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Based on observation and interview with staff, the facility failed to provide doors with a means suitable for keeping the door closed. 19.3.6.3 Findings,

The door to the Pre-Op Room on the 2nd Floor East, was not provided with latching hardware.

Based on observation and interview with staff, the facility failed to provide in-service training so that staff is familiar with required fire drill procedures. 19.7.1.2 Findings,

The drills were held on each quarter and on each shift as required, however the staff member who conducted the fire drills failed to follow up with documentation of in-service training for those who failed to meet expectations on the fire drill critique form.

Based on observation and interview with staff, the facility failed to provide a piped in medical gas system that complies with NFPA 99, Chapter 4. Findings,

1. The Source valve located in the bulk Oxygen Site is not marked. Valves shall be read SOURCE VALVE FOR THE OXYGEN SUPPLY.

2. The main supply line for the Hyperbaric Chambers is not marked SOURCE VALVE FOR OXYGEN SUPPLY.

3. The main gas supply line for the Hyperbaric Chamber is not protected outside of the fence. The copper line is exposed and can be damaged by a lawn mower or similar equipment.

4 The facility failed to monitor Line Pressure of the Line supplying the Hyperbaric Chambers.

5 Medical Air sensors are not piped to mains on Neonatal Care Unit 1st Floor. No sensor installed on Medical Vacuum System at Pediatrics Nurses Station 2nd Floor. Medical Vacuum is not monitored in ICU, and Medical Air low set-point shall be calibrated for the alarm across from ICU Nurses Station on 3 rd floor. See Medical Gas Report May 30, 2012.

Based on observation and interview with staff, the facility failed to provide anesthetizing locations that are protected in accordance with NFPA 99, 1999 edition, Standard for Health Care Facilities. Findings,

1. The facility failed to provide humidification equipment that is installed and maintained to provide humidity levels equal to or greater than 35% per NFPA 99 4.3.1.2.3(an) and 5.4.1.1, 19.3.2.3. Logs provided depicted chronic levels of humidity below and above accepted levels with no documentation for a plan of correction or for repairs.

2. The facility failed to provide Smoke Evacuation Equipment designed to automatically evacuate products of combustion and smoke from the operating room suite.

3. The facility failed to provide WAGD "waste anesthesia gas disposal" network at anesthetizing locations.

1. Based on observation , interview with staff, and review of the Operating Room Fire Loss Prevention policy that provides details on how to prevent and control a fire in the Operating Room, Cardiac Cath Room, and in the Emergency Room, the facility failed to provide orientation and training in accordance with NFPA 99 1999 edition. Findings,

The program provided fails to include Doctors and Physicians.

2. Based on observation and interview with staff, the facility failed to provide Qualification and Training of Personal in the application of electrical appliances, that includes Doctors, Nurses, Nurses Aids, Engineers, Orderlies, and Surgeons. The staff shall be cognizant of the risks associated with their use in accordance with NFPA 99 1999 edition chapter 7-6.5 Findings,

Based on interview with the Education Director of the facility in the presence of the Director of Engineering, the facility could not provide documentation of an in-service program that includes periodic review of manufacturers' safety guidelines and usage requirements for electro-surgical units and similar appliances used by the Doctors and Surgeons; such as, electrical/surgical units, surgical laser, electrocautery, and fiberoptics.

Also, in the Emergency Room Suite, the facility has a one time use battery operated Bovie. This piece of equipment, when used, has the ability to start a fire in an oxygen enriched environment or with the combustible preps found in the supply room. Documentation for training of staff was not available

Based on observation and interview with staff, the facility failed to provide ventilation for the Micro-Biology Room with negative pressure in accordance with NFPA 99 5.4.3, 5.6.2. Findings,

The Micro-Biology Room door is propped open , the fume hood installed is not balanced in conjunction with the mechanical exhaust system to provide a negative pressure for that room with respect to the surrounding hospital occupancies.

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

The electrically operated Bear Hugger located in Operating Room No. 4 was last checked and labeled by Bio-Medical in January of 2011. The Operating Room Staff failed to remove this electrical equipment from use pending a bio-medical electrical check.

