HospitalInspections.org

Based on observations as referenced in the Life Safety Report of Survey completed March 16, 2011, the hospital's Governing Body failed to have oversight and have systems in place to ensure a safe environment for patients, staff, and visitors.

The findings include:

The hospital staff failed to develop and maintain the facilities in a manner to ensure the health and safety of patients, staff, and visitors.

~cross refer to 482.41 Physical Environment Condition: Tag A0700

Based on policy review, medical record review, and staff interview the hospital staff failed to ensure orders for the use of restraint and/or seclusion were not written as a standing order or on an as needed basis (PRN) for 1 of 2 patients sampled requiring restraint and/or seclusion for the management of violent and self-destructive behaviors (#17).

The findings include:

Review of current hospital policy "Restrictive Interventions," Reviewed/Revised: 02/11, revealed the policy does not address the use of PRN orders for restraint and/or seclusion.

Closed emergency department (ED) record review on 03/16/2011 for Patient #17 revealed a 26 year old female who presented to the hospital's ED on 12/02/2010 at 1820 with a chief complaint of "Was Violent at CRC (a facility) - is IVC (involuntary commitment) for suicidal". Record review revealed the patient was subsequently transferred to an acute care psychiatric hospital on 12/03/2010 at 0745 with a diagnosis of Schizophrenia and mild dilantin toxicity. Review of an ED Flowsheet (containing physician treatment orders) dated 12/02/2010 revealed a written physician's order for "Restrain if needed" (not dated or timed).

Interview on 03/16/2011 at 1040 with ED nursing management staff revealed orders for the use of restraint and seclusion should never be written as a standing order or PRN (as needed). Interview revealed physician orders are written on the ED Flowsheet. Interview confirmed the ED physician ordered "Restrain if needed" on the ED Flowsheet dated 12/02/2010. Interview confirmed the ED physician wrote a PRN order for the use of restraints and/or seclusion for Patient #17 during her visit to the ED on 12/02/2010 thru 12/03/2010.

Based on hospital policy review, medical record review, and staff interview, the hospital staff failed to ensure a time limited restraint order was obtained for 1 of 2 sampled patients who were restrained for the management of violent or self-destructive behaviors (#18).

The findings include:

Review of current hospital policy "Restrictive Interventions," Reviewed/Revised: 02/11, revealed, "...H. Violent/Self-destructive Restraint Orders....5. Each written order is limited to four hours for adults, two hours for children and adolescents age 9-17, and one hour four patients under nine years of age. ..."

Closed emergency department (ED) record review on 03/16/2011 for Patient #18 revealed a 63 year old female who presented to the hospital's ED on 12/29/2010 at 1914 with a chief complaint of "Suicide attempt". Record review revealed the patient subsequently transferred to an acute care hospital with psychiatric services on 12/30/2010 at 2040. Review of an Emergency Department (ED) Flowsheet dated 12/29/2010 (containing physician treatment orders) revealed a physician's order for "soft restraints" was written at 2035 by the ED physician. Review revealed the order for restraint was not time limited. Review of electronic restrictive intervention nursing documentation revealed the patient was placed into restraint on 12/29/2010 at 2038 for "Attempting self harm, Biting, Combative, Hostile, Non-complaint with instruction, Pulling on restraint, Repeated calling out, Self harming, Threatening, Yelling" and was released from restraint at 2107 (29 minutes later). Record review revealed no available documentation of a time limited order (4 hours for adults 18 years and older) for the use of the restraints on 12/29/2010 at 2035 for Patient #18.

Interview on 03/16/2011 at 1040 with ED nursing management staff revealed all orders for the use of restraints and seclusion for the management of violent and self-destructive behaviors are to be time limited according to age. Interview revealed the Violent Restrictive Intervention (RI) Order form contains preprinted time limits based on age and is used to document the restraint orders for the management of violent and self-destructive behaviors. Interview revealed orders for the restraint of adults 18 years and older should be time limited to 4 hours. Interview revealed the ED physician wrote the restraint order on 12/29/2010 at 2035 on the ED Flowsheet and not the Violent RI Order form. Interview confirmed the physician did not indicate a time limit for the use of restraint that was initiated on 12/29/2010 at 2038 by nursing staff. Interview revealed the physician should have used the Violent RI Order form that contains the pre-printed time limits. Interview revealed the hospital staff failed to follow the hospital's restrictive intervention policy.

Based on policy review, medical record review, and staff interview the hospital's nursing staff failed to monitor a restrained patient per hospital policy for 1 of 2 sampled patients who were restrained for the management of violent and self-destructive behaviors (#18).

