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Based on observation and interview, the facility failed to maintain the mean of egress. This was evidenced by items that projected out more than 4 inches into the egress corridor that did not meet the American with Disabilities Act (ADA) standards. This affected 3 of 3 smoke compartments in the Basement and could result in a delay in evacuation.

Federal Register / Vol. 81, No. 86 / Wednesday, May 4, 2016 / Rules and Regulations
Health care facilities must comply with the requirements of the Americans with Disabilities Act (ADA) 2010 Standards for Accessible Design:
307 Protruding Objects
307.1 General. Protruding objects shall comply with 307.
307.2 Protrusion Limits. Objects with leading edges more than 27 inches (685 mm) and not more than 80 inches (2030 mm) above the finish floor or ground shall protrude 4 inches (100 mm) maximum horizontally into the circulation path.
EXCEPTION: Handrails shall be permitted to protrude 4½ inches (115 mm) maximum

Findings:

During a facility tour and interview on 2/28/20 with the Director of Plant Operations, and the Quality Abstract of Clinical Operations, the mean of egress was observed.

1. At 8:08 a.m., the corridor by the Equipment room was observed with a patient transport backboard with a blue head immobilizer block. The blue head immobilizer block was projected out into the corridor at approximately 6 ½ inches horizontally. Upon interview, the Director of Plant Operations, and the Quality Abstract of Clinical Operations confirmed the finding.

2. At 8:11 a.m., the adjacent corridor by the Morgue was observed with a patient transport backboard with a clear head immobilizer block. The clear head immobilizer block was projected out into the corridor at approximately 6 ½ inches horizontally. Upon interview, the Director of Plant Operations and the Quality Abstract of Clinical Operations confirmed the finding.

3. At 8:28 a.m., the corridor by operation room 4 was observed with a patient transport backboard with a head immobilizer block. The head immobilizer block was projected out into the corridor at approximately 6 ½ inches horizontally. Upon interview, the Director of Plant Operations and the Quality Abstract of Clinical Operations confirmed the finding.

Based on record review and interview, the facility failed to maintain the anesthetizing locations. This was evidenced by the failure to follow the relative humidity (RH) policy and procedure (P&P). This affected the basement operating rooms (OR) and the third floor OR. This could result in a failure to reduce fire hazards.

Findings:

During record review and interview on 2/28/20 with the Director of Plant Operations, Chief Quality Officer, Chief Nursing Officer, and the Clinical Nurse Surgery Manager, the RH logs were requested and reviewed.

At 9:16 a.m., the policy titled, "Environmental Control Monitoring" approved on 2/26/20 indicated the "Relative humidity should be maintained between 30%-60%." The procedure indicated "In the event that the temperature or humidity falls out of range, Plant Operations is to be notified immediately, a work order is to be created and the work order number is to be recorded on the log by the person reporting the event."

The document titled, "Daily Humidity/Temperature Logs" indicated no work order numbers where generated when the RH were out of range for the following ORs:

Basement Operating Room 3 on 10/11/19 indicated the RH was out of range and a work order number was not generated. A hand written note indicated "supervisor notified."

Basement Operating Room 4 on 10/11/19 indicated the RH was out of range and a work order number was not generated. A hand written note indicated "supervisor notified." The RH on 1/10/20 indicated it was out of range and a work order number was not generated.

Basement Operating Room 5 on 10/11/19 indicated the RH was out of range and a work order number was not generated. A hand written note indicated "supervisor notified."

Basement Operating Room 6 on 10/11/19 indicated the RH was out of range and a work order number was not generated. A hand written note indicated "supervisor notified." The RH on 8/24/19 failed to indicated the problem and a hand written note indicated "Manager/Phone."

Basement Operating Room 7 on 10/11/19 indicated the RH was out of range and a work order number was not generated. A hand written note indicated "supervisor notified."

Third floor Labor and Delivery Operating Room 2 on 10/22/19 and 10/23/19 indicated the RH were out of range and work order numbers were not generated for those two days. No work order number was generator on 11/3/19 when the RH was out of range.

Upon interview, the Clinical Nurse Surgery Manager stated that the staff will usually write and notify Plant Operations, but she was not sure what happened with those dates.

Based on observation and interview, the facility failed to maintain the portable fire extinguishers. This was evidenced by one fire extinguisher that was obstructed from access. This affected 1 of 3 smoke compartments in the Basement and could result in a delay in extinguishing a fire.

NFPA 101 - Life Safety Code, 2012 Edition
19.3.5.12 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.
9.7.4 Manual Extinguishing Equipment.
9.7.4.1 * Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10 - Standard for Portable Fire Extinguishers, 2010 Edition
7.2 Inspection.
7.2.1 Frequency
7.2.1.2 * Fire extinguishers shall be inspected either manually or by means of an electronic monitoring device/system at a minimum of 30-day intervals.
7.2.2 Procedures. Periodic inspection or electronic monitoring of fire extinguishers shall include a check of at least the following items:
(1) Location in designated place
(2) No obstruction to access or visibility
(3) Pressure gauge reading or indicator in the operable range or position
(4) Fullness determined by weighing or hefting for self-expelling-type extinguishers, cartridge-operated extinguishers, and pump tanks
(5) Condition of tires, wheels, carriage, hose, and nozzle for wheeled extinguishers
(6) Indicator for non-rechargeable extinguishers using push-to-test pressure indicators

Findings:

During a facility tour and interview on 2/27/20 with the Director of Plant Operations, and the Clinical Nurse Surgery Manager, the portable fire extinguishers were observed.

At 4:02 p.m., in Operating Room 3, the portable fire extinguisher was obstructed by a mobile monitor cart and an Olympus electro cauterization unit. Upon interview, the Director of Plant Operations stated that the staff just turned the room over and moved the equipment. The Clinical Nurse Surgery Manager stated that the equipment was just moved.

Based on record review and interview, the facility failed to maintain the written evacuation plan. This was evidenced by evacuation equipment that were not stored in the designated location. This affected 3 of 3 smoke compartments in the Basement and could result in a delayed in response in the event of an emergency.

Findings:

During record review and interview on 2/27/20 with the Emergency Preparedness Coordinator, the evacuation plan was requested and reviewed.

At 3:47 p.m., the document titled, "Evacuation Plan" indicated 10 med-sleds were located and stored in the GI Suite storage room. The facility was observed with no GI Suite storage room. Upon interview, the Emergency Preparedness Coordinator stated that when the facility was writing the evacuation plan that they were planning on having a storage room for it.

Based on observation and interview, the facility failed to maintain the combustible decorations. This was evidenced by two patient transport backboards that were covered with combustible material. This affected the 3 of 3 smoke compartments and could result in a failure to reduce fire hazards.

Findings:

During facility tour and interview on 2/28/20 with the Director of Plant Operations, and the Quality Abstract of Clinical Operations, combustible decorations were observed.

1. At 8:08 a.m., the corridor by the Equipment room was observed with a patient transport backboard that was hanging on the corridor wall and was covered with plastic shrink wrap. Upon interview, the Director of Plant Operations and the Quality Abstract of Clinical Operations confirmed the finding.

2. At 8:11 a.m., the adjacent corridor by the Morgue was observed with a patient transport backboard that was hanging on the corridor wall and was covered with plastic shrink wrap. Upon interview, he Director of Plant Operations, and the Quality Abstract of Clinical Operations confirmed the finding.

3. At 8:28 a.m., the corridor by operation room 4 was observed with a patient transport backboard that was hanging on the corridor wall and was covered with plastic shrink wrap. Upon interview, he Director of Plant Operations, and the Quality Abstract of Clinical Operations confirmed the finding.