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1) Based on observation and interview with staff, the facility failed to provide doors that are provided with positive latching hardware in accordance with 19.3.6.3.2. Doors shall be provided with a means suitable for
keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.. Findings include:

a) Doors in the emergency department were provided with doors that do not lath. The doors only had push and pulls installed.

1) Based on observation and interview with staff, the facility failed to protect Anesthetizing locations in accordance with NFPA 99. Findings include:

a) The Policy and Procedure: Oxygen Enriched Environment, adopted by the facility in 8-23-05, reviewed in 2-25-14 and reviewed again on 3-01-11 was not enforced. The procedure forbidden the use of Flammables in oxygen -enriched environments. The Surgery Rooms are defined as an oxygen - enriched environment. Staff demonstrated that alcohol is pored onto a pad and used to wipe off the area to be operated on. 19 gallons of Alcohol was found stored in the storage room.

b) Relative humidity was not maintained equal to or greater than 30% . As an example, in December of 2013, room 9 was recorded less than the minimum of 30% . The facility could not provide documentation that the room was in compliance for the last days in December as recorded on Surgery Area-Relative Humidity Trend , Quarter 4, 2013. The facility failed to document steps taken, staff was not documented as informed, surgery staff failed to document precaution taken.

c) Based on interview with Operating Room Staff, the facility has not adopted Rules and Regulations or Posted Rules and Regulations that are in accordance with NFPA 99 1999 edition Chapter 12- 4.1.1.4 for the control of personal in Anesthetizing Locations.

1) The governing body failed to be responsible for services furnished in the hospital, under contracts. The governing body failed to ensure that the contractor of services, furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services in accordance with Interpretive Guidelines ?482.12(e) Findings include:

a) The governing body failed to take actions through the hospital ' s QAPI program to: assess the services furnished by the Bio Medical Contractor under contract, identify quality and performance problems, implement appropriate corrective or improvement activities, and to ensure the monitoring and sustainability of those corrective or improvement activities.

2)Based on observation and interview with staff, the facility failed to provide Personnel concerned with the application and maintenance of electric appliances, including physicians, nurses nurse aids, engineers, technicians, and orderlies, were not cognizant of the risks associated with their use. To achieve this end, the hospital shall provide appropriate programs of continuing education for its personnel in accordance with NFPA 99 1999 edition chapter 7-6.5 Qualification and Training of Personnel. Findings include:

a) The facility maintains a one time use Cauterizing tool in the Emergency Room, the cauterizing tool poses a fire risk in a oxygen enriched environment or where alcohol is used. The facility has not identified this area with the use of this equipment as a potential hazard or trained staff.

b) The facility has not included Physicians in the training programs that other staff participate in, also staff was not included on fire drills.

Based on observation and interview with staff, the facility failed to stored in approved containers Flammable and Combustible liquids that are used in accordance with NFPA 30, Flammable and Combustible Liquids Code, and NFPA 45, Standard on Fire Protection for Laboratories Using Chemicals. The facility failed to store flammable and combustible liquids in accordance with NFPA 30, Flammable and Combustible Liquids Code, NFPA 99. 4.3, 10.7.2.1. Findings include:

19 gallons of alcohol were stored on a shelf in Surgery Storage room located in the suite.

1) Based on observation and interview with staff, the facility failed to install and maintain Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2

The Performance-Based Design Option out of NFPA 101 2000 Life Safety Code chapter 5.8.14 requires that anyone involved in the ownership or management of the building, to notify and document the following upon remodeling, modification, renovation, change in use:
The building was approved as a performance-based design with certain specified design criteria and assumptions.
Any remodeling, modification, renovation, change in use, or change in the established assumptions will require a re-evaluation and re-approval.
a)The Ground Fault Receptacles located in all of the original Surgery Rooms were removed and installed with receptacles that do not provide protection. NFPA 99 requires that if the facility cannot tolerate the loss of power, which Ground faults creates, if tripped, that the facility install Line Isolation Monitors. Line Isolation Monitors allow a case to be completed, even if a fault has occurred.

b) Facility failed to provide Impedance Ground Testing for the receptacles removed and replaced with new in the Operating room suite, in accordance with NFPA 99 1999 edition chapter 3-3.3.2 through 3-3.4.3.1.

c) Facility also failed to test all other patient care areas as defined by NFPA 99 1999 edition chapter 3-3.3.2 through 3-3.4.3.1.