The findings include:

Review of current hospital policy "Restrictive Interventions," Reviewed/Revised: 02/11, revealed, "...G. Assessment/monitoring/patient care: violent self destructive restrictive intervention utilization 1. Assess and document at initiation and every 15 minutes: a. Respiratory quality and/or rate b. Restrictive intervention device in use c. Readiness for discontinuation of restraint/seclusion d. Safety and circulation adequate e. Less restrictive methods or alternatives f. Meets criteria to continue restrictive interventions..."

Closed emergency department (ED) record review on 03/16/2011 for Patient #18 revealed a 63 year old female who presented to the hospital's DED on 12/29/2010 at 1914 with a chief complaint of "Suicide attempt". Record review revealed the patient was subsequently transferred to an acute care hospital with psychiatric services on 12/30/2010 at 2040. Review of a "Violent Restrictive Intervention Order" form dated 12/29/2010 at 1938 revealed a physician's order for the use of restraint for "[X] Severely aggressive, violent or destructive behavior, immediate, serious danger to patient and others; requires rapid assessment and continuous monitoring." Review of electronic restrictive intervention nursing documentation revealed the patient was placed in restraint on 12/29/2010 at 1947 and was released from restraint at 2033 (46 minutes later) due to "effects of ordered/administered Haldol allows pt (patient) to rest. Restraints untied. No change in assessment other that now not combative because she is sleeping. Until removed." Review of an ED Flowsheet (containing physician treatment orders) revealed a physician's order for "soft restraints" was written at 2035 by the DED physician. Review of electronic restrictive intervention nursing documentation revealed the patient was placed back into restraint on 12/29/2010 at 2038 for "Attempting self harm, Biting, Combative, Hostile, Non-complaint with instruction, Pulling on restraint, Repeated calling out, Self harming, Threatening, Yelling" and was released from restraint at 2107 (29 minutes later). Review of electronic restrictive intervention nursing documentation from 1947 to 2107 (80 minutes) revealed no documentation Patient #18 was monitored every 15 minutes while restrained as required by hospital policy.

Interview on 03/16/2011 at 1040 with ED nursing management staff revealed the nursing staff are to monitor patients while in restraint for the management of violent and self-destructive behaviors every 15 minutes and document the required elements of the monitoring in the electronic medical record. Interview confirmed there was no available documentation that nursing staff monitored Patient #18 every 15 minutes while she was restrained on 12/29/2010, as required by hospital policy.

Based on hospital policy review, medical record review, and staff interview the physician or other licensed independent practitioner conducting the face-to-face evaluation within 1 hour after the initiation of restraint and/or seclusion failed to evaluate one or more of the following required elements: the patient's immediate situation; the patient's reaction to the intervention; the patient's medical and behavioral condition; and the need to continue or terminate the restraint for 2 of 2 sampled patients restrained and/or secluded for the management of violent or self-destructive behaviors (#18, #17).

The findings include:

Review of current hospital policy "Restrictive Interventions," Reviewed/Revised: 02/11, revealed, "...H. Violent/Self-destructive Restraint Orders....4. The face to face evaluation of the patient includes the patient's immediate situation, patient's reaction to the intervention, the patient's medical and behavioral condition, and the need to continue or terminate the restraint or seclusion...."

1. Closed emergency department (ED) record review on 03/16/2011 for Patient #18 revealed a 63 year old female who presented to the hospital's DED on 12/29/2010 at 1914 with a chief complaint of "Suicide attempt". Record review the patient was subsequently transferred to an acute care hospital with psychiatric services on 12/30/2010 at 2040. Review of a "Violent Restrictive Intervention (RI) Order" form dated 12/29/2010 at 1938 revealed a physician's order for the use of restraint for "[X marked in a box] Severely aggressive, violent or destructive behavior, immediate, serious danger to patient and others; requires rapid assessment and continuous monitoring." Review of electronic restrictive intervention nursing documentation revealed the patient was placed into restraint on 12/29/2010 at 1947 and was released from restraint at 2033 (46 minutes later). Review of the Violent RI order form revealed documentation the physician was present at 1935 (before the restraint) and signed the orders at 1938 (before the restraint was applied at 1947). Further record review revealed a physician's order at 2035 for "soft restraints". Review of electronic restrictive intervention nursing documentation revealed the patient was placed back into restraint at 2038 and was released from restraint at 2107 (29 minutes later). Review of the Violent RI Order form signed by the physician at 1938 revealed, "MD (physician) Assessment: Pt (patient) violent and attempting to hurt the staff. Restraints used to protect the staff and the patient." Record review revealed no documentation the physician conducted a face-to-face evaluation of the patient within one hour of the initiation of restraints at 1947 or at 2038.

