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1) Based on observation and interview with staff, the facility failed to provide Doors with a means suitable for keeping the door closed in its frame 19.3.6.3.

a) The door to the conference room was not provided with latching hardware.

b) There was no closure on the door to central processing room, located in the Operating Room suite.

c) There was no closure to the soiled utility room in the surgery suite.

d) Latching hardware to the ER door that allows egress out of the ED department was not provided.

1) Based on observation and interview with staff, the facility failed to provide Patient room doors that are arranged so that the patient can open the door from inside without using a key. 19.2.2.2.2. Findings include:

a) Locks on patient room doors were installed threw out the building, patients cannot open the door with out the use of a tool or key .

1) Based on observation and interview with staff, the facility failed to maintained the fire alarm system required for life safety that is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. Findings include:

a) The annual fire alarm test was not signed.

1) Based on observation and interview with staff, the facility failed to provide Heating, ventilating, and air conditioning 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

a) Test & Balance for Sterile Processing room showed to be negative, the room is required to be positive.

b) Sterile Storage was showed to be negative, the room is required to be positive.

c) ER room 3 was re-purposed from its original design, the room does not have air exchange and outside air.

d) ER waiting is not in an negative environment or has air recalculate threw the return with a HEPA Filter.

e) Air born Isolation Monitors in Rooms 116 and 117 does not have monitories and alarms that alert staff that the room is in non compliance with negative pressure requirement.

f) Exhaust for the sterilizer located in the sterile corridor was not provided.

1) Based on observation and interview with staff, the facility failed to create a room protected as a hazardous area when not attended or when Soiled linen or trash collection receptacles exceed 32 gal (121 L) in capacity. A capacity of 32 gal (121 L) shall not exceeded within any 64 sq ft (5.9-sq m) area . Findings include: 19.7.5.5

a) Two 50 gallon trash containers were found in the exit outside of the sterile corridor.

1) Based on observation and interview with staff, the facility failed to protect Anesthetizing locations that are in accordance with NFPA 99, Standard for Health Care Facilities. Relative humidity is maintained equal to or greater than 35%. NFPA 99 4.3.1.2.3(n) and 5.4.1.1, 19.3.2.3

a) Humidity Levels logged for the Operating Rooms in the surgical department were chronically out of compliance. The Range below 35% in winter months could not be maintained when Temperature were in the 20 degree range and below with low humidity.

b) Humidifier was not working that controlled humidity in the Operating Room Suites and in Central Processing Rooms. NFPA 99 1999 edition chapter 5-6.1.1 states that all ventilation and humidifying equipment be working.

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 a one time battery 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.

2) Based on review of the construction plans and interview with staff, the facility re-purposed, remodeling, modification, renovated the following spaces or change the use, 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) Front admitting and activity rooms are under construction with out approval.

b) The surgery suite unrestricted area, to semi restricted area, to restricted area was modified. Seating/ chairs in the egress corridor blocked; required egress corridors were not kept free and unobstructed in accordance with 7.1.10. Two 50 gallon Trash containers were staged in the egress corridor because soiled utility room has been modified and room for trach containers was not available.

c) Sterile storage and scope cleaning room was combined with out a separation. The door that separated the two rooms was removed.

d) Soiled utility and janitors closet was combined with the first stage of endo-scope cleaning; a hood required over the scope cleaning sink was not provided to remove chemical odors from the room.

e) ER 3 was not provided with Medical Gas piping,outlets and controlled by a zone valve. Dedicated Emergency Power circuits off of the Critical Care Branch and dedicated normal circuits were not provided in the room also.

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.

1) Based on observation and interview with staff, the facility failed to provide Doors with a means suitable for keeping the door closed in its frame 19.3.6.3.

a) The door to the conference room was not provided with latching hardware.

b) There was no closure on the door to central processing room, located in the Operating Room suite.

c) There was no closure to the soiled utility room in the surgery suite.

d) Latching hardware to the ER door that allows egress out of the ED department was not provided.

1) Based on observation and interview with staff, the facility failed to provide Patient room doors that are arranged so that the patient can open the door from inside without using a key. 19.2.2.2.2. Findings include:

a) Locks on patient room doors were installed threw out the building, patients cannot open the door with out the use of a tool or key .

1) Based on observation and interview with staff, the facility failed to maintained the fire alarm system required for life safety that is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. Findings include:

a) The annual fire alarm test was not signed.

1) Based on observation and interview with staff, the facility failed to provide Heating, ventilating, and air conditioning 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

a) Test & Balance for Sterile Processing room showed to be negative, the room is required to be positive.

b) Sterile Storage was showed to be negative, the room is required to be positive.

c) ER room 3 was re-purposed from its original design, the room does not have air exchange and outside air.

d) ER waiting is not in an negative environment or has air recalculate threw the return with a HEPA Filter.

e) Air born Isolation Monitors in Rooms 116 and 117 does not have monitories and alarms that alert staff that the room is in non compliance with negative pressure requirement.

f) Exhaust for the sterilizer located in the sterile corridor was not provided.

1) Based on observation and interview with staff, the facility failed to create a room protected as a hazardous area when not attended or when Soiled linen or trash collection receptacles exceed 32 gal (121 L) in capacity. A capacity of 32 gal (121 L) shall not exceeded within any 64 sq ft (5.9-sq m) area . Findings include: 19.7.5.5

a) Two 50 gallon trash containers were found in the exit outside of the sterile corridor.

1) Based on observation and interview with staff, the facility failed to protect Anesthetizing locations that are in accordance with NFPA 99, Standard for Health Care Facilities. Relative humidity is maintained equal to or greater than 35%. NFPA 99 4.3.1.2.3(n) and 5.4.1.1, 19.3.2.3

a) Humidity Levels logged for the Operating Rooms in the surgical department were chronically out of compliance. The Range below 35% in winter months could not be maintained when Temperature were in the 20 degree range and below with low humidity.

b) Humidifier was not working that controlled humidity in the Operating Room Suites and in Central Processing Rooms. NFPA 99 1999 edition chapter 5-6.1.1 states that all ventilation and humidifying equipment be working.

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 a one time battery 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.

2) Based on review of the construction plans and interview with staff, the facility re-purposed, remodeling, modification, renovated the following spaces or change the use, 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) Front admitting and activity rooms are under construction with out approval.

b) The surgery suite unrestricted area, to semi restricted area, to restricted area was modified. Seating/ chairs in the egress corridor blocked; required egress corridors were not kept free and unobstructed in accordance with 7.1.10. Two 50 gallon Trash containers were staged in the egress corridor because soiled utility room has been modified and room for trach containers was not available.

c) Sterile storage and scope cleaning room was combined with out a separation. The door that separated the two rooms was removed.

d) Soiled utility and janitors closet was combined with the first stage of endo-scope cleaning; a hood required over the scope cleaning sink was not provided to remove chemical odors from the room.

e) ER 3 was not provided with Medical Gas piping,outlets and controlled by a zone valve. Dedicated Emergency Power circuits off of the Critical Care Branch and dedicated normal circuits were not provided in the room also.

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.