1) Based on observation and interview with staff, the facility failed to provide doors that are provided with positive latching hardware in accordance with 19.3.6.3.2. Doors shall be provided with a means suitable for
keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.. Findings include:

a) Doors in the emergency department were provided with doors that do not lath. The doors only had push and pulls installed.

1) Based on observation and interview with staff, the facility failed to protect Anesthetizing locations in accordance with NFPA 99. Findings include:

a) The Policy and Procedure: Oxygen Enriched Environment, adopted by the facility in 8-23-05, reviewed in 2-25-14 and reviewed again on 3-01-11 was not enforced. The procedure forbidden the use of Flammables in oxygen -enriched environments. The Surgery Rooms are defined as an oxygen - enriched environment. Staff demonstrated that alcohol is pored onto a pad and used to wipe off the area to be operated on. 19 gallons of Alcohol was found stored in the storage room.

b) Relative humidity was not maintained equal to or greater than 30% . As an example, in December of 2013, room 9 was recorded less than the minimum of 30% . The facility could not provide documentation that the room was in compliance for the last days in December as recorded on Surgery Area-Relative Humidity Trend , Quarter 4, 2013. The facility failed to document steps taken, staff was not documented as informed, surgery staff failed to document precaution taken.

c) Based on interview with Operating Room Staff, the facility has not adopted Rules and Regulations or Posted Rules and Regulations that are in accordance with NFPA 99 1999 edition Chapter 12- 4.1.1.4 for the control of personal in Anesthetizing Locations.

1) The governing body failed to be responsible for services furnished in the hospital, under contracts. The governing body failed to ensure that the contractor of services, furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services in accordance with Interpretive Guidelines ?482.12(e) Findings include:

a) The governing body failed to take actions through the hospital ' s QAPI program to: assess the services furnished by the Bio Medical Contractor under contract, identify quality and performance problems, implement appropriate corrective or improvement activities, and to ensure the monitoring and sustainability of those corrective or improvement activities.

2)Based on observation and interview with staff, the facility failed to provide Personnel concerned with the application and maintenance of electric appliances, including physicians, nurses nurse aids, engineers, technicians, and orderlies, were not cognizant of the risks associated with their use. To achieve this end, the hospital shall provide appropriate programs of continuing education for its personnel in accordance with NFPA 99 1999 edition chapter 7-6.5 Qualification and Training of Personnel. Findings include:

a) The facility maintains a one time use Cauterizing tool in the Emergency Room, the cauterizing tool poses a fire risk in a oxygen enriched environment or where alcohol is used. The facility has not identified this area with the use of this equipment as a potential hazard or trained staff.

b) The facility has not included Physicians in the training programs that other staff participate in, also staff was not included on fire drills.

Based on observation and interview with staff, the facility failed to stored in approved containers Flammable and Combustible liquids that are used in accordance with NFPA 30, Flammable and Combustible Liquids Code, and NFPA 45, Standard on Fire Protection for Laboratories Using Chemicals. The facility failed to store flammable and combustible liquids in accordance with NFPA 30, Flammable and Combustible Liquids Code, NFPA 99. 4.3, 10.7.2.1. Findings include:

19 gallons of alcohol were stored on a shelf in Surgery Storage room located in the suite.

1) Based on observation and interview with staff, the facility failed to install and maintain Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2

The Performance-Based Design Option out of NFPA 101 2000 Life Safety Code chapter 5.8.14 requires that anyone involved in the ownership or management of the building, to notify and document the following upon remodeling, modification, renovation, change in use:
The building was approved as a performance-based design with certain specified design criteria and assumptions.
Any remodeling, modification, renovation, change in use, or change in the established assumptions will require a re-evaluation and re-approval.
a)The Ground Fault Receptacles located in all of the original Surgery Rooms were removed and installed with receptacles that do not provide protection. NFPA 99 requires that if the facility cannot tolerate the loss of power, which Ground faults creates, if tripped, that the facility install Line Isolation Monitors. Line Isolation Monitors allow a case to be completed, even if a fault has occurred.

b) Facility failed to provide Impedance Ground Testing for the receptacles removed and replaced with new in the Operating room suite, in accordance with NFPA 99 1999 edition chapter 3-3.3.2 through 3-3.4.3.1.

c) Facility also failed to test all other patient care areas as defined by NFPA 99 1999 edition chapter 3-3.3.2 through 3-3.4.3.1.