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

a) The door to physical therapy was not provided with a closure.

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) Air flow for the Operating Room suite was not documented.

b) Air flow to ER is not negative or provided with HEPA Filtration. The exhaust fan located on the roof to the ER Waiting was not working .

c) Manometers were not logged for HEPA Filter efficiencies in the Operating Rooms .

1) Based on interview with staff, and observation, the facility failed to provide Piped in medical gas systems comply with NFPA 99, Chapter 4. Findings include:

a) Sign for the main gas shut off was not displayed in the bulk storage site.

1) Based on interview with Operating Room Staff, the facility has not adopted Rules and Regulations or Posted Rules and Regulations that are in accordance with NFPA 99 1999 edition Chapter 12- 4.1.1.4 for the control of personal in Anesthetizing Locations.

a) Operating Room Staff had not been throughly in-serviced for Specific Area Requirements for Anesthetizing Locations in accordance with 12-4.1.1 through 12-4.1.2.10.

1) Based on observation and interview with staff, the facility failed to provide a Type I Essential Electrical System powered by a generator with a transfer switch and separate power supply. The EES is in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4. Findings include:

a) There was not an remote enunciator located in a 24 hour manned station. The only alarm was located in the maintenance shop.

b) The alarm low temp light was on the emergency generator .

c) The alarm lights were so diem on the alrm in the maintenance shop that the generator could not be monitored, temp light on was discovered when door to Emergency Generator room was opened.

1) Based on review of the construction plans and interview with staff, the facility re-purposed, remodeling, modification, renovated the following spaces or equipment , or change specified design criteria and assumptions with out a re-evaluation and re-approval in accordance with NFPA 101 2000 edition chapter 5.8.14.

a) The renovation of the HVAC Equipment, designed in December 12, by Engineering Future Focused Solutions was not installed in accordance with specifications and construction documents stamped by an engineer.

b) The design was not submitted to the authority having jurisdiction.

c) Designed documents/as built's were not reviewed by an engineer and a part of required construction documents.

d) Design of the equipment installed was not designed and stamped by an engineer.

e) Test and Balance for equipment installed was not available for review or was conducted.

2) Based on review and interview with staff, the facility modified the following spaces or equipment , or change specified design criteria and assumptions with out a re-evaluation and re-approval in accordance with NFPA 101 2000 edition chapter 5.8.14.

a) The CT Scan mobile Trailer was located on the north side of the building, the facility failed to provide protection from inclement weather, the facility failed to have authority having jurisdiction review physis report.

3) Battery back up lights in operating room, and over the transfer switches were not on a 30 day and annual testing program in accordance with 7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test.

a) Written records of visual inspections and tests were not kept by the owner for inspection by the authority having jurisdiction.

b) Battery Back up lights in the CT Mobile Trailer were not on a testing program.

1) Based on observation and interview with staff, the facility failed to have a program in accordance with NFPA 99 1999 edition chapter 7-6.5.1 that requires Personnel concerned with the application and maintenance of electric appliances, including physicians, nurses nurse aids, engineers, technicians, and orderlies, shall be cognizant of the risks associated with their use. To achieve this end the hospital shall provide appropriate programs of continuing education for its personnel

a) The facility did not have a program that include periodic review of manufactures units and similar appliances and usage requirements for electrosurgical units and similar appliances in the hospital.

b) Staff has not been trained with the use of the cautery tool located in the Emergency Department. This tool in conjunction with Oxygen and Alcohol in a room will create a fire, the facility did not have time out in accordance with NFPA 12-4.1.2.10. Emergency procedures were not established for extinguishing drapery, clothing, or equipment fires.

c) The facility failed to have a Impedance Testing, Receptacle Testing, and Record Keeping Program in accordance with 3-3.3.2 through 3-3.4.3

d) The Line Isolation Monitores were not tested in accordance with 3-3.3.4.2

2) Bio Medical Equipment and Exterminator programs was not monitored in accordance with Interruptive Guidelines. The facility governing body failed to take actions through the hospital ' s QAPI program to: assess the services furnished directly by provided under contract, identify quality and performance problems, implement appropriate corrective or improvement activities, and to ensure the monitoring and sustainability of those corrective or improvement activities.

a) Bio Medical Equipment for the hospital was not monitored with manufacture guidelines for compliance, accuracy,and documented.

b) The governing body also failed to monitor the exterminator used by the facility in accordance with the Director of Maintenance.

