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Based on observation it was determined that the facility failed to ensure corridor doors were provided with positive latching hardware. Findings:

On 9/24/15 at 3:15 p.m., it was observed that the housekeeping closet next to the endo room did not have positive latching hardware.

Based on observation and interview with staff the facility failed to ensure: proper airflow and air quality was being monitored and documented, and the facility failed to provide and ensure heating, ventilating, and air-conditioning systems complied with the manufacturer's specifications and recommendations. Findings:

On 9/25/15 the facility failed to ensure the required airflow for the sterile storeage and endoscope processing rooms was in accordance with ANI/ASHE Standard 170-208 Ventilation of Health Care Facilities. A 1.1 of ANI/ASHE Annex A, recommends operating rooms to be tested semi annually for positive airflow.

At 10:28 a.m., the operating rooms airfilter quality logs were not available when requested. Airflow manometer readings were not being recorded or documented. The airflow quality of the life of the final filters were not being documented or maintained.

At 10:30 a.m., the building maintenance person was interviewed. The Director of Plant Operations was asked for the documentation of airflow quality for the operating rooms. He said that he does not document when he changes air filters, but that he changes all HVAC filters every month. He was asked how he determines the condition of the air filters that serve the operating rooms. He said he has not done that. He was asked where the HVAC manometers were located. He said there is one manometer. He was asked if there were any manometers downstream to the HVAC that serve operating room 1 and the endo room within their surgical suite. He said no.

AIA Health Care Guidelines & ANI/ASHE Standard 170-208 Ventilation of Health Care Facilities requires the manometers to be used to determine the life of the filter. A 1.1 of ANI/ASHE Annex A states that filters shall be replaced on air pressure drop in accordance with the manometer readings.


NFPA 101, 2000 Edition, Chapter 9
9.2 HEATING, VENTILATING, AND AIR CONDITIONING
9.2.1 Air Conditioning, Heating, Ventilating Ductwork, and Related Equipment.
Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.
9.2.2 Ventilating or Heat-Producing Equipment.
Ventilating or heat-producing equipment shall be in accordance with NFPA 91, Standard for Exhaust Systems for Air Conveying of Vapors, Gases, Mists, and Noncombustible Particulate Solids; NFPA 211, Standard for Chimneys, Fireplaces, Vents, and Solid Fuel-Burning Appliances; NFPA 31, Standard for the Installation of Oil-Burning Equipment; NFPA 54, National Fuel Gas Code; or NFPA 70, National Electrical Code, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

Based on observation and interview it was determined the facility failed to ensure portable heating devices were not being used in sleeping staff room(s). Findings:

On 9/24/15 at 2:20 p.m., it was observed a portable space heater was in the physican's assistant/doctor sleeping room near the emergnecy room.

At 2:22 p.m., the Director of Plant Operations was interviewed. He was asked what device was located in the physican's assistant/doctor sleeping room. He said it was a portable heater.

Based on obsevation it was determined the facility failed to ensure trash collection receptacles did not exceed 32 gallons. Findings:

On 9/24/15 at 01:20 p.m., it was observed that a trash collection receptacle that exceeded 32 gallons was next to the sliding door leading to the endo room in the semi-restricted corridor of the surgical suite.

Based on observation and itnerview it was determined the facility failed to ensure medical gas storage tanks were secured. Findings:
It was observed on 9/24/15 at 3:41 p.m., one oxygen H cylinder located in a bank of 12 H cylinders was unsecured.
At 3:44 p.m., the Director of Plant Operations was interviewed. The Director of Plant Operations was shown the unsecured oxygen H tank. The Director of Plant Operations stated that their medical gas vendor was recently there and acknowledged the unsecured oxygen tank.

Based on observation, and record review the facility failed to ensure protection of the facilities anesthetizing locations. Findings:

On 9/24/15 it was observed the facility failed to post rules and regulations in the operating room suite, necessary to acquaint all personnel with the rules and regulations established and to ensure enforcement in accordance with NFPA 99, 1999 Edition, Chapter 12-4.1.1.4. "Hospital authorities and professional staff shall jointly consider and agree upon necessary rules and regulations for the control of personnel concerned with anesthetizing locations. Upon adoption, rules and regulations shall be prominently posted in the operating room suites. Positive measures are necessary to acquaint all personnel with the rules and regulations established and to ensure enforcement."

