HospitalInspections.org

Based on observation and interview, the facility does not ensure that penetrations are sealed with a fire rated material at the main hospital site and Dundee extension clinic. Failure to provide adequate separation may potentially cause fire/smoke to be present on adjoining floors through unprotected openings.

Findings include:

Observation on 06/15/16 at 10:30AM revealed penetrations were present in the walls of the mechanical room at the Dundee extension clinic. On 06/16/16 at 3:30PM, penetrations were noted around the municipal sewer line from the 1st floor, above ceiling tiles in rehab office of the main hospital. These penetrations must be sealed to prevent fire/smoke from entering adjacent areas.

Interview on 06/15/16 at 10:40AM with Staff #26 and on 06/16/16 at 3:40PM with Staff
#26 and 27 verified these findings.

Based on observation and interview, the facility does not ensure that door assemblies are identified with a fire protection rating. Failure to provide this labeling may result in the assembly failing prematurely in the event of an actual fire.

Findings include:

Observation on 06/16/16 at 2:30PM revealed the door frame between the hospital and the adjoining nursing home did not indicate that the frame was fire rated in this assembly. Interview with Staff #26 and #27 indicated that this wall and door opening created a 2-hour separation between the two facilities. Without the presence of this rating, it is not possible to determine if this opening is adequately protected in the event of an actual fire emergency.

Based on observation and interview, the facility does not ensure that a self-closing device is present on the custodial closet that opens into the egress pathway at the Dundee extension clinic site. Failure to provide a self-closing device on this door may obstruct the egress pathway to the marked exit.

Findings include:

Observation on 06/15/16 at 11:20AM at the Dundee extension clinic revealed that a self-closing device was not present on the door entering the custodial closet. This door opened into the rear egress pathway and was greater than ½ the width of the 4 ' corridor.

Interview on 06/15/16 at 11:30AM with Staff #26 verified this finding.

Based on document review and interview, the facility does not ensure fire drills are performed quarterly at the Dundee extension clinic. Failure to perform fire drills may cause harm to the staff and patients.

Findings include:

Review on 06/15/16 at 9:50AM of fire drill documentation for the Dundee extention clinic revealed the facility performed only one fire drill in 2014 and 2015. Only one drill has been performed to date for 2016.

Interview on 06/15/16 at 10:00AM with Staff #33 verified these findings and was not aware of the frequency that the drills had to be performed.

Based on document review and interview, the facility does not ensure that the fire alarm system is tested annually at the Dundee extension clinic. Failure to test this system may cause harm to the staff and patients in the event of an actual fire.

Findings include:

Document review on 06/15/16 at 10:30AM revealed no evidence of a fire alarm inspection report. Interview with Staff #26 and #33 verified that the fire alarm system is not tested annually. All components that comprise the fire alarm system must be tested annually to ensure proper operation. The components consist of the fire alarm control panel and batteries, smoke detectors, heat detectors, hold open devices, pull stations and any other device that may be a component of the system.

Based on document review, observation and interview, the facility does not ensure that adequate air changes per hour (ACH) are provided for the airborne infectious isolation rooms or that self-closing devices were present on rooms that require specific pressure relationship to adjacent areas. Failure to provide and maintain adequate ACH may result in inadequate protection for the staff, patients and equipment.

Findings include:

Review on 06/14/16 at 11:00AM of the monthly preventative maintenance reports for 5 of 5 isolation rooms indicated that the ACH ranged from 6-8.5 ACH. These rooms are located in the emergency department room #8, Intensive Care Unit room "C", the morgue and room #120 and #122. A minimum of 12 ACH must be provided in these rooms to ensure that an adequate pressure differential is maintained in relationship to adjoining areas. Interview with Staff #26 and 27 verified this finding.

Observation on 06/16/16 at 10:50AM revealed the doors entering the clean and dirty/reprocessing room in the endoscopy suite did not have a self-closing device present. A self-closing device must be installed on these doors to ensure that the correct pressure differential is maintain in relationship to the adjacent areas. Interview with Staff #26 and 27 verified this finding.