Interview on 03/16/2011 at 1040 with ED nursing management staff revealed the nursing staff does not conduct the one hour face-to-face evaluation in the emergency department for patients who have been restrained and/or secluded for the management of violent or self-destructive behaviors. Interview revealed the ED physician conducts the evaluation. Interview revealed the physicians document the findings of the one hour face-to-face-evaluation on the Violent RI Order form under the section "MD Assessment." Interview confirmed there was no available documentation in the medical record the ED physician assessed all of the required elements to include the patient's immediate situation; reaction to the intervention; medical and behavioral condition; and the need to continue or terminate the restraint within one hour of the restraint that was initiated on 12/29/2010 at 1947 or at 2038. Further interview confirmed the one hour face-to-face evaluation was conducted at 1938 (9 minutes before the patient was placed into restraint at 1947) not after the initiation of the restraint.

2. Closed emergency department (ED) record review on 03/16/2011 for Patient #17 revealed a 26 year old female who presented to the hospital's DED on 12/02/2010 at 1820 with a chief complaint of "Was Violent at CRC (a facility) - is IVC (involuntary commitment) for suicidal". Record review revealed the patient was subsequently transferred to an acute care psychiatric hospital on 12/03/2010 at 0745 with a diagnosis of Schizophrenia and mild dilantin toxicity. Review of a "Violent Restrictive Intervention (RI) Order" form dated 12/03/2010 at 0335 revealed a physician's order for the use of "[X marked in a box] Door Closed (seclusion) Room 10" for "[X marked in a box] Severely aggressive, violent or destructive behavior, immediate, serious danger to patient and others; requires rapid assessment and continuous monitoring." Review of restrictive intervention nursing documentation revealed the patient was placed into seclusion on 12/03/2010 at 0335 and was released from seclusion at 0435 (60 minutes later). Review of the Violent RI Order form signed by the ED physician at 0335 revealed "MD Assessment: Pt (patient) c (with) IVC, tried to escape." Further record review revealed no documentation the ED physician assessed all of the required elements of a one hour face-to-face evaluation, including: the patient's immediate situation; reaction to the intervention; medical and behavioral condition; and the need to continue or terminate the restraint.

Interview on 03/16/2011 at 1040 with ED nursing management staff revealed the nursing staff does not conduct the one hour face-to-face evaluation in the emergency department for patients who have been restrained and/or secluded for the management of violent or self-destructive behaviors. Interview revealed the ED physician conducts the evaluation. Interview revealed the physicians document the findings of the one hour face-to-face-evaluation on the Violent RI Order form under the section "MD Assessment." Interview confirmed there was no available documentation the ED physician assessed all of the required elements of a one hour face-to-face evaluation, including: the patient's immediate situation; reaction to the intervention; medical and behavioral condition; and the need to continue or terminate the restraint for the seclusion initiated on 12/03/2010 at 0335.

Based on review of medical staff bylaws, credentialing file reviews, and staff and physician interviews, the hospital's medical staff failed to evaluate the competencies for privileges granted at the time of reappointment for 3 of 7 sampled Allied Health Practitioners (AHP #1, AHP #2, and AHP #3).

The findings include:

Review of Medical Staff Bylaws, approved January 26, 2010 and updated August 24, 2010, revealed, "Article V Allied Health Professionals ... 5.1.3 The Physician employer shall develop, with the assistance of the Credentials Committee, a job description for the following practitioners....The job description shall include, without limitation, the scope or services or procedures for each category of AHPs and shall be limited solely to the permitted scope of practice of the particular AHP:....(b) Physician Assistants;... (e) Operating Room Technicians/Assistants employed by a Member of the Medical Staff; and (f) Nurse midwives....5.1.5 Procedures for Specification of Services.... Annual assessments in the performance of the AHP shall be done by the appropriate nurse manager of the Hospital and the AHP's Physician-employer....5.1.6....Specific privileges for AHPs must be requested and authorized in the same manner as Privileges are granted to Physician Members pursuant to Article VI of these Bylaws....5.1.7 Responsibilities (a) Each AHP who is approved to work with a Medical Staff Member shall have the following responsibilities:....(3) Participate as appropriate in the patient-care audit and other quality review, evaluation and monitoring activities required of the Medical Staff during the observed period, and in discharging such Medical Staff functions as may be required from time to time;...Article VI Clinical Privileges 6.1....a Member providing clinical services at this Hospital shall be entitled to exercise only those Clinical Privileges specifically granted. Such Privileges and services must be Hospital specific, within the scope of any license, certificate or other legal credential authorizing practice in this state....Each applicant has the burden of establishing qualifications and current competence for all Clinical Privileges requested....6.2.2...Requests for Clinical Privileges shall be evaluated on the basis of...(b) the applicant's current demonstrated professional competence and judgment, (c) the applicant's clinical performance of privileges...."

