HospitalInspections.org

Based on observation and interview with staff, the facility failed to conduct fire drills that are held at unexpected times under varying conditions, and at least quarterly on each shift in accordance with 19.7.1.2.

Findings:

Staff member HH was asked on September 26, 2013 for logs for fire drills for the past year. Staff member HH stated that the records indicated fire drills were not conducted from January 2013 to June 28, 2013.

Based on observation and interview with staff, the facility failed to maintain automatic sprinkler systems in reliable operating condition, inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5.

Findings:

Staff member HH was asked on September 26, 2013, to provide logs for the last two years of fire suppression annual inspections. Staff member HH indicated that the last inspection was conducted on October 3, 2011, by Simplex, Oklahoma Sprinkler Technician #2176. At that time the sprinkler system was yellow-tagged.

Based on observation and interview with staff, the facility failed to maintain heating, ventilating, and air conditioning equipment that comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2.

Findings:

1) The exhaust for the equipment sterilizer, two soiled utility rooms, and the janitor's closet was not working. These rooms require ten air exchanges and negative air flow with relationship to adjacent spaces.

2) The facility could not provide documentation that the clean work room had positive air with four air exchanges and 30-60% humidity levels.

3) The facility failed to provide documentation that operating rooms were positive with three outside air exchanges, fifteen total air exchanges, with humidity levels within 30-60% range. The facility provided a temperature/humidity log. However, humidity levels were chronically high or low depending on the time of the year.

Based on observation and interview with staff, the facility failed to continuously maintain means of egress that are free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects obstruct exits, access to, egress from, or visibility of exits. 7.1.10

Findings:

In Corridor 148 adjacent to the Employee Locker Room 149, in accordance with architectural drawings provided by staff member HH, two gray plastic trash containers, (one with red bag labeled Bio-Hazard and one clear bag and two cardboard boxes on top) and with a cart providing shoe covers and head covers were staged in the egress corridor. Staff DD indicated that these items were housekeeping's empty containers. Staff DD indicated that there was no room in the OR Suite.

Based on observation, review of Operating Room Logs, and interview with staff, the facility failed to protect Anesthetizing locations in accordance with NFPA 99, Standard for Health Care Facilities. Findings include:

1) The OSDH surveyor was provided with months of humidity logs; the logs indicated high and low reading that exceeded 60% in the warm months and humidity levels less than 30% in cold months when outside temperature and humidity were low. The logs indicated that maintenance was notified, however there is no documentation that corrective action was taken. As noted on Initial Comments, Director of Maintenance indicated that the humidifier was removed; there is no documentation or evidence that humidifier was re-installed.

2) There is no evidence of a smoke evacuation testing or if the system is installed in accordance NFPA 99, 1999 edition, chapter 5-4 through 5-4.1.6

3) The vacuum supply system is not functioning. Based on interview with staff member HH and quality assurance meeting minutes, the vacuum system can not maintain normal pressure if left unattended.

Based on observation and interview with staff, the facility failed provide an essential electrical system powered by a generator with a transfer switch and separate power supply in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4.

Finding:

1) The remote annunciator panel, located at the nurses' station, was not working (a light indicated malfunction).

2) Staff HH could not provide an interim life safety alert for staff or documentation that staff was inserviced concerning the remote annunciator panel not functioning properly.

3) Nursing staff (in the presence of staff member HH), located at the nurses' station in the southwest corner on September 26, 2013, at 2:30 pm, was asked to demonstrate what the panel was relaying at that time. Staff could not verbally explain the indication of equipment malfunction.

Based on observation and interview with staff, the facility failed to inspect the emergency generator weekly and exercise it under load for thirty minutes per month in accordance with NFPA 99, 3.4.4.1.

Findings:

1) The emergency generator weekly inspection checklist failed to indicate if the generator was run under load and for how long.
a) what percentage of load was the generator run,
b) what the monthly time frame that the generator was run (time not logged, thirty minutes minimum).

2) Staff member HH could not provide documentation when the diesel fuel was last inspected or treated.

Based on observation and interview with staff, the facility failed to provide electrical wiring and equipment that is in accordance with NFPA 70, National Electrical Code, 9.1.2.
Findings:

1) Bio-Medical Equipment Program (Medical Equipment Management Plan, approved February 11, 2013) under the heading of Equipment Inspection, Preventive Maintenance & Testing, states that life sustaining equipment will be inspected semi-annually. The last Preventive Maintenance Program conducted on the Anesthesia Machine (GASMOD III, MODEL 4985603-H3) was last tested on October 17, 2012. The anesthesia machine was not tagged or removed from service. Staff failed to recognize and implement the removal of out-of-date equipment in accordance with policy and procedure. The effectiveness of the area specific orientation and training failed. The Director of Nursing failed to contact the IT/Biomedical Department to coordinate and inspection. There was no documentation that objectives, performance, and effectiveness of the Biomedical Equipment Plan was evaluated annually as indicated by the P & P Program.

