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1) Based on observation and interview with staff, the facility failed to maintain corridors that are separated from use areas by walls constructed with at least ? hour fire resistance rating 19.3.6.1, 19.3.6.2.1, 19.3.6.5. Findings include:

a) The corridor walls throughout the hospital from original construction have holes and voids that are not sealed with material capable of maintaining the fire resistance of the fire barrier. Penetrations can be found above ceiling and above the duct work at the base of the roof.

1) Based on observation and interview with staff, the facility failed to test, and maintain the fire alarm system required for life safety in accordance with NFPA 70 National Electrical Code and NFPA 72. The system shall have an approved maintenance and testing program complying with applicable requirements of NFPA 70 and 72. 9.6.1.4 Findings include:

a) The Fire Alarm System has not had an annual inspection since April 26, 2012.

b) The facility failed to establish a preventive maintenance program that called for the inspection of the system in a timely manner.

1) Based on observation and interview with staff, the facility failed to provide heating, ventilating, and air conditioning systems 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 include:

a) An acceptance test was not performed to determine that protective measures required of equipment were working to restrict the spread of fire and smoke. NFPA 90 A 7.. Exhaust fans were not working, requirement for smoke evacuation was not tested

b ) There was no test and balance report that provided documentation of required outside air exchanges, room air exchanges within the operating room suite, and recovery area. Recovery area may not have units that recirculate air.

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

a) The facility failed to provide anesthetizing locations with humidity levels that are within 30-60%. The levels were documented with chronic levels that did not meet the minimum with no documented corrective action.

b) The HVAC System installed did not have a smoke evacuation system installed to evacuate smoke and products of combustion from the operating room suite in accordance with 5-4.1.2

c) The humidifier and ventilating equipment was not in operation in accordance with NFPA 99 5-6.1.1.

1)Manometer required to monitor the HEPA Filters was not being logged or was not installed. HEPA filters installed could not be verified for parameters of efficiency and life of the filter.

2) Three of the four exhaust fans on the roof were not working.

d) Based on interview with staff , the operating room staff had not conducted or made a hazard evaluation or conducted a fire drill to evaluate hazards that could be encountered during surgical procedures 12-4.1.2.10. The evaluation shall include hazards associated with the properties of electricity, hazards associated with the operation of surgical equipment, and hazards associated with the nature of the environment. Periodic reviews of surgical operations and procedures shall be conducted with special attention given to any change in materials, operations, or personnel.

1) The facility did not have Rules and Regulations posted in the operating room suite for personal concerned with Anesthesia locations. The established rules and regulations are to make familiar and to ensure enforcement.

2) The facility did not have a documented fire drill with doctors, nurses, scrub techs and other staff dedicated to the operating room that familiarizes staff with safety practices and an evaluation of hazards that could be encountered during surgical procedures. The evaluation shall include hazards associated with the properties of electricity, hazards associated with the operation of surgical equipment, and hazards associated with the nature of the environment. 12-4.1.2.10.

3) Documention of monthly incidents and annual review of Policies and Procedures yearly were not available. 12-4.1.2.10.

1) Based on observation and interview with staff, the facility failed to maintain design features initially approved for construction. The building must be maintained in accordance with approved design specifications. Any variations shall require the approval of the authority having jurisdiction prior to the actual change NFPA101 2000 Life Safety Code 5.1.7.
(5.1.7* Maintenance of Design Features. The design features
required for the building to continue to meet the performance
goals and objectives of this Code shall be maintained for
the life of the building. Such performance goals and objectives
shall include complying with all documented assumptions and
design specifications. Any variations shall require the approval
of the authority having jurisdiction prior to the actual change.)
(See also 4.6.9.2) Findings include:

a) The use of combustibles (alcohol) outside the operating room door and other agents in the sterile corridor for purpose of cleaning endoscopes is not allowed. A scope cleaning area was created outside the operating rooms without approval.

b) The recovery room was relocated in room 109, the room was designed as a doctors lounge.

c) The Decontamination/ Soiled utility room 61 has now been repurposed as an exam room. Dirty utility rooms are designed and located for storage of material that may combust with storing ,wrapping, and compacting, to relocate burdens on other areas of the hospital and items do not get handled appropriately.

d) Labor and delivery room, OB Corridor wall separation, and the wall separating the scrub /surgical 109 was removed without approval.

1) Based on review of the emergency Generator Logs, observation and interview with staff, the facility failed to inspect weekly and exercise under load for 30 minutes per month the Emergency Generator in accordance with NFPA 99. 3.4.4.1. Findings include:

a) The emergency generator was last documented as being run on July of 2013. Emergency Generator was not logged in 2014.