On review of documentation provided the facility humidity levels in December 2014 and January 2015 were recorded less than the 30% as allowed by state law levels in accordance with S&C Letter S&C: 13-25-LSC & ASC - This Waiver Does Not Apply: When more stringent RH control levels are required by State or local laws and regulations.


The ventilating systems for the operating room and the endo room were not provided with an automatic smoke evacuation system in accordance with NFPA 99, 1999 Edition, Chapter 5-4.1.2. Supply and exhaust systems for windowless anesthetizing locations are not arranged to automatically vent smoke and products of combustion.

On 09/25/15 the director of plant operations was asked for the inspection report of the facility's smoke evacuation units for the operating room and the endo room. The director of operations provided an undated APS Fire inspection reporting indicating the sensitivity settings of smoke detectors located in the facility. The report provided did not outline or confirm the facility having smoke evacuation mechanical venting devices to be present, and to be in manufactures' recommended working condition.

Based on observation it was determined the facility failed to ensure the Type I EES was divided into critical branch, and life safety branch. Findings:

It was observed on 9/24/15 at 12:15 p.m., in the "old" electrical room the electrical panels were labled LSC and critical. On inspection of the contents of each electrical panel it was observed the componets of the LSC branch panel were mixed with the critical branch panel.

NFPA 99, 1999 Edition, Chapter 3 Electrical Systems
3-4.2.2 Specific Requirements.
3-4.2.2.1* General.
Type I essential electrical systems are comprised of two separate systems capable of supplying a limited amount of lighting and power service, which is considered essential for life safety and effective facility operation during the time the normal electrical service is interrupted for any reason. These two systems are the emergency system and the equipment system.
The emergency system shall be limited to circuits essential to life safety and critical patient care. These are designated the life safety branch and the critical branch. The equipment system shall supply major electrical equipment necessary for patient care and basic Type I operation.
Both systems shall be arranged for connection, within time limits specified in this chapter, to an alternate source of power following a loss of the normal source. The number of transfer switches to be used shall be based upon reliability, design, and load considerations. Each branch of the emergency system and each equipment system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA (120 kW).

NFPA 99, 1999 Edition,
Chapter 3-4.2.2.2 Emergency System.
(a) General. Those functions of patient care depending on lighting or appliances that are permitted to be connected to the emergency system are divided into two mandatory branches, described in 3-4.2.2.2(b) and (c).
All ac-powered support and accessory equipment necessary to the operation of the EPS shall be supplied from the load side of the automatic transfer switch(es), or the output terminals of the EPS, ahead of the main EPS overcurrent protection, as necessary, to ensure continuity of the EPSS operation and performance. (NFPA 110: 5-12.5)
(b) Life Safety Branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment:
1. Illumination of means of egress as required in NFPA 101,® Life Safety Code®
2. Exit signs and exit direction signs required in NFPA 101, Life Safety Code
3. Alarm and alerting systems including the following:
a. Fire alarms
b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, " Gas and Vacuum Systems "
4. * Hospital communication systems, where used for issuing instruction during emergency conditions
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location
6. Elevator cab lighting, control, communication, and signal systems
7. Automatically operated doors used for building egress.No function other than those listed above in items 1 through 7 shall be connected to the life safety branch.
Exception: The auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm Code, shall be permitted to be connected to the life safety branch.
(c) * Critical Branch. The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and selected power circuits serving the following areas and functions related to patient care. It shall be permitted to subdivide the critical branch into two or more branches.
1. Critical care areas that utilize anesthetizing gases, task illumination, selected receptacles, and fixed equipment
2. The isolated power systems in special environments
3. Patient care areas - task illumination and selected receptacles in the following:
a. Infant nurseries
b. Medication preparation areas
c. Pharmacy dispensing areas
d. Selected acute nursing areas
e. Psychiatric bed areas (omit receptacles)
f. Ward treatment rooms
g. Nurses ' stations (unless adequately lighted by corridor luminaires)
4. Additional specialized patient care task illumination and receptacles, where needed
5. Nurse call systems
6. Blood, bone, and tissue banks
7. * Telephone equipment rooms and closets
8. Task illumination, selected receptacles, and selected power circuits for the following:
a. General care beds (at least one duplex receptacle per patient bedroom)
b. Angiographic labs
c. Cardiac catheterization labs
d. Coronary care units
e. Hemodialysis rooms or areas
f. Emergency room treatment areas (selected)
g. Human physiology labs
h. Intensive care units
i. Postoperative recovery rooms (selected)
9. Additional task illumination, receptacles, and selected power circuits needed for effective facility operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch.

