HospitalInspections.org

Based on observation, interview, and tour of the facility it was confirmed that several areas of the hospital failed to provided appropriate security to protect patients and staff.

Findings include:

During tour on 2/9/12 of the operation rooms it was observed that there is no security on who has access into the operating rooms, this was confirmed through interview with Staff I (Surgical Services). Staff I stated they are in the process of having card swipe installed due to the inability of knowing if unauthorized personal have entered the unit. At this point Staff I stated they have had two different proposals and are waiting for a decision.

Also during tour of the radiology department on 2/9/12 it was observed that there were multiple means of accesses even after hours where the general public could, and was walking throughout the unit as confirmed through interview with Staff H (Director of Radiology). Also Staff H confirmed that the unit can not be locked down and there are many different ways to access the department and at night there is only one technician on staff and with this size department it is very difficult to protect employees from outside visitors.

Also during tour on 2/9/12 with Staff F (Administrative Director of Nursing) it was confirmed that the elevator that is labeled "staff only" can be entered at any time which was confirmed through interview and observation. This elevator travels only to the Emergency department floor, (ICU) intensive care unit floor, operating rooms surgical suite floor, and the heliport and has direct access and any person can use it. On 2/9/12 Staff F and surveyor accesses the elevator off the back side of the emergency department by walking through the radiology department. The elevator button was pushed and the doors opened and Staff F and surveyor entered the elevator, then pushed the buttons inside the elevator and the doors closed, when they reopened we were standing in the surgical suite. Based on these findings the facility has failed to provide appropriate security mechanisms to protect the safety of the patients and staff .

Based on observation and interview the facility failed to ensure that all medical records in the out-patient sites were secure from unauthorized access.

Findings include:

During tour of the hospital satellite offices on 2/7/12 and 2/8/12 it was identified that some out-patient offices had not yet converted in whole to the electronic medical record. In these offices where paper records were in use it was identified that during off hours a contracted cleaning service was used at which times the paper records were not secure and were not protected from unauthorized access. Interview with Staff F (RN Administrative Director of Nursing) during observation confirmed the above findings.

Based on observation and interview the facility failed to secure drugs and biologicals to prevent access of unauthorized individuals to and into 3 anesthesia carts in a sample of 5.

Findings include:

Observation on tour of the surgical suite on 2/8/12 at 1:30 p.m. revealed the anesthesia carts in Operating Room 3, 5, and 8 were unlocked. The drawers of the anesthesia carts contained medications for the administration of anesthesia, and also contained needles and syringes.

Interview on 2/8/12 at 1:30 p.m. with Staff D, (Vice President of Operation Services), confirmed the anesthesia carts in the Operating Rooms 2, 5, and 8 were not locked. Staff D confirmed non clinical personnel did have unmonitored access to the surgical area.


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Based on tour of the facility and interview with staff it was found that the facility failed to kept biologicals in a secure and locked area.

Findings include:

During tour of the kitchen on 2/7/12 on the way to the Dumpsters with Staff G (Kitchen Director) it was observed that the facility had multiple full biological waste containers sitting on the loading dock unsecured. On 2/9/12 Staff F (Administrative Director of Nursing) was informed of the findings and was taken to the loading dock at which time there were no full containers of biologicals, but the room located on the loading dock where the biologicals hazard materials are stored was unable to be locked or secured. This was confirmed through interview with Staff F at time of finding.

AIA, (American Institute of Architecture) Guidelines for Design and Construction of Health Care Facilities 2.1 General Hospitals 8.2 General Standards for Details and Finishes 8.2.3.4 Ceilings

(3) Semirestricted areas

(a) Ceiling finishes in semirestricted areas such as air born infection isolation rooms, protective environment rooms, clean corridors, central sterile supply spaces, specialized radiographic rooms, and minor surgical procedure rooms shall be smooth, scrubbable, nonabsorptive, non perforated, capable of withstanding cleaning with chemicals, and without crevices that can harbor mold and bacterial growth.

(b) If lay-in ceiling is provided, it shall be gasketed or clipped down to prevent the passage of particles from the cavity above the ceiling plane into the semirestricted environment. Perforated, tegular, serrated, or highly textured tiles shall not be used.

(3) Restricted areas

(a)Ceilings in restricted areas (e.g., operating rooms) shall be of monolithic construction. Cracks or perforations in these ceilings shall not be permitted.

(b) Ceiling finishes shall be scrubbable and capable of withstanding cleaning and/or disinfecting chemicals.

(c) All access openings in these ceilings shall be gasketed.

Based on tour of the surgical suites on 2/8/12 with Staff E (Director of Moms place) it was observed that the facility failed to maintain a environment to meet surgical services.

Findings include:

During tour of the surgical suites in Moms place (birthing center) on 2/8/12 it was observed and shown to Staff E that the ceiling tiles located in the semi-restricted corridors between operating rooms 1 and 2 failed to be clipped down.

Also during tour of operating rooms 1 and 2 it was observed that the ceiling over the neonatal holding area were suspended ceiling tiles that were perforated and non monolithic. Both area are located within the operating rooms, and ceilings need to be of monolithic construction and finishes must be scrubbable and capable of withstanding cleaning and/or disinfecting chemicals. Both above findings were shown to Staff E at time of findings.

