HospitalInspections.org

Based on observation and staff interview, the facility does not ensure that the fire doors entering the extension clinic have a positive latching mechanism. (Horseheads)

Findings include:

On 11/20/13 at 12:30 PM, it was observed that the fire doors entering the clinic area did not provide a positive latching mechanism. It was noted that these doors are located in a one-hour fire rated wall. Further observation of these doors revealed that the door on the south side of the assembly was a ? hour door and the door on the north side of the assembly was a 1 ? hour door.

Interview with Staff #63, Facilities/Maintenance, and Staff #5, Risk Management System Coordinator, verified this finding on 11/20/13 at 1:30 PM. (Horseheads)

Based on document review, the facility does not ensure that battery operated emergency lighting is tested monthly for 10 of 10 operating rooms and annually for 10 of 10 operating rooms and 3 of 3 catheterization (cath) labs. (AOMC)

Findings include:

Review of the Emergency Lighting log on 11/21/13 revealed that the required battery operated emergency lighting is not tested monthly. Review of this log indicated that monthly testing was not performed for the following:

-Operating rooms #1-8 were not tested during February, June and September 2013.
-Operating rooms #A and B were not tested during January and October 2013.
-Cath labs #A, B and C were not tested during February, May and August 2013.

Review of the Emergency Lighting log on 11/21/13 does not provide documentation verifying that the required battery emergency lighting is tested annually for 90 minutes.

This 30 second testing must be performed monthly to ensure that immediate illumination is provided in these areas during the 10 second delay between the loss of normal power and the activation of emergency power. An annual 90 minute testing must be performed to ensure that continuous illumination is provided in the event of emergency power failure or in the event of an internal failure.

Based on document review and staff interview, the facility does not ensure that one fire drill/shift/quarter is performed at the extension clinic (Horseheads) or that documented fire drills include the scenario, an evaluation, drill critique, staff participation and any follow-up activity that is performed. (AOMC and Horseheads)

Findings include:

Interview with Staff #64, Director of Emergency Preparedness and Security, on 11/20/13 revealed that the facility only conducts one fire drill/year. (Horseheads)

Review of the Fire Drill Reports on 11/22/13 at 9:00 AM with Staff #11, Supervisor of Safety and Security, verified that only one fire drill is conducted each year at the approved extension clinics. Review of this document indicated that a fire drill had been conducted on 03/20/13 and 07/12/12. (Horseheads)

Review of the Fire Drill Reports on 11/22/13 at 9:00 AM also revealed that the scenario, evaluation, drill critique, staff participation and follow-up activities were not indicated on the documented drills performed at the hospital or extension clinic.

This finding was verified by Staff #5, Risk Management System Coordinator, and Staff #9 on 11/22/13 at 9:30 AM.

Based on document review and staff interview, the facility does not ensure that annual inspection of the fire alarm system, sensitivity testing of the photo smoke detectors or that all components that comprise the system are tested annually. (Horseheads)

Findings include:

Review of the fire alarm inspection report for 2012 on 11/20/13 revealed that the fire alarm system is not inspected annually. It was noted that the fire alarm system was inspected on 12/10/2012 and prior to this date, the fire alarm system was last inspected on 09/16/2009.

Review of the fire alarm inspection report for 2012 does not indicate that all the components that compile the fire alarm system are tested annually. Review of these reports does not indicate that the notification devices, audio and audio/visual devices, are tested. The report dated 12/10/2012 indicates that these devices " WERE NOT TESTED/SOUNDED PER REQUEST OF CUSTOMER " .

Review of the fire inspection reports does not indicate that sensitivity testing has been performed on the photo smoke detectors or the last time sensitivity testing had been performed. Sensitivity testing must be performed within one year after installation of the device and every alternate year thereafter. After the second required testing, if the device sensitivity remains within the manufacturer recommendations for sensitivity, the time between testing may be extended to a maximum of five years.

Interview with Staff #63, Facilities (Horseheads) on 11/20/13 at 12:00 PM verified this finding.

Based on document review and staff interview, the facility does not ensure that the sprinkler system is maintained in a reliable operating condition. (Horseheads)

Findings include:

Review of 3 of 3 sprinkler reports from 2013, dated 01/25/13, 04/12/13 and 07/26/13 on 11/20/13 at 11:00 AM indicated that a five-year internal inspection of the sprinkler piping is required. Review of these documents did not indicate when the previous five-year inspection had been performed.