1. Review on 03/17/2011 of AHP #1's credentialing file revealed the staff member was a Certified Ophthalmic Technician (COT) with a letter of recommendation for reappointment from AHP #1's supervising physician dated 08/29/2010. Further review of the file revealed a list of privileges (not dated) for "Private Scrub Assistant" that included "close subcutaneous (tissue) and skin only." Review of the file revealed "Basic Skills Checklist for Private Scrub Assistant" that included pre-printed functions that could be performed "competently." Review of the list of functions included "close subcutaneous and skin only." Review of the list revealed no check mark (blank) beside "close subcutaneous and skin only" indicating no competency with closing subcutaneous tissue and skin. Further review revealed the form was signed by AHP #1 and her sponsoring physician. Review revealed no date on the form. Review of AHP #1's file revealed no further evaluation of competencies or job description present in the file. Review of Medical Executive Meeting Minutes dated 09/21/2010 revealed AHP #1 was presented and recommended for reappointment to the medical staff. Review of Committee Trustee Council Executive Committee (Board) Meeting Minutes dated 09/29/2010 revealed AHP #1 was approved for reappointment with requested privileges granted.

Interview on 03/17/2011 at 1320 with a medical staff credentialing staff member confirmed AHP #1 was reappointed with privileges granted on 09/29/2010 that included "close subcutaneous and skin only." Interview revealed there was no evidence of evaluation of competencies for closing of subcutaneous tissue and skin. Interview further revealed there was no job description in the file for AHP #1.

Interview on 03/17/2011 at 1330 with the Chief Medical Officer revealed AHP #1 would not "close skin" during a surgical procedure since she worked with eye surgeons. Interview confirmed there was no evidence of competencies demonstrated for this approved privilege. Interview revealed the privilege to "close subcutaneous and skin only" should not have been granted to AHP #1.

2. Review on 03/17/2011 of AHP #2's credentialing file revealed the staff member was a Certified Physician Assistant (PAC) with a letter of recommendation for reappointment from AHP #2's supervising physician dated 08/24/2010. Further review of the file revealed a list of privileges for "Physician Assistant" that included "assist on surgical procedures consistent with demonstrated training and competencies." Review of the file revealed a "Recredentialing Assessment" form that was completed by AHP #2's supervising physician and dated 05/07/2010. Review of the form revealed a checkmark under "Meets Expectations" for the following "Categories: General Practice Knowledge/Expertise; Technical and Clinical Skills; Clinical Judgement; Use of Conferring Preceptor, if needed; Availability and Thoroughness in Patient Care; Relationships with Patients; Relationships with Peers; Relationships with Hospital Staff; Adherence to Hospital Policy and Procedure." Review of AHP #2's file revealed no further evaluation of competencies or job description present in the file. Review of Medical Executive Meeting Minutes dated 09/21/2010 revealed AHP #2 was presented and recommended for reappointment to the medical staff. Review of Committee Trustee Council Executive Committee (Board) Meeting Minutes dated 09/29/2010 revealed AHP #2 was approved for reappointment with requested privileges granted.

Interview on 03/17/2011 at 1320 with a medical staff credentialing staff member confirmed AHP #2 was reappointed with privileges granted on 09/29/2010 that included "assist on surgical procedures consistent with demonstrated training and competencies." The credentialing staff member was asked if AHP #2 was privileged to "close skin" during a surgical procedure. The staff member stated she was not sure what "assist on surgical procedures consistent with demonstrated training and competencies" meant and that she didn't think AHP #2 was closing skin. The staff member was unable to provide evidence of evaluation of competencies for "assist on surgical procedures consistent with demonstrated training and competencies." Interview further revealed there was no job description in the file for AHP #2.

Interview on 03/17/2011 at 1330 with the Chief Medical Officer revealed AHP #2 would not "close skin" during a surgical procedure. Interview confirmed there was no evidence of competencies demonstrated for the approved privilege to "assist on surgical procedures consistent with demonstrated training and competencies."



