supply grill adjacent to OR 1..

Based on observation and interview with staff, the facility failed to provide heating, ventilating, and air conditioning 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:

a) Sterilizer unit located in the central processing room is not exhausted out creating a negative environment for internal workings of the unit. Internal workings of the unit is open to the room, heat and steam is allowed to expel into the room when door is opened creating potential for humidity levels and heat to exceed standards.

b) Sterilizer unit located in the operating room sterile corridor is not exhausted out creating a negative environment for internal workings of the unit. Internal workings of the unit is open to the room, heat and steam is allowed to expel into the space when the door is opened creating potential for humidity levels and heat to exceed standards. Also rust is found on the supply grill over the sterilizer, from when the steam escapes the unit, after excessive use.

c) Isolation rooms located on the patient wing are not provided with manometries that indicate the room is negative. The facility also could not provide documentation that the room had a test and balance that indicated 12 air exchanges with 2 outside air exchanges.

Based on observation and interview with staff the facility failed to store soiled linen and trash collection receptacles greater than 32 gallons in capacity in a located in a room protected as a hazardous area when not attended.

Findings:

A tour of the OR, with Staff D was conducted on the morning of 10/13/2014.

A housekeeping cart and a large trash receptacle was stored in an alcove in the semi-restricted area of the OR.

The above information was verified by Staff D during the tour.

1) Based on observation and interview with staff, the facility failed to protect Anesthetizing locations in accordance with NFPA 99 1999 edition chapters 4, 5, 12. Findings include:

a) Humidity logs indicate that the Humidifier does not meet minimum requirements. In the cold months of the year when humidity levels are in single digits or in the teens, the facility's humidity is chronically low or below 30%, with no corrective action. In the warmer months the humidity levels are above 60% with no corrective action. This was verified by readings taken from Daily logs report for both Operating Rooms 1 & 2.

b) Rules and regulations posted in the Operating Room did not provide or facility's policy and procedures did not address the method of delivering anesthesia when working above the shoulders. The Doctor of Anesthesia verified that is a verbal protocol when in the Operating Room and not written. Rules and Regulations shall be in accordance with NFPA 99 1999 edition chapter 12-4.1.1. through 12-4.1.2.10.

c) Facility did not have a policy that defined anesthesia locations 12-2.7.

d) Facility has not defined wet locations . Receptacles in the operating room were not provided with Ground Fault Protection.

1) Based on observation and interview with staff, the facility failed to provide electrical wiring and equipment in accordance with NFPA 70, National Electrical Code. 9.1.2

a) Facility failed to conduct Impedance Test for Patient Care Areas in accordance with 3-3.3.2 Grounding System in Patient Care Areas and Receptacle Testing in accordance with 3-3.3.3

b) Battery-Powered Emergency Lighting Units located in the Operating Room and over the Transfer Switch were not on a preventive maintenance program. No evidence of battery lights being tested.

c) The operating rooms were not provided with normal circuit. The operating rooms receptacles were provided with all red covers that indicate emergency power. 3-3.2.1.2 ( a) 1.* requires that all critical care areas to be fed from at least one emergency and one normal circuit.

d) Based on observation, review of Bio Medical Equipment and interview with staff, the governing body, the facility failed to ensure that contractor of services, comply with all applicable conditions of participation and standards for the contracted services, in accordance with Interruptive Guideline Appendix A, A-0083 §482.12(e) Standard: Contracted Services . Findings include:
a) The facility did not review results of the contractors equipment checks against manufacturers recommendations to determine if the contractor was completing preventive maintenance in accordance with manufacture recommendations.

b) DATEX -OMEDA machine located in the operating rooms was checked on a yearly basis. NFPA 99 1999 edition chapter 7-6.2.1.2 requires critical care areas to be tested on a annual basis. Equipment through out the facility was found to be tested yearly. At the time of the survey, an Alternative method of testing was not communicated and passed by the governing body to be used for testing on a yearly basis in accordance with Interruptive guidelines appendix A Alternate Equipment Management (AEM) Program §482.41(c)(2)