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AIA (American Institute of Architects) 2006 edition
3.9 Gastrointestinal Endoscopy Facilities
1 General Considerations
1.5.2 Circulation and Restricted Access
The endoscopy suite shall be designed to facilitate movement of patients and personal into, through, and out of defined areas with the procedure suite. Signs shall be provided at all entrances to restricted areas and shall clearly indicate the proper attire required.


Based on interview and tour of the facility it was observed and shown to staff that the endoscopy suite traffic flow and environment failed to meet the above written standards.

Findings include:

During tour of the surgical suite it was confirmed through interview, and observation with Staff D (Operating Room Manager) that the surgical space failed to have a semirestricted area for the procedures that were occurring within the suite. Staff D stated that the only restricted area was the operating rooms themselves, where the surgical attire is required to be worn. Further interview with Staff D confirmed that the endoscopy suite was in the same common hallway that was used for the two operating rooms where patient families would wait during the patients surgical case. Also there was no Signs or delineation by doors or other structures to show that you were entering into a semirestricted/restricted area where proper attire is required.

Guidelines for the Design and Construction of Heath Care Facilities 2.1-8 Building Systems.
2.1-8.4.3.2 Hand-washing stations (2) Sinks (c) Hand-washing basins/countertops shall be made of porcelain, stainless steel, or solid surface materials...

2.1-8.4.3.6 Scrub sinks. Freestanding scrub sinks and lavatories used for scrubbing in procedure rooms shall be trimmed with foot, knee, or ultrasonic controls; single-lever wrist blades are not permitted.

Based on tour of the surgical suite with Staff D (Operating Room Manager) it was observed that both surgical scrub sinks failed to have hands free controls and one scrub sink had a break/chip in the solid surface sink basin.

Findings include:

During tour of the surgical suite on 11/4/10 it was observed and shown to Staff D that the two compartment scrub sinks failed to meet the standards written above by having wrist blades for shut offs on both sinks. Also during this observation it was found that a large chip in one of the sink basin breaking the integrity of the solid surface.

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.1 O&M in health care facilities:
A1.1 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.

ASHRAE/ASHE STANDARD 170-2008 Ventilation of Health Care Facilities page 4.

6. Systems and Equipment.


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..."

7. Space Ventilation
7.1 General Requirements. The following general requirements shall apply for space ventilation:

1. Spaces shall be ventilated according to Table 7-1.

TABLE 7-1 Design Parameters.
Function of Space Class A Operating/Procedure room
Pressure relationship to adjacent Areas Positive
Minimum Outdoor [air changes an hour] (3)
Minimum Total [air changes an hour] (15)
Air Recirculated by Means of Room Units (No)
[Relative Humidity] (20-60%)
Design Temperature Farenheit (70-75)


Based on review of the facility's records, interview and tour of the endoscopy procedure suite it was determined that the facility failed to maintain an environment that meets the standards listed above.

Findings include:

During tour of the endoscopy suite it was noted that the ventilation in the suite was running in positive by using the tissue test (Placing tissue at base of door to see movement of tissue in or out from suite). Staff C (Plant Operation/Maintenance) was asked to see the balance report for the suite to see if it meets the standard written above. Staff C confirmed that the suite has not been balanced since he has worked there and there are no records on file to show if the positive pressure meets the minimum air changes.



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 it was found that the facility failed to have a differential pressure indicator device to properly monitor the pressurization of the two surgical suites.

Findings include:

During tour on 11/4/10 at 2:30 p.m. of the surgical suite it was observed and shown to Staff D (Operating Room Manager) both surgical suites failed to have air pressurization monitoring devices to show the appropriate air pressurization. Staff D confirmed that no pressurization monitoring were on the surgical suites.

Based on tour, and record review of the facility's kitchen on 11/3/10 it was found that the facility failed to maintain manufacturers standards for two pieces of equipment.

Findings include:

During the initial tour of the facility kitchen it was observed and shown to Staff E (Director of Food Services) on 11/3/10 by the documented temperature log that the final rinse temperatures on the dish machine failed to meet manufacturer recommendations of 180 degrees Fahrenheit or greater. Once the finding was made Staff E was asked to provide the last three months of temperature logs along with the service reports during this time. During the months of September, October and November 2010 the final rinse temperatures for the dish machine were between 165 and 175 on average. Also on review of the service reports dated May, July, and August 2010 the final rinse temperatures were documented at 175 degrees Fahrenheit with no corrections made.