Based on observation it was determined the facility failed to ensure the emergency electrical outlets in the operating suite room were labeled, and each emergency electrical outlet in the operating suite outlets were wired appropriately. Findings:

It was observed on 9/24/15 in the operating room and endo room each of the emergency/normal power outlets were not identified or labeled. At the electrical panel housing the operating suite emergency/normal power outlets did not have a breaker for each one, and were also not labeled.


The Director of Plant Operations stated that the operating room and endo room has combination plugs. He was asked to explain what he meant by combination electrical outlets. He said they are normal power outlets and when the normal power goes out the generator powers the same outlets. He said that the operating room and endo room have 5 normal/emergency power outlets that are served by only 2 breakers for each group of five outlets.

NFPA 99, 1999 Edition, Chapter 3 Electrical Systems
3-4.2.2 Specific Requirements.
3-4.2.2.1* General.
Type I essential electrical systems are comprised of two separate systems capable of supplying a limited amount of lighting and power service, which is considered essential for life safety and effective facility operation during the time the normal electrical service is interrupted for any reason. These two systems are the emergency system and the equipment system.
The emergency system shall be limited to circuits essential to life safety and critical patient care. These are designated the life safety branch and the critical branch. The equipment system shall supply major electrical equipment necessary for patient care and basic Type I operation.
Both systems shall be arranged for connection, within time limits specified in this chapter, to an alternate source of power following a loss of the normal source. The number of transfer switches to be used shall be based upon reliability, design, and load considerations. Each branch of the emergency system and each equipment system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA (120 kW).

NFPA 99, 1999 Edition,
Chapter 3-4.2.2.2 Emergency System.
(a) General. Those functions of patient care depending on lighting or appliances that are permitted to be connected to the emergency system are divided into two mandatory branches, described in 3-4.2.2.2(b) and (c).
All ac-powered support and accessory equipment necessary to the operation of the EPS shall be supplied from the load side of the automatic transfer switch(es), or the output terminals of the EPS, ahead of the main EPS overcurrent protection, as necessary, to ensure continuity of the EPSS operation and performance. (NFPA 110: 5-12.5)
(b) Life Safety Branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment:
1. Illumination of means of egress as required in NFPA 101,® Life Safety Code®
2. Exit signs and exit direction signs required in NFPA 101, Life Safety Code
3. Alarm and alerting systems including the following:
a. Fire alarms
b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, " Gas and Vacuum Systems "
4. * Hospital communication systems, where used for issuing instruction during emergency conditions
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location
6. Elevator cab lighting, control, communication, and signal systems
7. Automatically operated doors used for building egress.No function other than those listed above in items 1 through 7 shall be connected to the life safety branch.
Exception: The auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm Code, shall be permitted to be connected to the life safety branch.
(c) * Critical Branch. The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and selected power circuits serving the following areas and functions related to patient care. It shall be permitted to subdivide the critical branch into two or more branches.
1. Critical care areas that utilize anesthetizing gases, task illumination, selected receptacles, and fixed equipment
2. The isolated power systems in special environments
3. Patient care areas - task illumination and selected receptacles in the following:
a. Infant nurseries
b. Medication preparation areas
c. Pharmacy dispensing areas
d. Selected acute nursing areas
e. Psychiatric bed areas (omit receptacles)
f. Ward treatment rooms
g. Nurses ' stations (unless adequately lighted by corridor luminaires)
4. Additional specialized patient care task illumination and receptacles, where needed
5. Nurse call systems
6. Blood, bone, and tissue banks
7. * Telephone equipment rooms and closets
8. Task illumination, selected receptacles, and selected power circuits for the following:
a. General care beds (at least one duplex receptacle per patient bedroom)
b. Angiographic labs
c. Cardiac catheterization labs
d. Coronary care units
e. Hemodialysis rooms or areas
f. Emergency room treatment areas (selected)
g. Human physiology labs
h. Intensive care units
i. Postoperative recovery rooms (selected)
9. Additional task illumination, receptacles, and selected power circuits needed for effective facility operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch.

Electrical wiring and equipment is to be installed and maintained in accordance with NFPA 70, National Electrical Code. 9.1.2.