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3. Review on 03/17/2011 of AHP #3's credentialing file revealed the staff member was a Certified Surgical Technician (CST) with a letter of recommendation for reappointment from AHP #3's supervising physician dated 08/12/2009. Further review of the file revealed a list of privileges for "Private Scrub Assistant" that included "close subcutaneous (tissue) and skin only". Review of the file revealed a "Recredentialing Assessment" form that was completed by AHP #3's supervising physician and dated 05/07/2009. Review of the form revealed a checkmark under "Meets Expectations" for the following categories: "General Practice Knowledge/Expertise; Technical and Clinical Skills; Clinical Judgement; Use of Conferring Preceptor, if needed; Availability and Thoroughness in Patient Care; Relationships with Patients; Relationships with Peers; Relationships with Hospital Staff; Adherence to Hospital Policy and Procedure." Review of AHP #3's file revealed no further evaluation of competencies or job description present in the file. Review of Medical Executive Meeting Minutes dated 08/25/2009 revealed AHP #3 was presented and recommended for reappointment to the medical staff. Review of Committee Trustee Council Executive Committee (Board) Meeting Minutes dated 08/27/2009 revealed AHP #3 was approved for reappointment with requested privileges granted.

Interview on 03/17/2011 at 1550 with a medical staff credentialing staff member confirmed AHP #3 was reappointed with privileges granted on 08/27/2009 that included "close subcutaneous (tissue) and skin only". Interview revealed AHP #3 worked with a plastic surgeon at the hospital. Interview revealed the medical staff credentialing staff member was not sure if AHP #3 closed subcutaneous tissues and skin during procedures or not. Interview confirmed there was no documentation of an evaluation of competencies for closing of subcutaneous tissues and skin. Interview further confirmed there was no job description in the AHP #3's file.

Based on policy review, staff interview, hospital documentation review, and medical record review, the hospital's nursing staff failed to rotate the subcutaneous administration sites of Lovenox for for 2 of 4 sampled patients that received subcutaneous Lovenox (Patients #32 and #33).

Findings include:

The hospital policy for the administration of Lovenox was requested on 03/16/2011. No written policy was provided. Interview with a staff nurse on 3/16/2011 at 1330 revealed Lovenox injections should be rotated so that the same site was not repetitively used for each injection.

Review of a documentation provided by a hospital nurse manager revealed a copied page from the book "Clinical Nursing Skills" Chapter 18 "Medication Administration". Review of a section titled "Administering Subcutaneous (SUB Q) Injections" revealed the following procedure states: "5. Select site for injection (e.g., abdomen, avoiding 2 inch radius around umbilicus, alternating sites for each injection...."

1. Open record review on 3/16/2011 of patient #32 revealed an 82 year old female that was admitted to the hospital on 3/11/2011 with body aches and fever. Record review revealed a physician's order dated 3/11/2011 for the patient to have Lovenox 40 mg SQ (milligrams subcutaneously) every 24 hours. Record review revealed nursing staff administered Lovenox subcutaneously into the left lower quadrant of the patient's abdomen on 3/14/2011 and 3/15/2011 (same site two days in a row). Interview with the staff nurse on duty on 3/16/2011 at 1335 (during record review) revealed this was not appropriate procedure and the site should be rotated with each injection.

2. Open record review on 3/16/2011 of patient #33 revealed an 81 year old female that was admitted to the hospital 3/10/2011 with Fever, ?Sepsis and Respiratory Distress. Record review revealed a physician's order dated 3/10/2011 for the patient to have Lovenox 40 mg SQ (milligrams subcutaneously) every 24 hours. Record review revealed nursing staff administered Lovenox subcutaneously into the left lower quadrant of the patient's abdomen on 3/12/2011. Record review revealed no documentation of the injection site for the dose of Lovenox administered on 3/13/2011. Record review revealed nursing staff administered Lovenox subcutaneously into the right lower quadrant of the patient's abdomen on 3/14/2011 and 3/15/2011 (same site two days in a row). Interview with the staff nurse on duty on 3/16/2011 at 1340 (during record review) revealed this was not appropriate procedure and the site should be rotated with each injection.

Based on policy review, observation and staff interviews, the Hospital's dietary staff failed to ensure a clean and sanitary environment for the safe handling of food and equipment use in the dietary services area.

Findings include:

Review of hospital policies revised 6/09 revealed, "All food, non-food items and supplies used in food preparation shall be stored in such a manner as to maintain the safety and wholesomeness of the food for human consumption....Hang scoop. Scoops may be stored in bins on a scoop holder. The food level must be no closer than one-inch below the handle of the scoop....Morrison Orange Label... 1. Orange Label must be used on all foods that are: (a) prepared in kitchen (except Outtake items) (b) After opening any food packages (c) Defrosting food items. 2. You must write: Date, Product Name, Time (see below) Expiration date, your initials."