This inspection is required to ensure that obstructions/debris are not present in sprinkler piping that would interfere with the water flow in the event of an emergency.

Interview with Staff #63, Facilities/Maintenance, on 11/20/13 at 11:30 AM verified this finding.

Based on observation and staff interview, the facility does not ensure that the heating, cooling, ventilation and air-conditioning (HVAC) systems are maintained. (AOMC and Horseheads)

Findings include:

During the facility tour on 11/21/13 and 11/22/13, it was observed that the mechanical exhaust in the utility environmental services closet (room E115), the electrical closet (room E118) and in the dirty side of the endoscopy reprocessing room was not operational. It was also observed that supply air on the clean side of the reprocessed endoscope room was not operational. (AOMC)

Interview with Staff #6 on 11/21/13 at 3:15 PM indicated that mechanical exhaust was provided in Room E115 and E118 but was inadequate.

Interview with Staff #63 on 11/20/13 at 12:00 PM revealed that documentation for HVAC maintenance and repair for the Horseheads clinic is maintained by the staff at AOMC.

Interview with Staff #6 on 11/21/13 at 3:00 PM indicated that the facility is not able to provide documentation regarding the maintenance and repairs of the HVAC system.

Based on document review and staff interview, the facility does not ensure that the medical gas system is maintained or that vacuum outlets are present in the Electrophysiology Lab.

Findings include:

Review of the 2013 ANNUAL VERIFICATION report for the medical gas system indicated that multiple deficiencies were identified during the January 2013 inspection. Review of this report indicated the following:

-In Operating Room #1, three vacuum outlets leaked;
-In Operating Room #2, two vacuum outlets were obstructed, one vacuum outlet leaked and one vacuum outlet had low pressure;
-In Operating Room #3, three vacuum outlets leaked, one vacuum outlet was broken and two vacuum outlets had low pressure;
-In Operating Room #4, the pressure for the NO2 and CO2 was low and two vacuum outlets leaked;
-In Operating Room #5, outlet #723-0 for oxygen did not have any pressure, the incorrect color hose was present on the medical air and eight vacuum outlets leaked;
-In Operating Room #7, one vacuum outlet was broken and two vacuum outlets leaked;
-The medical air report for the Same Day Surgery Center on 3E noted that there was a slight odor in all the medical air outlets. This report does not indicate that the source of the odor was identified;
-In Emergency Rooms 3-6 the report indicates that the Nitrous Oxide is not in use but documentation is not provided to verify that the line has been capped or properly sealed;
-In the ICU on 2nd floor the report indicates that the oxygen outlet leaks;
-In Xray room #3 the vacuum leaks;
-In NICU Pod #3, the medical air leaks;
-On the 4th floor, the flow meter on the oxygen outlet is stuck for room 4C-10.

Review of the 2013 ANNUAL VERIFICATION report for the medical gas system did not indicate that vacuum outlets were present in the Electrophysiology Lab (EP). Review of this report indicates that only Oxygen and Medical Air are present in this lab.

Review of the requirements for medical gas outlets in the EP Lab indicates that two outlets of vacuum are required.

Interview with Staff #6, Director of Facilities, on 11/22/13 at 12:45 PM verified this finding.


Based on observation and staff interview, the facility does not ensure that the piped medical gases, Oxygen and Medical Air, are utilized for patient use only. (AOMC)

Findings include:

During the facility tour of the endoscopy reprocessing area on 11/22/13 at 12:00 PM, it was observed that an oxygen outlet was present on the clean side of the reprocessing area.

Interview with Staff #62, Assistant Director of Surgical Services, on 11/22/13 at 12:15 PM indicated that this outlet is utilized to " blowout " the scopes after the endoscopes have completed the reprocessing procedure and alcohol has been purged through the scope. This interview also indicated that this gas is utilized to enhance the scope drying process prior to the scopes being stored.

Based on document review and staff interview, the facility does not maintain documentation to indicate the daily humidity and temperature for 10 of 10 operating rooms. (AOMC)

Findings include:

Review of the provided documentation on 11/19/13 at 10:00 AM, noted that documentation was not provided to verify that the humidity and temperature readings in the operating rooms were within the acceptable parameters.