Based on observation and interview, the facility does not ensure that the manual pull station is provided in the egress pathway for the fire extinguishing equipment in the kitchen area or that caps are present on the extinguishing system. Failure to provide this pull station in the egress pathway and the caps on the nozzles may result in harm to the staff or malfunctioning of the extinguishing equipment.

Findings include:

Observation on 06/17/16 at 11:00AM revealed that the pull station for the Ansul hood that is located in the kitchen was not located in the pathway of egress. This device was located on the east wall, on the opposite side of the stainless steel prep table, behind the grill and grease fryer. This device must be located in the pathway of egress to ensure proper activation in the event of a fire emergency. Additionally, 1 of 3 caps were not present on the nozzles on the extinguishing system.

Interview on 06/17/16 at 11:15AM with Staff #26 and #27 verified these findings.

Based on observation, document review and interview, the facility failed to ensure that piped medical air is utilized for patient use only and/or that the medical gas system is maintained. Failure to use medical air for patient use only may result in potentially introducing opportunities for contamination and failure to maintain the medical gas system my result in patient harm.

Findings include:

Observation on 06/16/16 at 10:00AM of the endoscope reprocessing unit revealed Staff #49 utilized the piped medical air to blow out the endoscope after it had been reprocessed. Use of this compressed air supply must not be utilized for purposes other than patient care because such use may increase service interruptions, reduce service life and potentially introduce additional opportunities for contamination. Interview with Staff #40 and #48 verified this finding.

Review on 06/14/16 of the June 2015 Medical Gas Inspection report indicated that 9 check valves were leaking on the vacuum outlets, 3 check valves were leaking on the oxygen outlets, 2 vacuum outlets had low dynamic flow, 4 oxygen outlets had low flow and 2 oxygen outlets had the flow meter stuck on 0.5 liters per minute (LPM). A label was not present on the area alarm for Intensive Care Unit and rooms 101-111. Gauges were not present on the shut-off valves for the ground floor, imaging unit or for rooms 112-123. No evidence was found to indicate corrective actions were performed on issues identified to be deficient.

Interview on 06/14/16 at 10:55AM with Staff #26 verified these findings.

Based on observation, document review and interview, the facility does not ensure that the eye wash station is tested weekly at the Dundee extension clinic. Failure to test this device weekly may result in harm to the staff.

Findings include:

Observation on 06/15/16 at 12:00PM at the Dundee extension clinic nursing station revealed no evidence that the emergency eyewash station is tested weekly. Interview with Staff #8 verified that the facility does not test the emergency eyewash station and was informed that this device was not an "emergency eyewash", but was for eye flushing only. Review of the chemical list located in the custodial closet indicated that corrosive products are present in the facility. This device must be tested weekly to ensure that the unit is operating properly and that the temperature is adequate for this device.

Interview on 06/15/16 at 12:15PM with Staff #26 verified this finding.

Based on document review and interview, the facility does not ensure that weekly inspections are performed on the emergency generator. Failure to perform these inspections may result in the generator not being operational in the event of a power failure.

Findings include:

Review on 06/13/16 at 11:30AM of the emergency generator logs revealed weekly inspections were not performed on the emergency generator. Interview with Staff #51 revealed he does not perform weekly inspections on the emergency generator. Weekly inspections are to consist of visual inspections of the following: the fuel supply, the lubrication system, the cooling system, the battery system, electrical system and the general condition of the generator system.

Based on observation and interview, the facility does not ensure that non-hospital grade electrical outlets are tested annually and that ground fault circuit interrupters (GFCI) are tested semi-annually in patient care areas or annually in other areas. Failure to test these devices may result in patient harm.

Findings include:

Observation on 06/15/16 at 11:00AM at the Dundee extension clinic revealed that non-hospital grade outlets and GFCI were present. On 06/16/16 at 2:00PM at the main hospital campus revealed GFCI were present.

An interview with Staff #26 on 06/14/16 at 10:05AM and on 06/15/16 at 11:15AM verified that the facility does not perform GFCI testing every six months in patient care areas or annually in other locations. Non-hospital grade electrical outlets are not tested annually for tension, polarity and grounding.

