HospitalInspections.org

Based on observation, the facility failed to ensure doors to all patient rooms closed and latched securely in accordance with 19.3.6.3.2, to resist the passage of smoke into corridors or patient rooms, potentially affecting the staff, visitors and as many as XX of the patients as listed on the admission data sheets. The hospital census was 267 inpatients.

Findings include:

1. Observation on 04/29/11 at 10:40 PM showed a jammed latch on the door to room 521 caused the door not to latch when pulled closed.

2. During an interview on 04/29/11 at 10:45 AM, Staff II stated door latches were checked for latching during regular PM rounds. He/she worked the mechanism several times and said it seemed to be jammed from being knocked out of alignment by a heavy object, probably a bed.

Based on observation and interview, the facility failed to provide secure storage of medical gases in accordance with NFPA 99, (5.1.3.3.2(7)) with racks, chains or other fastenings to individually secure all cylinders, whether connected, unconnected, full, or empty, to prevent them from falling or inadvertently being tipped over during change-outs, potentially affecting staff, visitors and the facility census of 267 inpatients.

Findings included:

1. Observation on 04/26/11 at 1:40 PM showed an unsecured "E" size cylinder of compressed oxygen in the corner of storage closet 600, next to patient room 601.

2. Observation on 04/26/11 at 1:41 PM showed an unsecured "E" size cylinder of compressed oxygen in the RIC (materials handling storage room) on 6th floor.

3. Observation on 04/29/11 at 10:40 AM showed an unsecured "E" size cylinder of compressed oxygen in a storage closet across from the "Team 4" office.

4. During an interview on 04/29/11 at 10:40 AM, Staff HH said there was no excuse for cylinders unsecured. He/she said it was mentioned on rounds that unsecured cylinders can result in a deficiency against them. He/she said most of these rules have been in place for a long time and haven't changed, so staff should have learned them.

Observation on 04/28/11 at 10:34 AM showed Staff Y, patient transporter, carried an "E" sized cylinder of oxygen down the hall by the handle on top to room 826, bed 2, to Patient #24. Staff Y sat the cylinder upright on the floor without placing it in a stand or collar, then placed the cylinder in a clear plastic bag and placed it on top of the bed with the patient. The cylinder rested against the lower left side rail of the patient's bed. A gap of approximately 16 inches was present between the end of the cylinder and the foot of the bed allowed a space where the cylinder could slide and fall from the bed to the floor. Staff Y failed to secure the cylinder in the cradle built into the hospital bed.

5. During an interview on 04/28/11 at 10:50 AM, Staff Y, patient transporter, stated he/she transports patients throughout the hospital. Staff Y stated he/she normally carries oxygen cylinders to and from patient rooms by the handle affixed on the top of the cylinder and does not use wheeled dolly. He/she stated he places the oxygen tanks on top of the bed with the patients. He/she stated he/she had worked at the hospital for a year and did have training how to safely work with the cylinders. However, he/she failed to recall what may happen if a cylinder falls over and hits the floor. He/she failed to recall the correct method of securing the cylinders during transport and how to safely secure one on a hospital bed specially equipped with a cradle or support brackets. Staff Y identified the location where he/she obtained the oxygen tank as the oxygen storage room on the 8th floor.

6. During an interview on 04/28/11 at 11:09 AM, Staff SS, Certified Respiratory Therapist, (CRT) confirmed the size of oxygen cylinders in the oxygen storage room on the 8th floor as "E" size cylinders of compressed oxygen at 22 pressure per square inch (PSI), holding 622 liters of oxygen with a volume size of 22 cubic feet. Staff SS stated oxygen cylinders should be transported in or attached to a secure device that affords protection for the neck and valve. Staff SS also stated the hospital beds they use have a formed cradle that is part of the bed's frame, where nominal "E" size cylinders may be secured. Staff SS stated damage to the top of an unsecured oxygen cylinder can result in the cylinder propelling itself through a concrete wall and travel up to a ¼ mile away. Staff SS stated even an unsecured empty cylinder of oxygen has the potential to cause substantial damage.

