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Based on record review and interview the hospital failed to ensure the emergency preparedness policies and procedures addressed the facility's role in emergencies where the President declares a major disaster.

Findings:

Record review showed the facility did not develop and maintain a 1135 policy and procedure in the emergency preparedness plan as required.

On 09/14/21 at 2:14pm the surveyor asked staff A for the facility's 1135 waiver policy and procedure. Staff A stated the facility had not developed the policy but will to be in compliance.

Based on record review and interview the facility failed to ensure ASHRAE 170-2008 ventilatory standards were maintained as required.

Findings:

Record review showed the facility test and balance from Tulsa Air Specialists, Inc dated 03/23/21 failed to include the following areas to ensure they met ventilatory requirements as required: two surgical housekeeping closets, isolation patient room 105, isolation patient room 123.

On 09/15/21 at 2:27pm the surveyor asked staff C why the test and balance vendor left out the four areas. Staff C stated they did not know but will ensure all the areas will be tested to ensure ventilatory requirements are met in order to be in compliance.

Based on observation and interview the facility failed to ensure protection of medical gas storage areas as required.

Findings:

On 09/15/21 at 1:43pm the surveyor observed a combustible plastic trash receptacle filled with paper and plastic caps in the medical gas manifold room.

On 09/15/21 at 1:43pm the surveyor asked staff C why the combustible items were stored within the medical gas manifold room. Staff C stated they did not know why but will have it removed to be in compliance.

Based on record review and interview the facility failed to ensure impedance and line isolation monitor (LIM) testing/maintenance was completed per NFPA 99 2012 Edition requirements.

Findings:

Record review showed the facility did not complete impedance testing for patient care related electrical receptacles as required in NFPA 99 2012 Edition.

Record review showed the facility did not complete LIM testing for the operating room for 2020 and 2021 as required in NFPA 99 2012 Edition.

On 09/14/21 at 1:16pm the surveyor asked staff C why the impedance testing has not been completed per the requirements outlined in NFPA 99 2012 Edition. Staff C stated they were not fully familiar with the requirements for life safety code but will get the testing scheduled to be in compliance.

On 09/14/21 at 1:29pm the surveyor asked staff C why the LIM system was not tested annualy as required. Staff C stated they have been completing monthly self tests but will get the annual certification test done to be in compliance.

Based on observation and interview the facility failed to ensure power strips use in patient care locations were properly protected as required.

Findings:

On 09/14/21 at 2:02pm the surveyor observed a power strip and a electrical module for a endoscope monitor laying on the floor of operating room one.

On 09/14/21 at 2:02pm the surveyor asked staff G why the power strip and electric power module were on the floor of the wet location operating room. Staff G stated she did not know and will get it corrected. The surveyor stated operating rooms are wet locations and code requires the items to be permanently attached to the equipment assembly off the floor to decrease the shock hazard.



NFPA 99, 2012 Edition
Chapter 10.2.3.6
Multiple Outlet Connection. Two or more power receptacles
supplied by a flexible cord shall be permitted to be used
to supply power to plug-connected components of a movable
equipment assembly that is rack-, table-, pedestal-, or cartmounted,
provided that all of the following conditions are met:
(1) The receptacles are permanently attached to the equipment
assembly.
(2)*The sum of the ampacity of all appliances connected to
the outlets does not exceed 75 percent of the ampacity of
the flexible cord supplying the outlets.
(3) The ampacity of the flexible cord is in accordance with
NFPA 70, National Electrical Code.
(4)*The electrical and mechanical integrity of the assembly is
regularly verified and documented.
(5)*Means are employed to ensure that additional devices or
nonmedical equipment cannot be connected to the multiple
outlet extension cord after leakage currents have
been verified as safe.

Based on observation and interview the facility failed to ensure medical gas storage area was protected as required.

Findings:

On 09/15/21 at 1:35pm the surveyor observed a combustible plastic trash can filled with paper tabs and plastic caps in the medical gas manifold room.

On 09/15/21 at 1:35pm the surveyor observed four areas around piping where an expanding foam like substance was used to fill the annular space.

On 09/15/21 at 1:37pm the surveyor asked staff C why there was a plastic combustible trash can in the medical gas storage room. Staff C stated the gas vendor must have place it there but they will remove it to be in compliance.

On 09/15/21 at 1:39pm the surveyor asked staff C for the can of material or manufacturers documentation for the foam like substance to verify the fire rated resistance. Staff C stated they do not have the can or documentation.