Based on observation and interview, the facility does not ensure that penetrations are sealed with a fire rated material at the main hospital site and Dundee extension clinic. Failure to provide adequate separation may potentially cause fire/smoke to be present on adjoining floors through unprotected openings.

Findings include:

Observation on 06/15/16 at 10:30AM revealed penetrations were present in the walls of the mechanical room at the Dundee extension clinic. On 06/16/16 at 3:30PM, penetrations were noted around the municipal sewer line from the 1st floor, above ceiling tiles in rehab office of the main hospital. These penetrations must be sealed to prevent fire/smoke from entering adjacent areas.

Interview on 06/15/16 at 10:40AM with Staff #26 and on 06/16/16 at 3:40PM with Staff
#26 and 27 verified these findings.

Based on observation and interview, the facility does not ensure that door assemblies are identified with a fire protection rating. Failure to provide this labeling may result in the assembly failing prematurely in the event of an actual fire.

Findings include:

Observation on 06/16/16 at 2:30PM revealed the door frame between the hospital and the adjoining nursing home did not indicate that the frame was fire rated in this assembly. Interview with Staff #26 and #27 indicated that this wall and door opening created a 2-hour separation between the two facilities. Without the presence of this rating, it is not possible to determine if this opening is adequately protected in the event of an actual fire emergency.

Based on observation and interview, the facility does not ensure that a self-closing device is present on the custodial closet that opens into the egress pathway at the Dundee extension clinic site. Failure to provide a self-closing device on this door may obstruct the egress pathway to the marked exit.

Findings include:

Observation on 06/15/16 at 11:20AM at the Dundee extension clinic revealed that a self-closing device was not present on the door entering the custodial closet. This door opened into the rear egress pathway and was greater than ½ the width of the 4 ' corridor.

Interview on 06/15/16 at 11:30AM with Staff #26 verified this finding.

Based on document review and interview, the facility does not ensure fire drills are performed quarterly at the Dundee extension clinic. Failure to perform fire drills may cause harm to the staff and patients.

Findings include:

Review on 06/15/16 at 9:50AM of fire drill documentation for the Dundee extention clinic revealed the facility performed only one fire drill in 2014 and 2015. Only one drill has been performed to date for 2016.

Interview on 06/15/16 at 10:00AM with Staff #33 verified these findings and was not aware of the frequency that the drills had to be performed.

Based on document review and interview, the facility does not ensure that the fire alarm system is tested annually at the Dundee extension clinic. Failure to test this system may cause harm to the staff and patients in the event of an actual fire.

Findings include:

Document review on 06/15/16 at 10:30AM revealed no evidence of a fire alarm inspection report. Interview with Staff #26 and #33 verified that the fire alarm system is not tested annually. All components that comprise the fire alarm system must be tested annually to ensure proper operation. The components consist of the fire alarm control panel and batteries, smoke detectors, heat detectors, hold open devices, pull stations and any other device that may be a component of the system.

Based on document review, observation and interview, the facility does not ensure that adequate air changes per hour (ACH) are provided for the airborne infectious isolation rooms or that self-closing devices were present on rooms that require specific pressure relationship to adjacent areas. Failure to provide and maintain adequate ACH may result in inadequate protection for the staff, patients and equipment.

Findings include:

Review on 06/14/16 at 11:00AM of the monthly preventative maintenance reports for 5 of 5 isolation rooms indicated that the ACH ranged from 6-8.5 ACH. These rooms are located in the emergency department room #8, Intensive Care Unit room "C", the morgue and room #120 and #122. A minimum of 12 ACH must be provided in these rooms to ensure that an adequate pressure differential is maintained in relationship to adjoining areas. Interview with Staff #26 and 27 verified this finding.

Observation on 06/16/16 at 10:50AM revealed the doors entering the clean and dirty/reprocessing room in the endoscopy suite did not have a self-closing device present. A self-closing device must be installed on these doors to ensure that the correct pressure differential is maintain in relationship to the adjacent areas. Interview with Staff #26 and 27 verified this finding.