1) 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 include:

a) The recovery room is not provided with emergency power. The room, (111) was repurposed from a lounge to a recovery room. The room was not provided with dedicated an emergency circuit from the Critical Care Branch of the Emergency Distribution System.

b) Impedance testing of patient care areas is not a part of a Preventive Maintenance Program. 3-3.3.2.5. Measurements plus or minus of +/- 20% shall be made in patient Care Areas.

c) The emergency power distribution was not labeled and staff could not locate circuits. The facility emergency system was not labeled/defined with a Life Safety Branch Panel, Critical Care Branch Panel , and an Equipment Branch Panel. The facility did not have a single line drawing that depicts electrical distribution. Panel circuits were not all readable and labeled.

2) Based on observation, interview with staff, the facility failed to provide a program that provides an environment that is reasonably safe from the shock and burn hazards with the use of electricity in patient care areas. The hospital failed to adopt regulations and practices concerning the use of electric appliances and failed to establish programs for the training of physicians, nurses, and other personnel who might be involved in the procurement, application, use inspection, testing, and maintenance of electrical appliances for the care of patients. The hospital shall select a specific electrical safety program that is appropriate to its particular needs. The purchase of appliances shall be augmented by having designated departments of the facility assume responsibility for the continued inspection, testing, and maintenance of electrical appliances (NFPA 99, Chapter 7-6.5). Findings include:

a) The Vital Sign Machine found in the room that has been repurposed from a dirty utility room (room 61) to an exam room was last checked on March of 2012. The piece of equipment was to be rechecked on March of 2013. The facility did not remove the equipment from service and was being transported to patient room 51 for use on this day May the 15, 2014, at 3:30 pm.

b) The emergency room department has a battery powered cautery tool. As an example the facility did not provide yearly in-service for the use of the tool in conjunction with alcohol and an oxygen environment atmosphere. All equipment used in the operating room, emergency room and throughout the facility shall have a program that identifies the means and method for use in a safe and effective manner.

c) The facility failed to monitor the Bio-Medical equipment program. The facility did not have any documentation that the Bio-Medical services provided under contract had any way to identify quality and performance problems, implement appropriate corrective action, improvement activities, or to ensure the monitoring and sustainability of those corrective or improvement activities. See ?482.21 QAPI.

1) Based on observation and interview with staff, the facility failed to maintain corridors that are separated from use areas by walls constructed with at least ? hour fire resistance rating 19.3.6.1, 19.3.6.2.1, 19.3.6.5. Findings include:

a) The corridor walls throughout the hospital from original construction have holes and voids that are not sealed with material capable of maintaining the fire resistance of the fire barrier. Penetrations can be found above ceiling and above the duct work at the base of the roof.

1) Based on observation and interview with staff, the facility failed to test, and maintain the fire alarm system required for life safety in accordance with NFPA 70 National Electrical Code and NFPA 72. The system shall have an approved maintenance and testing program complying with applicable requirements of NFPA 70 and 72. 9.6.1.4 Findings include:

a) The Fire Alarm System has not had an annual inspection since April 26, 2012.

b) The facility failed to establish a preventive maintenance program that called for the inspection of the system in a timely manner.

1) Based on observation and interview with staff, the facility failed to provide heating, ventilating, and air conditioning systems 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 include:

a) An acceptance test was not performed to determine that protective measures required of equipment were working to restrict the spread of fire and smoke. NFPA 90 A 7.. Exhaust fans were not working, requirement for smoke evacuation was not tested

b ) There was no test and balance report that provided documentation of required outside air exchanges, room air exchanges within the operating room suite, and recovery area. Recovery area may not have units that recirculate air.

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

a) The facility failed to provide anesthetizing locations with humidity levels that are within 30-60%. The levels were documented with chronic levels that did not meet the minimum with no documented corrective action.

b) The HVAC System installed did not have a smoke evacuation system installed to evacuate smoke and products of combustion from the operating room suite in accordance with 5-4.1.2

c) The humidifier and ventilating equipment was not in operation in accordance with NFPA 99 5-6.1.1.

1)Manometer required to monitor the HEPA Filters was not being logged or was not installed. HEPA filters installed could not be verified for parameters of efficiency and life of the filter.

2) Three of the four exhaust fans on the roof were not working.

d) Based on interview with staff , the operating room staff had not conducted or made a hazard evaluation or conducted a fire drill to evaluate hazards that could be encountered during surgical procedures 12-4.1.2.10. The evaluation shall include hazards associated with the properties of electricity, hazards associated with the operation of surgical equipment, and hazards associated with the nature of the environment. Periodic reviews of surgical operations and procedures shall be conducted with special attention given to any change in materials, operations, or personnel.

