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Based on observation and interview with staff, the facility failed to protect Anesthetizing locations in accordance with 1999 edition, NFPA 99 Chapters 5 and 12. Findings include:

The Governing Body failed to designate Inhalation Anesthetizing Locations in accordance with NFPA 99 12-2.7.

The Governing Body failed to ensure enforcement of safe practices for patients and staff in anesthetizing locations by failing to provide and document training that includes Physicians in Fire Loss Prevention, and Qualifications and Training of the application of electrical equipment and their use. NFPA 12-4.1.2.10., 7-6.5.1.

Humidity levels in January of 2013 were less than 35 % 15 days and 7 of these days the humidity was less than the 20%. The 7 days that were noted on the problem area of the Stillwater Surgery Center Temperature and Humidity Log was reported for corrective action. The facility stated that corrective action was taken, however there is no evidence to substantiate correction. The Humidity Log Levels are incorrect and require correction 30-60% are the correct ranges NFPA 99 5-4.1.

The facility failed to provide anesthetizing locations in Operating Rooms 1 and 2 with automatic smoke evacuation in accordance with 1999 edition, NFPA 5-4.1.2.

The Hospital Surgery Department Manager for OR 1 & 2 and the Outpatient Surgery Department Manager failed to provide documentation of policy and procedures for the control of personnel concerned with anesthetizing locations and failed to have said policies posted in the operating rooms in accordance with NFPA 99 12-4.1.1.4.

Staff members in Operating Rooms 1 and 2 failed to demonstrate knowledge of equipment. Staff were unable to describe the function of the Line Isolation Monitors. The Line Isolation Monitors were not on a monthly Preventive Maintenance Check List as required in NFPA 3-3.3.4.2.

Based on observation and interview with staff, the facility failed to provide periodic training in fire suppression for Staff involved in the use of energy-delivering devices located in procedure, diagnostic, and treatment rooms located in the facility NFPA 99 chapter 7-6.5. Findings include:

In the presence of the Assistant Administrator, the staff were asked questions regarding knowledge and training of Cardiac Catheterization Lab in the Emergency Department. Staff in the ER were asked about one time use battery backup Bovi (cauterizing tool). Staff had not been trained in fire prevention and fire suppression associated with the use of this tool. Periodic training and review of Manufactures Guidelines in the use of energy delivering and similar devices in these departments could not be documented. The Assistant Administrator indicated that the facility did not know the location of all similar energy delivering devices.

The Out Patient Surgery Director, Surgery Department Director, and Assistant Administrator indicated that Qualifications and Training of all staff (including Physicians); using a list of cognizant risks associated with the use, application and maintenance of electrical appliances, could not be documented as a establish program for continuing education for its personnel.

Staff in the Cath Lab failed to identify the location of shutoff valves for medical gas. Cath Lab did not have documentation for training of physicians for using a "time out" for drying of combustible preps before starting a case.

Based on observation and interview with staff, the facility failed to protect Anesthetizing locations in accordance with 1999 edition, NFPA 99 Chapters 5 and 12. Findings include:

The Governing Body failed to designate Inhalation Anesthetizing Locations in accordance with NFPA 99 12-2.7.

The Governing Body failed to ensure enforcement of safe practices for patients and staff in anesthetizing locations by failing to provide and document training that includes Physicians in Fire Loss Prevention, and Qualifications and Training of the application of electrical equipment and their use. NFPA 12-4.1.2.10., 7-6.5.1.

Humidity levels in January of 2013 were less than 35 % 15 days and 7 of these days the humidity was less than the 20%. The 7 days that were noted on the problem area of the Stillwater Surgery Center Temperature and Humidity Log was reported for corrective action. The facility stated that corrective action was taken, however there is no evidence to substantiate correction. The Humidity Log Levels are incorrect and require correction 30-60% are the correct ranges NFPA 99 5-4.1.

The facility failed to provide anesthetizing locations in Operating Rooms 1 and 2 with automatic smoke evacuation in accordance with 1999 edition, NFPA 5-4.1.2.

The Hospital Surgery Department Manager for OR 1 & 2 and the Outpatient Surgery Department Manager failed to provide documentation of policy and procedures for the control of personnel concerned with anesthetizing locations and failed to have said policies posted in the operating rooms in accordance with NFPA 99 12-4.1.1.4.

Staff members in Operating Rooms 1 and 2 failed to demonstrate knowledge of equipment. Staff were unable to describe the function of the Line Isolation Monitors. The Line Isolation Monitors were not on a monthly Preventive Maintenance Check List as required in NFPA 3-3.3.4.2.

Based on observation and interview with staff, the facility failed to provide periodic training in fire suppression for Staff involved in the use of energy-delivering devices located in procedure, diagnostic, and treatment rooms located in the facility NFPA 99 chapter 7-6.5. Findings include:

In the presence of the Assistant Administrator, the staff were asked questions regarding knowledge and training of Cardiac Catheterization Lab in the Emergency Department. Staff in the ER were asked about one time use battery backup Bovi (cauterizing tool). Staff had not been trained in fire prevention and fire suppression associated with the use of this tool. Periodic training and review of Manufactures Guidelines in the use of energy delivering and similar devices in these departments could not be documented. The Assistant Administrator indicated that the facility did not know the location of all similar energy delivering devices.

The Out Patient Surgery Director, Surgery Department Director, and Assistant Administrator indicated that Qualifications and Training of all staff (including Physicians); using a list of cognizant risks associated with the use, application and maintenance of electrical appliances, could not be documented as a establish program for continuing education for its personnel.

Staff in the Cath Lab failed to identify the location of shutoff valves for medical gas. Cath Lab did not have documentation for training of physicians for using a "time out" for drying of combustible preps before starting a case.