AIA (American Institute of Architecture) 2006
5.2.2 Finishes, 5.2.2.4 walls. Wall finishes shall be appropriate for the areas in which they are located and shall be as follows:...

3) Wall finishes in areas such as operating rooms, delivery rooms, and trauma rooms shall be scrubbable, able to withstand chemical cleaning and monolithic.

Findings include:

During tour of the surgical suites on 2/7/12 it was observed by surveyor and shown to Staff E that the 2 surgical suites(operating rooms) had wall paper border on all four walls. The wall paper was textured making it porous and failing to be scrubbable to withstand chemicals.

AIA (American Institute of Architecture) 2010 2.2-5 General Support Services and Facilities.
2.2-5.1.3.1 Clean/Sterile medical/surgical supplies

(1) A room for breakdown shall be provided for manufacturers' clean/sterile supplies. The clean processing area shall not be in this area but in an adjacent space.

Based on tour of the Central sterile supply room it was observed that the facility failed to breakdown supply's from shipping cartons before entering the Central sterile supply room.


Findings include:

During tour of the facility's Central sterile supply room on 2/8/12 it was observed that several corrugated boxes were being emptied in the central sterile supply core and had not been taken out of the shipping boxes and broken down before entering this area.

AIA (American Institute of Architecture) 2010 2.1-7.2.3 Surfaces 2.1-7.2.3.2 Flooring

(1) Selected flooring surfaces shall be easily maintained, readily cleanable,and appropriately wear-resistant for the location.

Based on tour of the radiology department it was observed that the floor located in the radiology department was cracked and worn.

Findings include:

During tour of the radiology department with Staff H (Director of Radiology) it was observed and shown to Staff H that the floor labeled as "Patient Prep B" was cracked and worn in multiple areas and unable to be cleanable due to the surface.

Based on observation and interview the facility failed to ensure that all equipment was maintained in a manner to allow for complete disinfection after patient use.

Findings include:

During the validation survey dated 2/7/12 through 2/9/12 observations at out-patient satellites identified that several exam tables had tears and worn areas on the vinyl covers. Interview with Staff F (RN Administrative Director of Nursing) during all observations confirmed the condition of the tables.

ANSI [Approved American National Standard]/ASHRAE/ASHE [American Society for Healthcare Engineering] Standard 170-2008 Ventilation of Health Care Facilities. Page 11. 7.4 Surgery Rooms. 7.4.1 Class B and C Operating Rooms. Operating rooms shall be maintained at a positive pressure with respect to all adjoining spaces at all times. A pressure differential shall be maintained at a value of at least =0.01 in. wc (2.5Pa).

ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) Chapter 7 Health Care Facilities. Specific Design Criteria Surgery and Critical Care. 7.5 The following conditions are recommended for operating, catheterization, cystoscopic, and fracture rooms:

*Air pressure should be kept positive with respect to any adjoining rooms by supplying excess air.

*A differential-pressure-indication device should be installed to permit air pressure readings in the rooms. Thorough sealing of all wall, ceiling, and floor penetrations, and tight-fitting doors are essential to maintaining readable pressure.

Based on observation and interview the facility failed to maintain and monitor 11 surgical suits for positive pressure using differential-pressure-indication devices.

Findings include:

During tour of the hospitals surgical suites it was observed that 11 class B and C operating rooms failed to have differential pressure indication devices on the walls to show that the rooms are in positive pressure to the adjoining spaces. This finding was also shown to Staff D (Director of Surgical Services) at the time of tour.


ANSI [Approved American National Standard]/ASHRAE/ASHE [American Society for Healthcare Engineering] Standard 170-2008 Ventilation of Health Care Facilities. Page (5-6).
6.7 Air Distribution Systems

6.7.1 "General. Maintain the pressure relationships required in Table 7-1 in all modes of HVAC system operation, except as noted in the table. Spaces listed in Table 7-1 that have required pressure relationships shall be served by fully ducted returns. The air -distribution design shall maintain the required space pressure relationships..."

7. Space Ventilation

The ventilation requirements of this standard are minimums that provide control of environmental comfort, asepsis and odor in health care facilities. However, because they are minimum requirements and because of the diversity of the population the variations in susceptibility and sensitivity, these requirements do not provide assured protection from discomfort, airborne transmission of contagions and odors.

7.1 General Requirements. The following general requirements shall apply for space ventilation:
1. Space shall be ventilated according to Table 7-1.

Based on an observation and interview the facility failed to maintain proper air quality during tour of the pathologist grossing room due to a pungent/strong smell.

Findings include:

When touring the pathology lab on 2/9/12 the smell of chemical was very strong when entering the grossing room, eyes became irritated and watery and there was a strong odor and also was bothersome to the throat. Interview with Staff A (Pathologist ) and Staff B (specimen entree) confirmed that the smell is always strong in the grossing room and comes into the lab area also. When touring with Staff C (Pathologist supervisor) who confirmed that the only exhaust units in the room were the two Pathology benches. Staff C went on to say the one bench to the left runs one hundred percent of the time, and the other bench fluctuates on and off since it is connected to the hospital ventilation system. The facility did not have a balance report to show the air movement and due to the pungent smell in the area the movement of air is not sufficient to move odors from this area. The only ventilation in the room were the two supply units in the ceiling with no lower exhaust vents visible to remove the smells from this very large grossing room except the two bench units which do not run one hundred percent of the time.