HospitalInspections.org

Based on observation and staff interview, the facility failed to maintain construction, protection, and occupancy features necessary to minimize danger to life from smoke, fumes, fire, or panic should a fire or similar emergency occur. The facility failed to meet the requirements of NFPA 101 - 2000 edition chapter 19.7.5.5, "The soiled linen or trash collection receptacle shall not exceed 32 gallons incapacity and shall meet the following requirements: (1) The average density of container capacity in a room or space shall not exceed 0.5 gallons per square foot (2) A capacity of 32 gallons shall not be exceeded within any 64 ft.² area (3) Mobile soiled linen or trash collection receptacles with capacities greater than 32 gallons shall be located in a room protected as a hazardous area when not attended (4) Container size and density shall not be limited in hazardous areas."

Findings include:

During the tour of the building, at approximately 11:45 a.m. on the 5th floor tower, a collection of paper shredders was observed in the nurses' station. Each shredder exceeded the 32 gallon capacity limit. Inquiry revealed that the company located the shredders for convenience and for the large amount of paper that is processed.

At approximately 1:45 p.m. in the new tower Radiology area, large trash receptacles, soiled linen recycling and sharps containers were observed to be assembled in close proximity and in excess of the 32 gallon limit per 64 sq. ft.

Note: Several instances of concentrations of soiled linen and trash were observed throughout the building. Staff revealed that it is a management and educational issue with the staff.

These findings were reconfirmed with the administrator during the exit interview at 4:45 p.m.

Based on observations and testing and interviews during the tour of the building, the facility failed to comply with the standards established by NFPA 101 (2000) Chapter 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99." Per NFPA 99 Chapter 4-3.5.2.1(a) "Administrative authorities shall provide regulations to ensure the standards for safe practice in the specifications for cylinders ...." Under A-4-3.5.2.1(b) 16 Special Precautions-Oxygen Cylinders and Manifolds, it is specified that "Valves shall be closed on all empty cylinders." Additionally, per Chapter 9.7.2.3 "Cylinders shall be protected from damage" and under (11) "Freestanding cylinders shall be properly chained or supported ...."

Findings include:

During the tour of the exterior of the building at approximately 11:15 a.m., the area that contained cylinders of compressed gas was entered. Cylinders in storage were observed and the valves were tested. Several oxygen valves were observed to have the valves open and unsecured. This condition would allow contaminants to enter the cylinders through the open valve. Also in the cylinder storage area, cylinders were observed to be unsecured by chains or in racks.

These findings were reconfirmed with the administrator during the exit interview at 4:45 p.m.