1. During the dietary tour on 3/16/2010 at 0915 it was noted that in the dry food storage area the floor was dirty, with ground in dirt and debris. A food prep sink drain and a drain where steam kettles drain into was dirty with old grease, dirt, and debris. A shelf, located under a vent hood over the steam kettle area, had containers of spices and herbs, some with opened lids. Some of the spices and herb containers were not dated when opened or with expiration dates. These containers were noted to be covered with a very greasy film. Observation of a reach-in cooler revealed Necktar Thick and Easy containers sitting in a puddle of what appeared to be spilled tea. In the reach-in cooler, 10 to 12 containers of Resource for Diabetics had an expiration date of 12/3/2010 (3 months before observation). Further observation during tour of the dietary department revealed a large container that was used to store dry food products, i.e. flour, did not have a cover that would seal the products while not in use. Observation revealed the sugar and rice container covers were cracked, preventing a tight seal. It was also noted that the scoop used to dip the sugar was laying in the sugar, with the handle touching the sugar, rather than being in the scoop holder on the side of the sugar container. Observation during tour of the dry food storage area revealed a container of French Fried Onions, a container of Chocolate, and a container on Honey were opened with no date to indicate when they were opened or when they would expire.

Based on observations as referenced in the Life Safety Report of Survey completed March 16, 2011, the hospital staff failed to develop and maintain the facilities in a manner to ensure the health and safety of patients, staff, and visitors.

The findings include:

1. The hospital failed to develop and maintain a safe physical plant and overall safe environment to assure the safety and well being of patients.

~cross-refer to 482.41(a) Physical Environment: Maintenance of Physical Plant - Standard Tag A0701.

2. The hospital failed to assure the safety of patients, staff, and visitors by failing to ensure the essential electrical system was maintained to provide emergency power and lighting to critical and appropriate areas of the hospital during outages of normal power.

~cross-refer to 482.41(a)(1) Physical Environment: Emergency Power and Lighting - Standard Tag A0702.

3. The hospital failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association to assure the safety and well being of patients.

~cross-refer to 482.41(b) Physical Environment: Life Safety from Fire - Standard Tag A0709.

4. The hospital failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association.

~cross-refer to 482.41(b)(1)(2)(3) Physical Environment: Life Safety from Fire - Standard Tag A0710.

Based on observations as referenced in the Life Safety Report of Survey completed March 16, 2011, the hospital failed to develop and maintain a safe physical plant and overall safe environment to assure the safety and well being of patients.

The findings include:

Building 01:
1. Based on Life Safety Surveyor observation, on March 16, 2011 at 8:00 a.m. onward, the following was non-compliant:
a. The smoke duct detector located in in air handler unit #5 in mechanical room #1 was not clean and maintained in good condition.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 054.

2. Based on Life Safety Surveyor observation, on March 15, 2011 at approximately 1:00 p.m. onward, the mechanical systems are noncompliant due to the following:
a. Lack of service access opening for verification of fire damper installations or other means of maintaining rated enclosure of duct penetration of central service storage room - located on ground floor.
b. Air handling unit #13, and #16 does not have a manual shut-down switch at a supervised station (Sutton Building).

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 067.

3. Based on Life Safety Surveyor observation, on March 15, 2011 at approximately 1:00 p.m. onward, medical gas systems are noncompliant due to the following:
a. The oxygen manifold system contains cylinders that are not secured individually and protected from extremes of weather - the cylinders are exposed to direct sun and drifting precipitation.
b. Empty and full oxygen cylinders are stored in the same rack - located in third floor CCU soiled utility room. Cylinders must not be stored in soiled utility rooms.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 076.

4. Based on Life Safety Surveyor observation, on March 15, 2011 at approximately 1:00 p.m. onward, the required electrical systems were incomplete due to the following:
a. Broken lense on wet location rated fixture - exit discharge light serving stair #2.
b. Circuit directory for Life Safety Branch panelboard serving fourth floor is not labeled to indicate devices served.
c. Unit heater serving sprinkler riser room is wired to the normal power distribution system - located in outpatient pavilion.
d. Circuit #16 in the Life Safety Branch panelboard serves the nurse call system - nurse call system is not permitted to be wired to the Life Safety Branch system.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 147.

5. Based on Life Safety Surveyor observation, on March 15, 2011 at approximately 1:00 p.m. onward, dumbwaiter area at ground level has gaps between meeting edges of dumbwaiter doors.
~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 161.

Based on observations as referenced in the Life Safety Report of Survey completed March 16, 2011 the hospital failed to assure the safety of patients, staff, and visitors by failing to ensure the essential electrical system was maintained to provide emergency power and lighting to critical and appropriate areas of the hospital during outages of normal power.