Power Ball electrical equipment, that has never been electrically tested by Bio-Med, was located through-out the hospital. Staff failed to remove electrical equipment that was out of date on inspections and non tagged equipment from use.

Based on observation and interview with staff, the facility failed to provide doors with a means suitable for keeping the door closed. 19.3.6.3 Findings,

The door to the Pre-Op Room on the 2nd Floor East, was not provided with latching hardware.

Based on observation and interview with staff, the facility failed to provide in-service training so that staff is familiar with required fire drill procedures. 19.7.1.2 Findings,

The drills were held on each quarter and on each shift as required, however the staff member who conducted the fire drills failed to follow up with documentation of in-service training for those who failed to meet expectations on the fire drill critique form.

Based on observation and interview with staff, the facility failed to provide a piped in medical gas system that complies with NFPA 99, Chapter 4. Findings,

1. The Source valve located in the bulk Oxygen Site is not marked. Valves shall be read SOURCE VALVE FOR THE OXYGEN SUPPLY.

2. The main supply line for the Hyperbaric Chambers is not marked SOURCE VALVE FOR OXYGEN SUPPLY.

3. The main gas supply line for the Hyperbaric Chamber is not protected outside of the fence. The copper line is exposed and can be damaged by a lawn mower or similar equipment.

4 The facility failed to monitor Line Pressure of the Line supplying the Hyperbaric Chambers.

5 Medical Air sensors are not piped to mains on Neonatal Care Unit 1st Floor. No sensor installed on Medical Vacuum System at Pediatrics Nurses Station 2nd Floor. Medical Vacuum is not monitored in ICU, and Medical Air low set-point shall be calibrated for the alarm across from ICU Nurses Station on 3 rd floor. See Medical Gas Report May 30, 2012.

Based on observation and interview with staff, the facility failed to provide anesthetizing locations that are protected in accordance with NFPA 99, 1999 edition, Standard for Health Care Facilities. Findings,

1. The facility failed to provide humidification equipment that is installed and maintained to provide humidity levels equal to or greater than 35% per NFPA 99 4.3.1.2.3(an) and 5.4.1.1, 19.3.2.3. Logs provided depicted chronic levels of humidity below and above accepted levels with no documentation for a plan of correction or for repairs.

2. The facility failed to provide Smoke Evacuation Equipment designed to automatically evacuate products of combustion and smoke from the operating room suite.

3. The facility failed to provide WAGD "waste anesthesia gas disposal" network at anesthetizing locations.

1. Based on observation , interview with staff, and review of the Operating Room Fire Loss Prevention policy that provides details on how to prevent and control a fire in the Operating Room, Cardiac Cath Room, and in the Emergency Room, the facility failed to provide orientation and training in accordance with NFPA 99 1999 edition. Findings,

The program provided fails to include Doctors and Physicians.

2. Based on observation and interview with staff, the facility failed to provide Qualification and Training of Personal in the application of electrical appliances, that includes Doctors, Nurses, Nurses Aids, Engineers, Orderlies, and Surgeons. The staff shall be cognizant of the risks associated with their use in accordance with NFPA 99 1999 edition chapter 7-6.5 Findings,

Based on interview with the Education Director of the facility in the presence of the Director of Engineering, the facility could not provide documentation of an in-service program that includes periodic review of manufacturers' safety guidelines and usage requirements for electro-surgical units and similar appliances used by the Doctors and Surgeons; such as, electrical/surgical units, surgical laser, electrocautery, and fiberoptics.

Also, in the Emergency Room Suite, the facility has a one time use battery operated Bovie. This piece of equipment, when used, has the ability to start a fire in an oxygen enriched environment or with the combustible preps found in the supply room. Documentation for training of staff was not available

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

The electrically operated Bear Hugger located in Operating Room No. 4 was last checked and labeled by Bio-Medical in January of 2011. The Operating Room Staff failed to remove this electrical equipment from use pending a bio-medical electrical check.

Power Ball electrical equipment, that has never been electrically tested by Bio-Med, was located through-out the hospital. Staff failed to remove electrical equipment that was out of date on inspections and non tagged equipment from use.