Also during tour Staff E was asked when the last time the ice machine had been sanitized by flushing the system with sanitizing chemical. Staff E stated the bin is cleaned but was not sure about the mechanical parts. Staff E contacted the vendor and received a letter which was provided that read "The machine should be sanitized once every six months or as needed..." Based on the interview and the letter provided the facility failed to sanitize the ice machine mechanical parts as recommended.

Based on observations and interviews the hospital failed to ensure that patient medical information was 1. kept private and confidential, 2. stored securely to protect the records from unauthorized access and 3. stored to protect the records from fire and water damage.

Findings include:

1. On 11/3/10 during the 10:30 a.m. initial tour of the hospital, observations were made that cardiac monitor screens were positioned high up on the walls in the two medical surgical unit corridors where both the staff and visitors walk. Interview with Staff A, RN (Registered Nurse) DON (Director of Nursing) during the tour revealed that the hospital placed the monitors in the two medical surgical unit corridors so that staff members who passed by would be able to quickly view the monitors when a cardiac emergency occurred and identify the room where the patient in the emergency was located.

Observation of the cardiac monitor screen on 11/3/10 showed that patients in rooms 211A and 212A were being monitored and that the diagnoses of these two patients were displayed in their section of the cardiac monitor screen.

Observation of the cardiac monitor screen on 11/4/10 showed that patients in rooms 201, 211A and 216B were being monitored and that the diagnoses of these three patients were displayed in their section of the cardiac monitor screen.

On 11/4/10 in the early p.m. observation of one of the cardiac monitor screens located in a medical surgical unit corridor was made with Staff A present. Staff A was interviewed during the observation about the listing of patients' diagnoses in their sections of the cardiac monitoring screens and the protection of patients' privacy and confidentially of medical information.

Staff A stated during this interview that the two cardiac monitor screens, in the medical surgical unit corridors, show the same information as the cardiac monitor screens that are located at the medical surgical nurses station and in the ICU (Intensive Care Unit) nurses station. Staff A acknowledged during this interview that it would be possible for hospital personnel and visitors at the hospital who are not allowed access to patients' medical information to see the patients' medical diagnoses and room numbers and identify what patients are being monitored.

2. On 11/4/10, in the p.m. during an interview Staff B, HIM (Health Information Manager), stated that two years of hospital patients' death medical records are stored in the physicians' office building located across the street from the hospital.

On 11/5/10 in the a.m. observations were made of these hospital patient death medical records stored in the medical record room at the physicians' office building. Staff B was present and Staff B pointed out medical records filed on four long shelves which Staff B said were the two years of hospital patient death medical records. The observation showed that these records were in regular paper file folders stacked on edge along open metal shelves and they were not secured from all other medical records stored in the physicians' office practice medical record room.

Staff B was interviewed, during the observation, about the two staff members who work in the physicians' office medical record room and Staff B stated that these two staff members only work for the physicians' offices and are not hospital employees. These two years of death medical records are not filed and secured separately from the physicians' office records and they are not protected from unauthorized access by the physicians' office staff.

This same observation, of the two years of hospital patient death medical records, showed that these records were placed only in regular paper file folders and stacked on edge along metal shelves that have open sides - front and back. Interview with Staff B during the observation revealed that the medical record room has a smoke alarm system only, for fire protection, that rings when a fire occurs. These medical records have no protection from fire and no protection from water damage caused by water leaks or from water used to put out a fire.

3. On 11/5/10 in the early a.m. hospital medical records stored in the storage building on the hospital grounds were observed with Staff B present. The observation showed that the medical records were placed in covered boxes made of cardboard - boxes and covers. These cardboard boxes containing the medical records were stored in a chain-link enclosure and the boxes are piled directly on top of one another.

The 11/5/10 observation and interview with Staff B, showed that the storage building had other enclosures for paper record storage and that the building was equipped with only a smoke alarm system that rings when a fire occurs and alerts the staff in the hospital building of a fire at the storage building. These medical records stored in the cardboard boxes have no protection from fire and no protection from water damage caused by water leaks or from water used to put out a fire.