Interview with Staff #6 on 11/21/13 at 1:30 PM revealed that the documentation to verify the daily humidity and temperature readings of the operating rooms could not be provided.

Based on observation, document review and staff interview, the facility does not ensure that the smoke and fire dampers are tested. (AOMC and Horseheads)

Findings include:

During the facility tour on 11/20/13 and 11/21/13, it was observed that fire dampers and smoke dampers are present in the one-hour fire/smoke rated walls.

Review of the provided documentation on 11/22/13 at 10:00 AM did not indicate that these devices had been inspected or tested.

Interview with Staff # 6, Director of Facilities, on 11/22/13 at 10:30 AM revealed that the facility does not have documentation to verify the last time the devices were tested or that the devices have been tested within the past six years. This interview also revealed that the facility is currently in the process of locating and identifying these devices so that testing can be performed to ensure their proper operation.

Without the results of an inspection, it is not possible to determine if adequate separation and smoke compartments are provided on each of the patient floors.

Based on document review and staff interview, the facility does not ensure adequate warning of the medical gas systems to the master and area alarms panels. (AOMC)

Findings include:

Review of the 2013 ANNUAL VERIFICATION report for the medical gas system indicated that multiple deficiencies were identified during the January 2013 inspection. Review of this report indicates the following:

On the Master Alarms:

-A high/low pressure switch was not present on the Nitrous Oxide manifold.
-A high/low pressure switch was not present on the Medical Air compressor.
-A high/low pressure switch was not present on the Carbon Dioxide manifold and there was not an alarm for when changeover had occurred and Carbon Dioxide gas was being provided on the reserve system.
-The carbon monoxide monitor required calibration.
-There was not a monitor for the dew point level for the Medical Air.

On the area alarms:

-The alarms were not labeled for the areas they served outside of Room 3E17 and outside of trauma room 1&2 and 5&6.
-The alarm for Emergency Room #11, 17 and 18 was not functional.

Review of this report does not indicate that corrective action has been performed on any of the deficient areas that are identified in the report.

Interview with Staff #6, Director of Facilities, on 11/22/13 at 1:30 PM verified this finding.

Based on observation and staff interview, the facility does not ensure that the fire doors entering the extension clinic have a positive latching mechanism. (Horseheads)

Findings include:

On 11/20/13 at 12:30 PM, it was observed that the fire doors entering the clinic area did not provide a positive latching mechanism. It was noted that these doors are located in a one-hour fire rated wall. Further observation of these doors revealed that the door on the south side of the assembly was a ? hour door and the door on the north side of the assembly was a 1 ? hour door.

Interview with Staff #63, Facilities/Maintenance, and Staff #5, Risk Management System Coordinator, verified this finding on 11/20/13 at 1:30 PM. (Horseheads)

Based on document review, the facility does not ensure that battery operated emergency lighting is tested monthly for 10 of 10 operating rooms and annually for 10 of 10 operating rooms and 3 of 3 catheterization (cath) labs. (AOMC)

Findings include:

Review of the Emergency Lighting log on 11/21/13 revealed that the required battery operated emergency lighting is not tested monthly. Review of this log indicated that monthly testing was not performed for the following:

-Operating rooms #1-8 were not tested during February, June and September 2013.
-Operating rooms #A and B were not tested during January and October 2013.
-Cath labs #A, B and C were not tested during February, May and August 2013.

Review of the Emergency Lighting log on 11/21/13 does not provide documentation verifying that the required battery emergency lighting is tested annually for 90 minutes.

This 30 second testing must be performed monthly to ensure that immediate illumination is provided in these areas during the 10 second delay between the loss of normal power and the activation of emergency power. An annual 90 minute testing must be performed to ensure that continuous illumination is provided in the event of emergency power failure or in the event of an internal failure.

Based on document review and staff interview, the facility does not ensure that one fire drill/shift/quarter is performed at the extension clinic (Horseheads) or that documented fire drills include the scenario, an evaluation, drill critique, staff participation and any follow-up activity that is performed. (AOMC and Horseheads)

Findings include:

Interview with Staff #64, Director of Emergency Preparedness and Security, on 11/20/13 revealed that the facility only conducts one fire drill/year. (Horseheads)

Review of the Fire Drill Reports on 11/22/13 at 9:00 AM with Staff #11, Supervisor of Safety and Security, verified that only one fire drill is conducted each year at the approved extension clinics. Review of this document indicated that a fire drill had been conducted on 03/20/13 and 07/12/12. (Horseheads)

Review of the Fire Drill Reports on 11/22/13 at 9:00 AM also revealed that the scenario, evaluation, drill critique, staff participation and follow-up activities were not indicated on the documented drills performed at the hospital or extension clinic.