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

a) The door to physical therapy was not provided with a closure.

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) Air flow for the Operating Room suite was not documented.

b) Air flow to ER is not negative or provided with HEPA Filtration. The exhaust fan located on the roof to the ER Waiting was not working .

c) Manometers were not logged for HEPA Filter efficiencies in the Operating Rooms .

1) Based on interview with staff, and observation, the facility failed to provide Piped in medical gas systems comply with NFPA 99, Chapter 4. Findings include:

a) Sign for the main gas shut off was not displayed in the bulk storage site.

1) Based on interview with Operating Room Staff, the facility has not adopted Rules and Regulations or Posted Rules and Regulations that are in accordance with NFPA 99 1999 edition Chapter 12- 4.1.1.4 for the control of personal in Anesthetizing Locations.

a) Operating Room Staff had not been throughly in-serviced for Specific Area Requirements for Anesthetizing Locations in accordance with 12-4.1.1 through 12-4.1.2.10.

1) Based on observation and interview with staff, the facility failed to provide a Type I Essential Electrical System powered by a generator with a transfer switch and separate power supply. The EES is in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4. Findings include:

a) There was not an remote enunciator located in a 24 hour manned station. The only alarm was located in the maintenance shop.

b) The alarm low temp light was on the emergency generator .

c) The alarm lights were so diem on the alrm in the maintenance shop that the generator could not be monitored, temp light on was discovered when door to Emergency Generator room was opened.

1) Based on review of the construction plans and interview with staff, the facility re-purposed, remodeling, modification, renovated the following spaces or equipment , or change specified design criteria and assumptions with out a re-evaluation and re-approval in accordance with NFPA 101 2000 edition chapter 5.8.14.

a) The renovation of the HVAC Equipment, designed in December 12, by Engineering Future Focused Solutions was not installed in accordance with specifications and construction documents stamped by an engineer.

b) The design was not submitted to the authority having jurisdiction.

c) Designed documents/as built's were not reviewed by an engineer and a part of required construction documents.

d) Design of the equipment installed was not designed and stamped by an engineer.

e) Test and Balance for equipment installed was not available for review or was conducted.

2) Based on review and interview with staff, the facility modified the following spaces or equipment , or change specified design criteria and assumptions with out a re-evaluation and re-approval in accordance with NFPA 101 2000 edition chapter 5.8.14.

a) The CT Scan mobile Trailer was located on the north side of the building, the facility failed to provide protection from inclement weather, the facility failed to have authority having jurisdiction review physis report.

3) Battery back up lights in operating room, and over the transfer switches were not on a 30 day and annual testing program in accordance with 7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test.

a) Written records of visual inspections and tests were not kept by the owner for inspection by the authority having jurisdiction.

b) Battery Back up lights in the CT Mobile Trailer were not on a testing program.

1) Based on observation and interview with staff, the facility failed to have a program in accordance with NFPA 99 1999 edition chapter 7-6.5.1 that requires Personnel concerned with the application and maintenance of electric appliances, including physicians, nurses nurse aids, engineers, technicians, and orderlies, shall be cognizant of the risks associated with their use. To achieve this end the hospital shall provide appropriate programs of continuing education for its personnel

a) The facility did not have a program that include periodic review of manufactures units and similar appliances and usage requirements for electrosurgical units and similar appliances in the hospital.

b) Staff has not been trained with the use of the cautery tool located in the Emergency Department. This tool in conjunction with Oxygen and Alcohol in a room will create a fire, the facility did not have time out in accordance with NFPA 12-4.1.2.10. Emergency procedures were not established for extinguishing drapery, clothing, or equipment fires.

c) The facility failed to have a Impedance Testing, Receptacle Testing, and Record Keeping Program in accordance with 3-3.3.2 through 3-3.4.3

d) The Line Isolation Monitores were not tested in accordance with 3-3.3.4.2

2) Bio Medical Equipment and Exterminator programs was not monitored in accordance with Interruptive Guidelines. The facility governing body failed to take actions through the hospital ' s QAPI program to: assess the services furnished directly by provided under contract, identify quality and performance problems, implement appropriate corrective or improvement activities, and to ensure the monitoring and sustainability of those corrective or improvement activities.

a) Bio Medical Equipment for the hospital was not monitored with manufacture guidelines for compliance, accuracy,and documented.

b) The governing body also failed to monitor the exterminator used by the facility in accordance with the Director of Maintenance.