Based on observation and interview, the facility does not ensure that the manual pull station is provided in the egress pathway for the fire extinguishing equipment in the kitchen area or that caps are present on the extinguishing system. Failure to provide this pull station in the egress pathway and the caps on the nozzles may result in harm to the staff or malfunctioning of the extinguishing equipment.

Findings include:

Observation on 06/17/16 at 11:00AM revealed that the pull station for the Ansul hood that is located in the kitchen was not located in the pathway of egress. This device was located on the east wall, on the opposite side of the stainless steel prep table, behind the grill and grease fryer. This device must be located in the pathway of egress to ensure proper activation in the event of a fire emergency. Additionally, 1 of 3 caps were not present on the nozzles on the extinguishing system.

Interview on 06/17/16 at 11:15AM with Staff #26 and #27 verified these findings.

Based on observation, document review and interview, the facility failed to ensure that piped medical air is utilized for patient use only and/or that the medical gas system is maintained. Failure to use medical air for patient use only may result in potentially introducing opportunities for contamination and failure to maintain the medical gas system my result in patient harm.

Findings include:

Observation on 06/16/16 at 10:00AM of the endoscope reprocessing unit revealed Staff #49 utilized the piped medical air to blow out the endoscope after it had been reprocessed. Use of this compressed air supply must not be utilized for purposes other than patient care because such use may increase service interruptions, reduce service life and potentially introduce additional opportunities for contamination. Interview with Staff #40 and #48 verified this finding.

Review on 06/14/16 of the June 2015 Medical Gas Inspection report indicated that 9 check valves were leaking on the vacuum outlets, 3 check valves were leaking on the oxygen outlets, 2 vacuum outlets had low dynamic flow, 4 oxygen outlets had low flow and 2 oxygen outlets had the flow meter stuck on 0.5 liters per minute (LPM). A label was not present on the area alarm for Intensive Care Unit and rooms 101-111. Gauges were not present on the shut-off valves for the ground floor, imaging unit or for rooms 112-123. No evidence was found to indicate corrective actions were performed on issues identified to be deficient.

Interview on 06/14/16 at 10:55AM with Staff #26 verified these findings.

Based on observation, document review and interview, the facility does not ensure that the eye wash station is tested weekly at the Dundee extension clinic. Failure to test this device weekly may result in harm to the staff.

Findings include:

Observation on 06/15/16 at 12:00PM at the Dundee extension clinic nursing station revealed no evidence that the emergency eyewash station is tested weekly. Interview with Staff #8 verified that the facility does not test the emergency eyewash station and was informed that this device was not an "emergency eyewash", but was for eye flushing only. Review of the chemical list located in the custodial closet indicated that corrosive products are present in the facility. This device must be tested weekly to ensure that the unit is operating properly and that the temperature is adequate for this device.

Interview on 06/15/16 at 12:15PM with Staff #26 verified this finding.

Based on document review and interview, the facility does not ensure that weekly inspections are performed on the emergency generator. Failure to perform these inspections may result in the generator not being operational in the event of a power failure.

Findings include:

Review on 06/13/16 at 11:30AM of the emergency generator logs revealed weekly inspections were not performed on the emergency generator. Interview with Staff #51 revealed he does not perform weekly inspections on the emergency generator. Weekly inspections are to consist of visual inspections of the following: the fuel supply, the lubrication system, the cooling system, the battery system, electrical system and the general condition of the generator system.

Based on observation and interview, the facility does not ensure that non-hospital grade electrical outlets are tested annually and that ground fault circuit interrupters (GFCI) are tested semi-annually in patient care areas or annually in other areas. Failure to test these devices may result in patient harm.

Findings include:

Observation on 06/15/16 at 11:00AM at the Dundee extension clinic revealed that non-hospital grade outlets and GFCI were present. On 06/16/16 at 2:00PM at the main hospital campus revealed GFCI were present.

An interview with Staff #26 on 06/14/16 at 10:05AM and on 06/15/16 at 11:15AM verified that the facility does not perform GFCI testing every six months in patient care areas or annually in other locations. Non-hospital grade electrical outlets are not tested annually for tension, polarity and grounding.