HospitalInspections.org

Based on observation during the survey on May 7, 2013 this regulation has not been met by the facility as evidenced by;

The old intensive care unit (ICU) space is currently used to store various items including but not limited to clean linen, equipment, supplies, boxes, furnishings, and etc. This space is not properly ventilated and does impact the items stored inside.

In addition, there is an active handwash sink immediately adjacent to the live electric panel. The electric panel requires a minimum of three feet of clear floor in front of it and the live water lines with the live electric panel is a huge potential hazard. Also, other equipment is stored very close to the electric panel area.

Based on observation during the survey on May 7, 2013 this regulation has not been met by the facility as evidenced by;

High dust was visible above cabinets and equipment at various locations including but not limited to:
1. CT machine;
2. Nuclear Medicine;
3. Lint on the floor at the x-ray room; and
4. Task light and high cabinets in the Emergency Room. Proper dusting/cleaning program is required to provide a sanitary environment.

Based on observation during the survey on May 7, 2013 this regulation has not been met by the facility as evidenced by;
1. The use of two floor fans in the kitchen area was an indication of lack of proper ventilation
2. The illumination level in blood draw room serving in the lab area was measured at 24 to 28 foot-candles (fc) in lieu of the required 50 fc. The illumination level in the blood draw area is deficient.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on 5/8/2013, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated 5/8/2013 for Life Safety Code.

Based on Quality Assessment and Performance Improvement (QAPI) document review and interview the facility failed to ensure that the outpatient rehabilitation facility was incorporated in the QAPI program. Findings include:

During QAPI document review on 5/8/13 at approximately 1000 it was discovered that there was no QAPI involvement noted in the meeting minutes by the outpatient rehabilitation facility.
During a tour of the outpatient rehabilitation facility on 5/8/13 at approximately 1030, staff I and K were asked what type of QAPI involvement the facility was developing, they mutually responded, "None".