2) On August 13, 2013, a line isolation monitor in the endoscopy room indicated a HILL ROM Bed 8020, serial #73D0000 ECH experienced an open ground. The facility failed to tag and remove the bed from use. The maintenance person II removed the plug, installed a new one, and put the bed back into use. The facility failed to implement Bio-Med P&P. The bed did not get a Bio-Medical check after repair. The bed once again set the line isolation monitor off, however, the facility did not remove the bed from service, the relocated the bed to recovery. Staff allowed the bed to be put back in service with no sticker indicating it was safe for patient use. Staff member JJ told the surveyor that she did not know that beds were required to have a Bio-Medical check.

3) Dental instruments in the operating room suite were stored in the janitor closet, instruments (movable turbine) were not provided with a Bio-Medical check and sticker. Staff failed to remove equipment from service. Drills (tools), etc., used inside patients' mouths were processed off site. The facility failed to provide competencies for the sterilizer and the paper strip that indicated sterile processing of instruments.

4) There is an air purifier in the triage room with duct tape on it and not taken out of service, equipment throughout the emergency department, bedside monitors, electrical appliances such as a refrigerator that had no initial safety inspection. A baby scale in the isolation room was not tagged.

5) The facility failed to provide education, system demonstration, and training for staff about the laundry equipment.
a) On September 25, 2013, surveyors asked administrative staff to provide laundry policies and procedures. None were provided to surveyors throughout the survey (09-25-2013 through 09-27-13).
b) Surveyors asked laundry staff to verbally provide water temperature requirements for processing all facility laundry. All laundry staff were unable to do this.
c) Surveyors asked laundry staff to verbally provide the process of laundering facility linens. Staff was unable to do this.
Any system, electrical appliances shall be demonstrated as a complete system after installation by the vendor designated to assume system responsibility and prior to initial instruction for operators and maintenance personnel. HFPA 99, 1999 edition, chapter 9.

6) Surveyors asked staff member HH for the last line isolation monitor test. Staff member HH indicated the last record of certificate of compliance was on February 27, 2012, by Hurdle & Associates. The 2013 annual test was not done.

Based on observation and interview with staff, the facility failed to conduct fire drills that are held at unexpected times under varying conditions, and at least quarterly on each shift in accordance with 19.7.1.2.

Findings:

Staff member HH was asked on September 26, 2013 for logs for fire drills for the past year. Staff member HH stated that the records indicated fire drills were not conducted from January 2013 to June 28, 2013.

Based on observation and interview with staff, the facility failed to maintain automatic sprinkler systems in reliable operating condition, inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5.

Findings:

Staff member HH was asked on September 26, 2013, to provide logs for the last two years of fire suppression annual inspections. Staff member HH indicated that the last inspection was conducted on October 3, 2011, by Simplex, Oklahoma Sprinkler Technician #2176. At that time the sprinkler system was yellow-tagged.

Based on observation and interview with staff, the facility failed to maintain heating, ventilating, and air conditioning equipment that comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2.

Findings:

1) The exhaust for the equipment sterilizer, two soiled utility rooms, and the janitor's closet was not working. These rooms require ten air exchanges and negative air flow with relationship to adjacent spaces.

2) The facility could not provide documentation that the clean work room had positive air with four air exchanges and 30-60% humidity levels.

3) The facility failed to provide documentation that operating rooms were positive with three outside air exchanges, fifteen total air exchanges, with humidity levels within 30-60% range. The facility provided a temperature/humidity log. However, humidity levels were chronically high or low depending on the time of the year.

Based on observation and interview with staff, the facility failed to continuously maintain means of egress that are free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects obstruct exits, access to, egress from, or visibility of exits. 7.1.10

Findings:

In Corridor 148 adjacent to the Employee Locker Room 149, in accordance with architectural drawings provided by staff member HH, two gray plastic trash containers, (one with red bag labeled Bio-Hazard and one clear bag and two cardboard boxes on top) and with a cart providing shoe covers and head covers were staged in the egress corridor. Staff DD indicated that these items were housekeeping's empty containers. Staff DD indicated that there was no room in the OR Suite.

Based on observation, review of Operating Room Logs, and interview with staff, the facility failed to protect Anesthetizing locations in accordance with NFPA 99, Standard for Health Care Facilities. Findings include:

1) The OSDH surveyor was provided with months of humidity logs; the logs indicated high and low reading that exceeded 60% in the warm months and humidity levels less than 30% in cold months when outside temperature and humidity were low. The logs indicated that maintenance was notified, however there is no documentation that corrective action was taken. As noted on Initial Comments, Director of Maintenance indicated that the humidifier was removed; there is no documentation or evidence that humidifier was re-installed.