This finding was verified by Staff #5, Risk Management System Coordinator, and Staff #9 on 11/22/13 at 9:30 AM.

Based on document review and staff interview, the facility does not ensure that annual inspection of the fire alarm system, sensitivity testing of the photo smoke detectors or that all components that comprise the system are tested annually. (Horseheads)

Findings include:

Review of the fire alarm inspection report for 2012 on 11/20/13 revealed that the fire alarm system is not inspected annually. It was noted that the fire alarm system was inspected on 12/10/2012 and prior to this date, the fire alarm system was last inspected on 09/16/2009.

Review of the fire alarm inspection report for 2012 does not indicate that all the components that compile the fire alarm system are tested annually. Review of these reports does not indicate that the notification devices, audio and audio/visual devices, are tested. The report dated 12/10/2012 indicates that these devices " WERE NOT TESTED/SOUNDED PER REQUEST OF CUSTOMER " .

Review of the fire inspection reports does not indicate that sensitivity testing has been performed on the photo smoke detectors or the last time sensitivity testing had been performed. Sensitivity testing must be performed within one year after installation of the device and every alternate year thereafter. After the second required testing, if the device sensitivity remains within the manufacturer recommendations for sensitivity, the time between testing may be extended to a maximum of five years.

Interview with Staff #63, Facilities (Horseheads) on 11/20/13 at 12:00 PM verified this finding.

Based on document review and staff interview, the facility does not ensure that the sprinkler system is maintained in a reliable operating condition. (Horseheads)

Findings include:

Review of 3 of 3 sprinkler reports from 2013, dated 01/25/13, 04/12/13 and 07/26/13 on 11/20/13 at 11:00 AM indicated that a five-year internal inspection of the sprinkler piping is required. Review of these documents did not indicate when the previous five-year inspection had been performed.

This inspection is required to ensure that obstructions/debris are not present in sprinkler piping that would interfere with the water flow in the event of an emergency.

Interview with Staff #63, Facilities/Maintenance, on 11/20/13 at 11:30 AM verified this finding.

Based on observation and staff interview, the facility does not ensure that the heating, cooling, ventilation and air-conditioning (HVAC) systems are maintained. (AOMC and Horseheads)

Findings include:

During the facility tour on 11/21/13 and 11/22/13, it was observed that the mechanical exhaust in the utility environmental services closet (room E115), the electrical closet (room E118) and in the dirty side of the endoscopy reprocessing room was not operational. It was also observed that supply air on the clean side of the reprocessed endoscope room was not operational. (AOMC)

Interview with Staff #6 on 11/21/13 at 3:15 PM indicated that mechanical exhaust was provided in Room E115 and E118 but was inadequate.

Interview with Staff #63 on 11/20/13 at 12:00 PM revealed that documentation for HVAC maintenance and repair for the Horseheads clinic is maintained by the staff at AOMC.

Interview with Staff #6 on 11/21/13 at 3:00 PM indicated that the facility is not able to provide documentation regarding the maintenance and repairs of the HVAC system.

Based on document review and staff interview, the facility does not ensure that the medical gas system is maintained or that vacuum outlets are present in the Electrophysiology Lab.

Findings include:

Review of the 2013 ANNUAL VERIFICATION report for the medical gas system indicated that multiple deficiencies were identified during the January 2013 inspection. Review of this report indicated the following:

