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Based on document review and interview, it was determine there was no evidence policies and procedures were in place to accept and facilitate the use of volunteers in the event of an emergency. The failed practice had the potential to affect all patients, visitors, and staff because rapid response could be impeded in the event of an influx of patients during an emergency. There was a census of 23 patients on 03/26/18. Findings follow:

A. Review of the Emergency Preparedness Plan on 03/27/18 at 8:30 AM showed no evidence of policies and procedures were in place to facilitate support from volunteers of varying skills (both medical and non-medical), credentialing, and training in the event of an emergency.
B. During an interview with the Facility Administrator on 03/27/18 at 3:00 PM, it was verified no further evidence was available for review.

Based on observation and interview, it was observed in two of two (Emergency Room Electrical Closet and Engineering Office Electrical Room) electrical rooms located in the surgical corridor four electrical panels which did not have a minimum of 36 inches (three feet) working space in front of the panels because of equipment stored in the electrical room. The failed practice had the potential to affect all patients, visitors, and staff because rapid access to the panels could not be gained in the event of an emergency in addition to creating a potential fire hazard. Findings follow:

A. While touring the facility on 03/27/18 at 1:00 PM, observation showed a chair and a cart stored in front of two electrical panels in the Emergency Room Electrical Closet.
B. While touring the facility on 03/27/18 at 2:00 PM, observation showed a file cabinet stored in front an electrical panel in the Engineering Office Electrical Room.
C. During the tour, it was verified by the Engineering Technician the electrical panels were blocked.

Referenced Codes: NFPA 101, 2012 edition, Section: 9.1.2; NFPA 99, 2012 edition, Section: 6.3.2.1; NFPA 70, 2011 edition, Article: 110.26

Based on observation and interview, it was determined three of three (Operating Rooms (ORs) #1, and #2 and the endoscopy procedure room) procedure rooms were not protected by either isolated power or Ground-Fault Circuit Interrupters (GFCIs); nor, was there evidence presented a risk assessment had been performed to indicate that the ORs were not to be considered as "wet locations" in which the receptacles need to be protected. The failed practice had the potential to affect all patients and staff in the ORs because it could not be assured that any electrical equipment connected to the receptacles would not present a shock hazard. Findings follow:

A. While touring the facility on 03/27/18 at 2:00 PM, observation showed:
1. The receptacles in OR#1 were neither connected to an isolated electrical panel; nor, were they Ground Fault Circuit Interrupting (GFCI).
2. The receptacles in OR#2 were neither connected to an isolated electrical panel; nor, were they GFCI.
3. The receptacles in the Endoscopy Procedure Room were neither connected to an isolated electrical panel; nor, were they GFCI.
B. During the tour, the Engineering Technician verified the receptacles were not protected by either an isolation panel or were they GFCI and no evidence was presented to indicate that a risk assessment had been performed to determine that the receptacles did not need to be protected in the above manner.

Referenced codes: NFPA 99, 2012 Edition, Sections: 6.3.2.2.8.4, 6.3.2.2.8.7; NFPA 70, 2011 Edition, Article: 517.20