2) There is no evidence of a smoke evacuation testing or if the system is installed in accordance NFPA 99, 1999 edition, chapter 5-4 through 5-4.1.6

3) The vacuum supply system is not functioning. Based on interview with staff member HH and quality assurance meeting minutes, the vacuum system can not maintain normal pressure if left unattended.

Based on observation and interview with staff, the facility failed provide an essential electrical system powered by a generator with a transfer switch and separate power supply in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4.

Finding:

1) The remote annunciator panel, located at the nurses' station, was not working (a light indicated malfunction).

2) Staff HH could not provide an interim life safety alert for staff or documentation that staff was inserviced concerning the remote annunciator panel not functioning properly.

3) Nursing staff (in the presence of staff member HH), located at the nurses' station in the southwest corner on September 26, 2013, at 2:30 pm, was asked to demonstrate what the panel was relaying at that time. Staff could not verbally explain the indication of equipment malfunction.

Based on observation and interview with staff, the facility failed to inspect the emergency generator weekly and exercise it under load for thirty minutes per month in accordance with NFPA 99, 3.4.4.1.

Findings:

1) The emergency generator weekly inspection checklist failed to indicate if the generator was run under load and for how long.
a) what percentage of load was the generator run,
b) what the monthly time frame that the generator was run (time not logged, thirty minutes minimum).

2) Staff member HH could not provide documentation when the diesel fuel was last inspected or treated.

Based on observation and interview with staff, the facility failed to provide electrical wiring and equipment that is in accordance with NFPA 70, National Electrical Code, 9.1.2.
Findings:

1) Bio-Medical Equipment Program (Medical Equipment Management Plan, approved February 11, 2013) under the heading of Equipment Inspection, Preventive Maintenance & Testing, states that life sustaining equipment will be inspected semi-annually. The last Preventive Maintenance Program conducted on the Anesthesia Machine (GASMOD III, MODEL 4985603-H3) was last tested on October 17, 2012. The anesthesia machine was not tagged or removed from service. Staff failed to recognize and implement the removal of out-of-date equipment in accordance with policy and procedure. The effectiveness of the area specific orientation and training failed. The Director of Nursing failed to contact the IT/Biomedical Department to coordinate and inspection. There was no documentation that objectives, performance, and effectiveness of the Biomedical Equipment Plan was evaluated annually as indicated by the P & P Program.

2) On August 13, 2013, a line isolation monitor in the endoscopy room indicated a HILL ROM Bed 8020, serial #73D0000 ECH experienced an open ground. The facility failed to tag and remove the bed from use. The maintenance person II removed the plug, installed a new one, and put the bed back into use. The facility failed to implement Bio-Med P&P. The bed did not get a Bio-Medical check after repair. The bed once again set the line isolation monitor off, however, the facility did not remove the bed from service, the relocated the bed to recovery. Staff allowed the bed to be put back in service with no sticker indicating it was safe for patient use. Staff member JJ told the surveyor that she did not know that beds were required to have a Bio-Medical check.

3) Dental instruments in the operating room suite were stored in the janitor closet, instruments (movable turbine) were not provided with a Bio-Medical check and sticker. Staff failed to remove equipment from service. Drills (tools), etc., used inside patients' mouths were processed off site. The facility failed to provide competencies for the sterilizer and the paper strip that indicated sterile processing of instruments.

4) There is an air purifier in the triage room with duct tape on it and not taken out of service, equipment throughout the emergency department, bedside monitors, electrical appliances such as a refrigerator that had no initial safety inspection. A baby scale in the isolation room was not tagged.

5) The facility failed to provide education, system demonstration, and training for staff about the laundry equipment.
a) On September 25, 2013, surveyors asked administrative staff to provide laundry policies and procedures. None were provided to surveyors throughout the survey (09-25-2013 through 09-27-13).
b) Surveyors asked laundry staff to verbally provide water temperature requirements for processing all facility laundry. All laundry staff were unable to do this.
c) Surveyors asked laundry staff to verbally provide the process of laundering facility linens. Staff was unable to do this.
Any system, electrical appliances shall be demonstrated as a complete system after installation by the vendor designated to assume system responsibility and prior to initial instruction for operators and maintenance personnel. HFPA 99, 1999 edition, chapter 9.

6) Surveyors asked staff member HH for the last line isolation monitor test. Staff member HH indicated the last record of certificate of compliance was on February 27, 2012, by Hurdle & Associates. The 2013 annual test was not done.