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Tag No.: A0502
Based on observation and interview the facility failed to secure drugs and biologicals to prevent access by unauthorized individuals on 1 of 6 units.
Findings include:
Observation on 1/4/12 at 2:45 p.m. revealed two medication storage areas in the surgical area of the Family Birthing Place were not secure. The anesthesia cart in the Operating Room of the Family Birthing Place was found to be unlocked. The drawers contained medications for the administration of anesthesia, needles and syringes. The medication refrigerator located in the corridor of the Family Birthing Place surgical area was not locked and contained medications for the administration of anesthesia.
Interview on 1/4/12 at 2:45 p.m. with Staff A, (Director of Surgical Services), confirmed the anesthesia cart in the Family Birthing Place was not locked and the medication refrigerator located in the surgical area of the Family Birthing Place was not locked. Staff A confirmed non clinical personnel did have unmonitored access to the surgical area in the Family Birthing Place.
Tag No.: A0726
ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) Ventilation of Health Care Facilities 8. (Planning, construction, and sytem startup) 8.5 Owners shall retain an acceptance testing report for their files. In addition, the design shall include requirements for operations and maintenance staff training that is sufficient for the staff to keep all HVAC equipment in a condition that will maintain the original design intent for ventilation. Training of operating staff shall include an explanation of the design intent. The training materials shall include, at a minimum, the following:
a. O&M (Operations and Maintenance) procedures.
b. Temperature and pressure control operation in all modes.
c. Acceptable tolerances for system temperatures and pressures.
d. Procedures for operations under emergency power or other abnormal conditions that have been considered in the facility design.
A.1 O&M in health care facilities:
A.1.1 Operating Rooms. Each operating room should be tested for positive pressure semi-annually or on an effective preventative maintenance schedule. When HEPA filters are present within the diffuser of operating rooms, the filter should be replaced based on pressure drop.
Based on interview with Staff B (Director of Facility Plants) on 1/5/12 it was confirmed that the facility failed to have air balance reports for several areas within the hospital's surgical suite.
Findings include:
During tour of the hospital on 1/4/12 and 1/5/12 it was found through interview that there were several surgical areas that failed to have balance reports. These areas are as follows:
1) Two Endoscopy rooms
2) One Cystoscopic room
3) Delivery room (Caesarean)
4) Central Surgical Supply
Interview with Staff B on 1/5/12 confirmed that there are no balance reports for any of the above areas. Also there is no ability to confirm that in Central Supply that the decontamination room is in negative pressure to the adjoining clean workroom and sterile storage.
ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) Standard 170-2008 Ventilation of Health Care Facilities.
6.7 Air Distribution Systems
6.7.1 "General. Maintain the pressure relationships required in Table 7-1 in all modes of HVAC system operation, except as noted in the table. Spaces listed in Table 7-1 that have required pressure relationships shall be served by fully ducted returns. The air-distribution design shall maintain the required space pressure relationships, taking into account recommended maximum filter loading, heating-season lowered airflow operation, and cooling-season higher airflow operation..."
Based on the tour of the surgical suites on 1/4/12 it was found that the facility failed to maintain the proper air flow on the return duct to provide proper pressure relationships for 1 of 6 operating rooms.
Findings include:
During tour of the surgical suites on 1/4/12 it was found through a paper test (placing paper over the grill to see if there is a draw) that out of the two return ducts located in Operating room #4 one failed to be drawing air. On review of the facility's balance report dated 11/2/11 it shows that this return duct labeled #26 has no air return occurring.
ANSI [Approved American National Standard]/ASHRAE/ASHE [American Society for Healthcare Engineering] Standard 170-2008 Ventilation of Health Care Facilities. Page 11. 7.4 Surgery Rooms. 7.4.1 Class B and C Operating Rooms. Operating rooms shall be maintained at a positive pressure with respect to all adjoining spaces at all times. A pressure differential shall be maintained at a value of at least =0.01 in. wc (2.5Pa).
ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) Chapter 7 Health Care Facilities. Specific Design Criteria Surgery and Critical Care. 7.5 The following conditions are recommended for operating, catheterization, cystoscopic, and fracture rooms:
*Air pressure should be kept positive with respect to any adjoining rooms by supplying excess air.
*A differential-pressure-indication device should be installed to permit air pressure readings in the rooms. Thorough sealing of all wall, ceiling, and floor penetrations, and tight-fitting doors are essential to maintaining readable pressure.
Based on observation and interview the facility failed to maintain and monitor 2 surgical suites for positive pressure using differential-pressure-indication devices.
Findings include:
During tour of the hospital's surgical suites it was observed that both the cystoscopic room and the delivery room (Caesarean) failed to have differential pressure indication devices on the walls to show that the rooms are in positive pressure to the adjoining spaces. This finding was also shown to Staff A (Director of Surgical Services) at the time of tour.
ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) Ventilation of Health Care Facilities.
6.6 Humidifiers. "When outdoor humidity and internal moisture sources are not sufficient to meet the requirements of Table 7-1, humidification shall be provided by means of the health-care facility air-handling systems..."
Based on tour of the facility's surgical suite and review of facility logs it was found that the humidity levels were below the acceptable level for 3 of the 6 surgical suites, the ranges for humidity in operating rooms is to be 20% for the low and 60% for the high.
Findings include:
During tour with Staff A (Director of Surgical Services) on 1/4/12 it was observed that operating rooms 1, 2, and 5's humidity levels were reading between 8-15 %. On further review of the facility's generated computer logs it showed that the humidity levels for these three operating rooms were ranging between the readings above for the past two months. Staff A called Staff C (Maintenance) who came to the surgical suite and found that all three operation rooms steam supply valves had been in the off position and failed to be turned on for the winter season as explained by Staff C at the time of finding to surveyor.