The findings include:

Building 01
1. Based on observation, on March 15, 2011 at approximately 1:00 p.m. onward, emergency lighting is incomplete in the following areas:
a. Exit discharge near room 449 - single bulb, point source light fixture is not adequate for lighting to the publicway.
b. Fourth floor corridor near room 421 - all lighting is controlled by wall-mounted switches. Emergency lighting is required to be connected to unswitched circuit supplied from the Life Safety Branch of the essential electrical system.
c. Exit discharge from stair #4 - area is not covered to the publicway.
d. Interior courtyard lighting at first floor old smoking area - there are no lights connected to the Life Safety Branch of the essential electrical system. At approximately 6:00 a.m. on March 16, 2011, the lights in operation were verified to be connected to the normal power distribution system.
e. Battery operated emergency lighting was not available in the main electrical/generator room.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 046.

2. Based on Life Safety Surveyor observation, on March 16, 2011 at approximately 5:00 a.m. onward, the essential electrical system is noncompliant due to the following:
a. Emergency power system required approximately fifteen seconds to restore power during loss of normal power to the Life Safety Branch transfer switch.
b. Generator annunciator panels located in the security room are not connected to provide audible and visual signals in accordance with NFPA 99; 1999 edition. Panel did not indicate emergency power system supplying load during loss of normal power to Life Safety Branch transfer switch.
c. Generator annunciator panelboard serving the outpatient pavilion is not equipped with a test switch - panel did not indicate emergency power system supplying load during loss of normal power to the Life Safety Branch transfer switch.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 145.

Based on observations as referenced in the Life Safety report of survey completed March 16, 2011, the hospital failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association to assure the safety and well being of patients.

The findings include:

Building 01
1. Based on Life Safety Surveyor observation on March 15, 2011, at approximately 1:00 p.m. onward, doors to patient rooms in third floor CCU corridor walls are equipped with bi-fold inactive door leaf. The doors require greater than a single hand motion to close and latch doors in an emergency. The inactive door leaf is not equipped with self-closing hardware and self-latching hardware.
~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 018.

2. Based on Life Safety Surveyor observation, on March 15, 2011 at 1:00 p.m. onward, the following was non-compliant:
a. The first floor door in Acute Radiology to the spiral staircase leading to ground floor CV unit was not self closing.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 020.

3. Based on Life Safety Surveyor observation, on March 15, 2011 at approximately 1:00 p.m. onward, the following sprinkler system components were noncompliant:
a. On March 16, 2011 at approximately 5:00 a.m. onward, cross corridor smoke barrier doors are not equipped with vision panels - doors from labor and delivery located on second floor.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 025.

4. Based on Life Safety Surveyor observation, on March 16, 2011 at 8:00 a.m. onward, the following was non-compliant:
a. In the ED department one smoke doors did not latch tight in its frame and one door was not equipped with self closing device (center section).

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 027.

5. Based on Life Safety Surveyor observation, on March 15, 2011 at approximately 1:00 p.m. onward, hazardous areas in the following locations are non-compliant:
a. Central service storage room, located on ground floor, has no fire dampers or other means to maintain required one hour enclosure at mechanical duct penetrations.
b. Hot water room located on ground floor - doors are not self-closing and latching.
c. Ground floor - kitchen chemical cleaning storage with flammable storage inside - doors are not self-closing and latching and door was not rated.
d. Storage room at loading dock outside kitchen area is not one hour enclose or sprinklered.
e. Conduit penetration in the ceiling in ground floor paper storage room was not sealed.
f. There is an excessive gap between the door and the floor to the hazardous storage room where the gallon containers of Ethel alcohol are located.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 029.

6. Based on Life Safety Surveyor observation, on March 16, 2011 at 8:00 a.m. onward, the following was non-compliant:
a. A dead end corridor greater than 30 exists in the ED department located next to clean supply room #3.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 036.

7. Based on Life Safety Surveyor observation, on March 15, 2011 at approximately 1:00 p.m. onward, exit directional signs are incomplete due to the following:
a. Lack of exit sign above cross corridor fire doors near old smoking area - located in the Sutton Building.
b. Lack of exit directional sign at corridor beyond first floor fire doors between hospital and business occupancy - near old smoking area.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 047.

8. Based on Life Safety Surveyor observation, on March 16, 2011 at approximately 5:00 a.m. onward, the fire alarm system is noncompliant due to the following:
a. Lack of smoke detector in room containing main fire alarm control panel - located in Sutton Building.
b. Lack of a trouble signal with disconnection of phone line from main fire alarm control panel - signal does not register at remote panel located in security room.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 051.

