HospitalInspections.org

Remains Cited

Based on observation, hospital policy review, and staff interview the hospital failed to ensure a safe environment by failing to ensure crash carts/defibrillators located in an outpatient cancer area were checked for the presence and functioning of the emergency equipment on a daily basis in accordance with the hospital policy. recommendations. This affected three of five crash carts on the unit. The hospital census at the time of the survey was 433 patients.


Findings include:

On 10/02/12 at 11:00 AM, an observation in the Barrett Cancer Center revealed five crash carts with defibrillators kept in various areas of this outpatient facility. Review of the crash cart logs revealed the monitoring documentation had not been completed daily for two of the crash carts since 2009. The logs were not completed on a daily basis for one of the crash carts from April, 2012, through to the present date of 10/02/12. All five of the crash cart logs intermittently lacked documentation of daily monitoring.



Review of the hospital policy, "Checking Crash Carts and Emergency Equipment" was completed on 10/4/12, and revealed the purpose of the policy was "To provide a systematic method to check the presence and functioning of emergency medical equipment." On page one under the heading "General Information" at Number 3, the policy stated: "There is a checklist on the crash cart. It lists items to be checked for the presence and appropriate function of emergency equipment, along with areas to sign while checking. This checklist is to be completed a minimum of twice daily on inpatient units and once daily in other areas on business days." As the Barrett Cancer Center is an outpatient unit the requirement for checking the crash care is one daily. The policy identified the Patient Care Services Staff (Nursing) as responsible for completing the checklist documentation daily on business days.

A crash cart is a mobile storage system outfitted with wheels and filled with medication and equipment commonly used to initiate advanced cardiac life support (ACLS) procedures, respiratory support procedures, and general medical supplies. A defibrillator is a key component of any crash cart. A cardiac defibrillator uses an electrical charge to enable the heart to correct disrupted rhythm. Manufacturers recommend daily defibrillator checks).


This finding was verified with Staff S 10/02/12 at 12:15 PM. Staff S stated that the nursing staff were designated as responsible for filling out the crash cart logs and he/she was not sure why they were not complete.

Based on observation and interview, the facility failed to ensure fire walls and smoke walls were free of penetrations, fire extinguishers were inspected and placed as required, exit signs were posted as required, delayed egress doors opened with activation of smoke detectors, chute doors closed automatically or had been in a locked room, areas with oxygen storage had signage, sprinkler heads were kept clean and were maintained with 18 inches of clearance, humidity was maintained at or greater than 35 percent in the operating rooms, and fire drills were conducted as required. This had the potential to affect all 433 patients.

Findings:

See A709.

Based on observation, interview, and record review, the facility failed to meet requirements for life safety, specifically, the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. This had the potential to affect all 433 patients.

Findings:

Please refer to the the following K tags cited on the Life Safety Code 2567 for the findings of the deficient practice;


Building 1, Main

K11 fire wall penetrations and fire doors failed to close
K22 exit signs not posted or not readily visible
K38 delayed egress doors failed to open when tested
K45 no exit discharge lighting outside one exit discharge
K64 fire extinguishers not checked at 30 day intervals, or not readily accessible
K71 chute discharge rooms had either chute doors or hallway doors that did not close automatically
K141 oxygen storage areas lacked signage

Building 2 Critical Care Pavilion

K11 fire wall penetrations
K18 dutch door without a latching device
K20 vertical opening with construction that had a penetration
K25 smoke barriers with penetrations
K38 delayed egress door did open when tested
K42 suites not kept to less than 5000 square feet
K62 sprinkler heads not clean
K64 row of chairs in front of fire extinguisher
K70 space heater observed in a patient care area
K76 more than 300 cubic feet of medical gas kept in a smoke compartment
K147 power strips daisy chained



Building 3 OR/OB
K11 fire wall penetrations and fire doors failed to close
K22 lack of exit sign
K27 smoke barrier door did not self close
K71 trash chute door did not automatically close
K78 medical gas shut-off valve not readily accessible

Building 4 OR Addition

K11 fire wall penetration
K29 hazardous areas with penetrations in wall

Building 5 Mont Reid Pavilion

K114 fire wall penetration

Building 6 Barrett Cancer Center
K130 stairwell door did not latch, two horizontal exit doors failed to self-close and latch, and lack of exit signs at two exit access doors

Building 7 Holmes Hospital

K20 chute room door not locked
K47 same day surgery suite lacking exit sign
K78 humidity level not kept at or above 35 percent
K115 penetration in the fire barrier
K130 flipper cabinets installed within 18 inches from the ceiling

Building 8 MRI
No deficiencies

Building 10 Deaconess West
K21 stairwell door on 6th floor failed to self-close and latch
K22 lack of exit signs at exit access doors
K29 one soiled utility room lacked self-closing device
K38 two delayed egress in the path of exit on all three inpatient floors (5, 6, and 7)
K45 lack of sufficient egress lighting in Stair 6
K50 fire drills not conducted on each shift per quarter (2 missing)



Building 11 B Pavilion

K64 fire extinguisher not kept monthly

Building 12 Radiology Oncology
K130 Fire door did not completely close