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Based on observation and staff interview it was determined the facility failed to ensure combustible materials are stored in a protected hazardous area.

Findings:

On 9/13/2016 at 16:32, on a tour of the post-operative area near the surgical suite, an area next to a patient bed with hanging curtains contained clean scrubs on two steel 4 shelve racks and one steel hanging rack. The two - four shelved metal stocking racks were observed to be fully stocked with clean surgical scrubs and one steel hanging clothes rack was fully stocked with clean surgical scrubs. The barrier to the stored scrubs was hanging curtains on three of the four sides.

At 16:33, the staff member following the surveyors was asked about the storage of combustible materials open to the egress corridor. The staff member stated the room that did contain the scrubs was negatively ventilated and should be positively ventilated for clean storage so it was decided to store them where they are since they did not want to store them in a negatively ventilated room.


NFPA 101, 2000 Edition, Chapter 8
8.4.1 General
8.4.1.1*
Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42.

Based on observation and staff interview it was determined the facility failed to ensure their medical gas system was inspected and maintained.

Findings:

On 9/13/2016 at 16:04, on a tour of the facility medical gas storage area revealed the left bank of the nitrous oxide system gauge indicated zero pressure.

A facility staff acknowledged the zero pressure reading of the nitrous oxide left bank gauge. The staff member stated it is either empty or we may have a defective gauge.


NFPA 99, 1999 Edition Chapter 4
Piped in medical gas, vacuum and waste anesthetic gas disposal systems comply with NFPA 99, Chapter 4.

Based on observation it was determined the facility failed to ensure wiring was protected as required.

Findings:

On 9/13/2016 at 14:56, on tour of the 4th floor of the facility a refrigerator in the staff break room was observed to be plugged into a power tap.

On 9/14/2016, power strips were observed to be in use in the operating rooms without the adoption of the CMS categorical wavier for power strips.

Based on observation and staff interview it was determined the facility failed to ensure combustible materials are stored in a protected hazardous area.

Findings:

On 9/13/2016 at 16:32, on a tour of the post-operative area near the surgical suite, an area next to a patient bed with hanging curtains contained clean scrubs on two steel 4 shelve racks and one steel hanging rack. The two - four shelved metal stocking racks were observed to be fully stocked with clean surgical scrubs and one steel hanging clothes rack was fully stocked with clean surgical scrubs. The barrier to the stored scrubs was hanging curtains on three of the four sides.

At 16:33, the staff member following the surveyors was asked about the storage of combustible materials open to the egress corridor. The staff member stated the room that did contain the scrubs was negatively ventilated and should be positively ventilated for clean storage so it was decided to store them where they are since they did not want to store them in a negatively ventilated room.


NFPA 101, 2000 Edition, Chapter 8
8.4.1 General
8.4.1.1*
Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42.

Based on observation and staff interview it was determined the facility failed to ensure their medical gas system was inspected and maintained.

Findings:

On 9/13/2016 at 16:04, on a tour of the facility medical gas storage area revealed the left bank of the nitrous oxide system gauge indicated zero pressure.

A facility staff acknowledged the zero pressure reading of the nitrous oxide left bank gauge. The staff member stated it is either empty or we may have a defective gauge.


NFPA 99, 1999 Edition Chapter 4
Piped in medical gas, vacuum and waste anesthetic gas disposal systems comply with NFPA 99, Chapter 4.

Based on observation it was determined the facility failed to ensure wiring was protected as required.

Findings:

On 9/13/2016 at 14:56, on tour of the 4th floor of the facility a refrigerator in the staff break room was observed to be plugged into a power tap.

On 9/14/2016, power strips were observed to be in use in the operating rooms without the adoption of the CMS categorical wavier for power strips.