9. Based on Life Safety Surveyor observation, on March 15, 2011 at approximately 1:00 p.m. onward, there are sprinklers missing in the following areas:
a. Ceiling above upper stair landing, and below lower stair landing - stair #1.
b. Walk-in cooler and freezers in the kitchen area.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 056.

10. Based on Life Safety Surveyor observation, on March 16, 2011 at approximately 5:00 a.m. onward, there is no electrical supervision of sprinkler control valves in the following areas:
a. Post indicator valve at fenced area outside of boiler room.
b. Accelerator valve at new ED.
c. Pressure switch valve for dry-pipe system near ER canopy.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 061.

11. Based on Life Safety Surveyor observation, on March 15, 2011 at approximately 1:00 p.m. onward, the following sprinkler system components were noncompliant:

a. Lack of greased valve stems for main sprinkler control valves located in pit serving outpatient pavilion.
b. Mechanical room #10, phone room and CV Mechanical room located on ground floor, are equipped with a sprinkler head rated for 200 degrees Fahrenheit. There are no heating sources within space to justify excessive rating above expected ambient temperatures.
c. Dry system near ER canopy is not equipped with low air pressure supervision and pressure gauge.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 062.

12. Based on Life Safety Surveyor observation, on March 15, 2011 at approximately 1:00 p.m. onward, the soiled linen chute is noncompliant due to the following:
a. Fire door assembly is blocked open at ground floor level.
b. Fire door to soiled linen room terminal room is less than 1.5 hour rated door - existing door is forty-five minute rated (Ground floor level).

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 071.

13. Based on Life Safety Surveyor observation, on March 15, 2011 at approximately 1:00 p.m. onward:
a. There are impediments not in immediate and continuous use in the corridor near room 447.
b. Cross-corridor smoke doors protrude greater than seven inches into the required egress path in the fully open position. Doors are located near room 447.
c. There is a sink mounted on the third floor CCU Unit corridor wall - the sink obstructs required corridor width and protrudes greater than three and one-half inches from corridor wall. The unit is not designed as a patient care suite.
d. There are impediments not in immediate and continuous use in the operating unit corridors located on the first floor. The operating room area is not designed as a patient care suite - existing corridors may not be used to store equipment and other objects.
e. There is a rooftop unit condensate drain obstructing required rooftop egress serving the fourth floor patient area.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 072

14. Based on Life Safety Surveyor observation, on March 16, 2011 at 8:00 a.m. onward, the following was non-compliant:

a. The one gallon containers of 200 proof Ethel alcohol located in the pharmacy were not stored in rated cabinets.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 135.

Based on observations as referenced in the Life Safety Report of survey completed 03/16/2011, the hospital failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association.

The findings include:

Building 01
1. Based on Life Safety Surveyor observation, on March 15, 2011 at approximately 1:00 p.m. onward, the facility is equipped with incomplete electromagnetic locking arrangements on cross corridor doors throughout as follows:
a. ED - corridor behind emergency department is equipped with incomplete access-controlled egress hardware. There is no sensor to unlock the door in the direction of egress. On March 16, 2011 at approximately 9:15 a.m. the locking system did not release with activation of the building fire alarm system - this action constitutes an immediate jeopardy to the health and safety of all occupants requiring egress in the subject area. The hospital administration was notified at 1210, after conferral with health care survey team and supervisory authority. The immediate jeopardy was abated at approximately 9:30 a.m. when hospital engineering staff removed noncompliant locking devices from subject doors.
b. Second floor near elevators - the facility utilizes delayed egress locks and NC special locking arrangements with remote switches in the same egress path.
c. CCU unit located on third floor - lack of master release switch located at nurse's station outside of CCU Unit, and switches adjacent to doors are greater than three feet from cross corridor doors.
d. First floor near physician call room - special locking arrangement does not comply with delayed egress, access controlled or NC special locking arrangement requirements. Locks release with the activation of a push switch, fire alarm activation, and loss of power.

2. Based on Life Safety Surveyor observation, on March 15, 2011 at approximately 1:00 p.m. onward, the exit discharge across fourth floor roof is incomplete. The discharge path is not bound by guardrails from the patient care area to the stair accessible from the roof.

3. Based on Life Safety Surveyor observation, on March 15, 2011 at approximately 1:00 p.m. onward, there is a steel chain secured across the handrails of stair serving fourth floor exit across roof. The chain obstructs stair egress path from the fourth level - located inside stair at third floor CCU area.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 032.