1) The facility did not have Rules and Regulations posted in the operating room suite for personal concerned with Anesthesia locations. The established rules and regulations are to make familiar and to ensure enforcement.

2) The facility did not have a documented fire drill with doctors, nurses, scrub techs and other staff dedicated to the operating room that familiarizes staff with safety practices and an evaluation of hazards that could be encountered during surgical procedures. The evaluation shall include hazards associated with the properties of electricity, hazards associated with the operation of surgical equipment, and hazards associated with the nature of the environment. 12-4.1.2.10.

3) Documention of monthly incidents and annual review of Policies and Procedures yearly were not available. 12-4.1.2.10.

1) Based on observation and interview with staff, the facility failed to maintain design features initially approved for construction. The building must be maintained in accordance with approved design specifications. Any variations shall require the approval of the authority having jurisdiction prior to the actual change NFPA101 2000 Life Safety Code 5.1.7.
(5.1.7* Maintenance of Design Features. The design features
required for the building to continue to meet the performance
goals and objectives of this Code shall be maintained for
the life of the building. Such performance goals and objectives
shall include complying with all documented assumptions and
design specifications. Any variations shall require the approval
of the authority having jurisdiction prior to the actual change.)
(See also 4.6.9.2) Findings include:

a) The use of combustibles (alcohol) outside the operating room door and other agents in the sterile corridor for purpose of cleaning endoscopes is not allowed. A scope cleaning area was created outside the operating rooms without approval.

b) The recovery room was relocated in room 109, the room was designed as a doctors lounge.

c) The Decontamination/ Soiled utility room 61 has now been repurposed as an exam room. Dirty utility rooms are designed and located for storage of material that may combust with storing ,wrapping, and compacting, to relocate burdens on other areas of the hospital and items do not get handled appropriately.

d) Labor and delivery room, OB Corridor wall separation, and the wall separating the scrub /surgical 109 was removed without approval.

1) Based on review of the emergency Generator Logs, observation and interview with staff, the facility failed to inspect weekly and exercise under load for 30 minutes per month the Emergency Generator in accordance with NFPA 99. 3.4.4.1. Findings include:

a) The emergency generator was last documented as being run on July of 2013. Emergency Generator was not logged in 2014.

1) 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 include:

a) The recovery room is not provided with emergency power. The room, (111) was repurposed from a lounge to a recovery room. The room was not provided with dedicated an emergency circuit from the Critical Care Branch of the Emergency Distribution System.

b) Impedance testing of patient care areas is not a part of a Preventive Maintenance Program. 3-3.3.2.5. Measurements plus or minus of +/- 20% shall be made in patient Care Areas.

c) The emergency power distribution was not labeled and staff could not locate circuits. The facility emergency system was not labeled/defined with a Life Safety Branch Panel, Critical Care Branch Panel , and an Equipment Branch Panel. The facility did not have a single line drawing that depicts electrical distribution. Panel circuits were not all readable and labeled.

2) Based on observation, interview with staff, the facility failed to provide a program that provides an environment that is reasonably safe from the shock and burn hazards with the use of electricity in patient care areas. The hospital failed to adopt regulations and practices concerning the use of electric appliances and failed to establish programs for the training of physicians, nurses, and other personnel who might be involved in the procurement, application, use inspection, testing, and maintenance of electrical appliances for the care of patients. The hospital shall select a specific electrical safety program that is appropriate to its particular needs. The purchase of appliances shall be augmented by having designated departments of the facility assume responsibility for the continued inspection, testing, and maintenance of electrical appliances (NFPA 99, Chapter 7-6.5). Findings include:

a) The Vital Sign Machine found in the room that has been repurposed from a dirty utility room (room 61) to an exam room was last checked on March of 2012. The piece of equipment was to be rechecked on March of 2013. The facility did not remove the equipment from service and was being transported to patient room 51 for use on this day May the 15, 2014, at 3:30 pm.

b) The emergency room department has a battery powered cautery tool. As an example the facility did not provide yearly in-service for the use of the tool in conjunction with alcohol and an oxygen environment atmosphere. All equipment used in the operating room, emergency room and throughout the facility shall have a program that identifies the means and method for use in a safe and effective manner.

c) The facility failed to monitor the Bio-Medical equipment program. The facility did not have any documentation that the Bio-Medical services provided under contract had any way to identify quality and performance problems, implement appropriate corrective action, improvement activities, or to ensure the monitoring and sustainability of those corrective or improvement activities. See ?482.21 QAPI.