Based on observation, the facility failed to ensure doors to all patient rooms closed and latched securely in accordance with 19.3.6.3.2, to resist the passage of smoke into corridors or patient rooms, potentially affecting the staff, visitors and as many as XX of the patients as listed on the admission data sheets. The hospital census was 267 inpatients.

Findings include:

1. Observation on 04/29/11 at 10:40 PM showed a jammed latch on the door to room 521 caused the door not to latch when pulled closed.

2. During an interview on 04/29/11 at 10:45 AM, Staff II stated door latches were checked for latching during regular PM rounds. He/she worked the mechanism several times and said it seemed to be jammed from being knocked out of alignment by a heavy object, probably a bed.

Based on observation and interview, the facility failed to provide secure storage of medical gases in accordance with NFPA 99, (5.1.3.3.2(7)) with racks, chains or other fastenings to individually secure all cylinders, whether connected, unconnected, full, or empty, to prevent them from falling or inadvertently being tipped over during change-outs, potentially affecting staff, visitors and the facility census of 267 inpatients.

Findings included:

1. Observation on 04/26/11 at 1:40 PM showed an unsecured "E" size cylinder of compressed oxygen in the corner of storage closet 600, next to patient room 601.

2. Observation on 04/26/11 at 1:41 PM showed an unsecured "E" size cylinder of compressed oxygen in the RIC (materials handling storage room) on 6th floor.

3. Observation on 04/29/11 at 10:40 AM showed an unsecured "E" size cylinder of compressed oxygen in a storage closet across from the "Team 4" office.

4. During an interview on 04/29/11 at 10:40 AM, Staff HH said there was no excuse for cylinders unsecured. He/she said it was mentioned on rounds that unsecured cylinders can result in a deficiency against them. He/she said most of these rules have been in place for a long time and haven't changed, so staff should have learned them.

Observation on 04/28/11 at 10:34 AM showed Staff Y, patient transporter, carried an "E" sized cylinder of oxygen down the hall by the handle on top to room 826, bed 2, to Patient #24. Staff Y sat the cylinder upright on the floor without placing it in a stand or collar, then placed the cylinder in a clear plastic bag and placed it on top of the bed with the patient. The cylinder rested against the lower left side rail of the patient's bed. A gap of approximately 16 inches was present between the end of the cylinder and the foot of the bed allowed a space where the cylinder could slide and fall from the bed to the floor. Staff Y failed to secure the cylinder in the cradle built into the hospital bed.

5. During an interview on 04/28/11 at 10:50 AM, Staff Y, patient transporter, stated he/she transports patients throughout the hospital. Staff Y stated he/she normally carries oxygen cylinders to and from patient rooms by the handle affixed on the top of the cylinder and does not use wheeled dolly. He/she stated he places the oxygen tanks on top of the bed with the patients. He/she stated he/she had worked at the hospital for a year and did have training how to safely work with the cylinders. However, he/she failed to recall what may happen if a cylinder falls over and hits the floor. He/she failed to recall the correct method of securing the cylinders during transport and how to safely secure one on a hospital bed specially equipped with a cradle or support brackets. Staff Y identified the location where he/she obtained the oxygen tank as the oxygen storage room on the 8th floor.

6. During an interview on 04/28/11 at 11:09 AM, Staff SS, Certified Respiratory Therapist, (CRT) confirmed the size of oxygen cylinders in the oxygen storage room on the 8th floor as "E" size cylinders of compressed oxygen at 22 pressure per square inch (PSI), holding 622 liters of oxygen with a volume size of 22 cubic feet. Staff SS stated oxygen cylinders should be transported in or attached to a secure device that affords protection for the neck and valve. Staff SS also stated the hospital beds they use have a formed cradle that is part of the bed's frame, where nominal "E" size cylinders may be secured. Staff SS stated damage to the top of an unsecured oxygen cylinder can result in the cylinder propelling itself through a concrete wall and travel up to a ¼ mile away. Staff SS stated even an unsecured empty cylinder of oxygen has the potential to cause substantial damage.