-In Operating Room #1, three vacuum outlets leaked;
-In Operating Room #2, two vacuum outlets were obstructed, one vacuum outlet leaked and one vacuum outlet had low pressure;
-In Operating Room #3, three vacuum outlets leaked, one vacuum outlet was broken and two vacuum outlets had low pressure;
-In Operating Room #4, the pressure for the NO2 and CO2 was low and two vacuum outlets leaked;
-In Operating Room #5, outlet #723-0 for oxygen did not have any pressure, the incorrect color hose was present on the medical air and eight vacuum outlets leaked;
-In Operating Room #7, one vacuum outlet was broken and two vacuum outlets leaked;
-The medical air report for the Same Day Surgery Center on 3E noted that there was a slight odor in all the medical air outlets. This report does not indicate that the source of the odor was identified;
-In Emergency Rooms 3-6 the report indicates that the Nitrous Oxide is not in use but documentation is not provided to verify that the line has been capped or properly sealed;
-In the ICU on 2nd floor the report indicates that the oxygen outlet leaks;
-In Xray room #3 the vacuum leaks;
-In NICU Pod #3, the medical air leaks;
-On the 4th floor, the flow meter on the oxygen outlet is stuck for room 4C-10.

Review of the 2013 ANNUAL VERIFICATION report for the medical gas system did not indicate that vacuum outlets were present in the Electrophysiology Lab (EP). Review of this report indicates that only Oxygen and Medical Air are present in this lab.

Review of the requirements for medical gas outlets in the EP Lab indicates that two outlets of vacuum are required.

Interview with Staff #6, Director of Facilities, on 11/22/13 at 12:45 PM verified this finding.


Based on observation and staff interview, the facility does not ensure that the piped medical gases, Oxygen and Medical Air, are utilized for patient use only. (AOMC)

Findings include:

During the facility tour of the endoscopy reprocessing area on 11/22/13 at 12:00 PM, it was observed that an oxygen outlet was present on the clean side of the reprocessing area.

Interview with Staff #62, Assistant Director of Surgical Services, on 11/22/13 at 12:15 PM indicated that this outlet is utilized to " blowout " the scopes after the endoscopes have completed the reprocessing procedure and alcohol has been purged through the scope. This interview also indicated that this gas is utilized to enhance the scope drying process prior to the scopes being stored.

Based on document review and staff interview, the facility does not maintain documentation to indicate the daily humidity and temperature for 10 of 10 operating rooms. (AOMC)

Findings include:

Review of the provided documentation on 11/19/13 at 10:00 AM, noted that documentation was not provided to verify that the humidity and temperature readings in the operating rooms were within the acceptable parameters.

Interview with Staff #6 on 11/21/13 at 1:30 PM revealed that the documentation to verify the daily humidity and temperature readings of the operating rooms could not be provided.

Based on observation, document review and staff interview, the facility does not ensure that the smoke and fire dampers are tested. (AOMC and Horseheads)

Findings include:

During the facility tour on 11/20/13 and 11/21/13, it was observed that fire dampers and smoke dampers are present in the one-hour fire/smoke rated walls.

Review of the provided documentation on 11/22/13 at 10:00 AM did not indicate that these devices had been inspected or tested.

Interview with Staff # 6, Director of Facilities, on 11/22/13 at 10:30 AM revealed that the facility does not have documentation to verify the last time the devices were tested or that the devices have been tested within the past six years. This interview also revealed that the facility is currently in the process of locating and identifying these devices so that testing can be performed to ensure their proper operation.

Without the results of an inspection, it is not possible to determine if adequate separation and smoke compartments are provided on each of the patient floors.

Based on document review and staff interview, the facility does not ensure adequate warning of the medical gas systems to the master and area alarms panels. (AOMC)

Findings include:

Review of the 2013 ANNUAL VERIFICATION report for the medical gas system indicated that multiple deficiencies were identified during the January 2013 inspection. Review of this report indicates the following:

On the Master Alarms:

-A high/low pressure switch was not present on the Nitrous Oxide manifold.
-A high/low pressure switch was not present on the Medical Air compressor.
-A high/low pressure switch was not present on the Carbon Dioxide manifold and there was not an alarm for when changeover had occurred and Carbon Dioxide gas was being provided on the reserve system.
-The carbon monoxide monitor required calibration.
-There was not a monitor for the dew point level for the Medical Air.

On the area alarms:

-The alarms were not labeled for the areas they served outside of Room 3E17 and outside of trauma room 1&2 and 5&6.
-The alarm for Emergency Room #11, 17 and 18 was not functional.

Review of this report does not indicate that corrective action has been performed on any of the deficient areas that are identified in the report.

Interview with Staff #6, Director of Facilities, on 11/22/13 at 1:30 PM verified this finding.