HospitalInspections.org

Based on observation, interview, and document review, the facility did not ensure that all areas of the hospital were in compliance with National Fire Protection Association (NFPA) 99 (2012 ed.) section 9.3.1, which requires the facility to maintain compliance with American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) Standard 170. Specifically, (1) the facility did not ensure that Upstate University Hospital at Community General's sterile processing department was maintained within required temperature ranges specified in ASHRAE Standard 170; (2) the facility did not ensure that Upstate University Hospital at Community General's pathology department was maintained within required temperature ranges specified in ASHRAE Standard 170 and did not maintain a negative pressure relationship between the pathology laboratory and the outside corridor.

Findings regarding (1) include:

-- Per observation at Upstate University Hospital at Community General's sterile processing department on 12/30/2024 at 9:15 am, the ambient room temperature inside the main clean workroom was 79 degrees Fahrenheit (F).

-- During interview of Staff F, on 12/30/2024 at 9:15 am, they acknowledged the above finding.

-- During interview of Staff L, on 12/30/2024 at 10:00 am, they stated that it was a constant struggle to maintain correct temperature within the sterile processing department. The temperatures had been consistently elevated and made it difficult to work in. They kept putting in work orders to the facility's Physical Plant department, but the issue was not being resolved.

-- During interview of Staff M, on 12/30/2024 at 3:10 pm, they stated that temperature was a constant issue in the sterile processing department. Staff had to wear cooling vests and a portable air conditioning unit had been brought in to bring the heat down. Temperatures had reached, at maximum, 83 degrees F. The facility's Physical Plant department had told them that the temperature issue was not fixable.

-- Review of the facility's temperature and humidity logs for Upstate University Hospital at Community General's sterile processing department's clean workroom, between 10/1/2024 - 12/27/2024, revealed that the sterile processing department had elevated temperatures above 76 degrees F, for at least an hour, on 55 out of 87 days. ASHRAE Standard 170 requires that temperatures inside a sterile processing department's clean workroom be maintained between 68 degrees F - 73 degrees F.

-- Review of the facility's work orders submitted for Upstate University Hospital at Community General's sterile processing department, between 4/1/2024 - 12/30/2024, revealed that sterile processing department staff submitted 5 different work orders complaining of excessive heat. All 5 work orders were closed, but the corrective action taken for each was not noted.

Findings regarding (2) include:

-- Per observation at Upstate University Hospital at Community General's pathology laboratory on 12/30/2024 at 11:15 am, the visual indicator manometer installed above the pathology laboratory's main entrance doors was indicating that the pathology laboratory's air had a positive pressure relationship to the outside corridor. The door to the pathology laboratory was also left open to the corridor, although the manometer still indicated the same positive pressure condition when the door was closed. ASHRAE Standard 170 requires that a negative air pressure relationship be maintained between a pathology laboratory space and all adjacent rooms.

-- During interview of Staff N, on 12/30/2024 at 11:15 am, they acknowledged the above findings.

-- Review of the facility's temperature and humidity logs for Upstate University Hospital at Community General's pathology laboratory, between 1/1/2023 - 12/30/2024, revealed that in spring 2023 and spring 2024, the laboratory experienced temperatures above 75 degrees F for a total of 76 days, with temperatures reaching a maximum of 82.5 degrees F. ASHRAE Standard 170 requires that temperatures inside a pathology laboratory been maintained between 70 - 75 degrees F.

-- During interview of Staff O, on 12/30/2024 at 2:45 pm, they stated that the temperatures within the pathology laboratory are only manageable due to 2 portable air conditioning units that the facility's Physical Plant department brought in due to the consistent heat. They also stated that in the springtime, they have had laboratory analyzers shut down due to the excessive heat, as they can only run analyzer tests within normal temperature parameters.

-- During interview of Staff P, on 12/31/2024 at 9:50 am, they stated that whenever the outside temperature reaches 50 degrees F, it gets excessively warm inside the pathology laboratory. If the temperature becomes excessively warm, above 80 degrees F, laboratory analyzers will shut down and not restart until the temperature has stabilized.

Based on document review and interview, the facility did not annually test all Line Isolation Monitors (LIMs) as of the start of the survey on 12/10/2024, as required per National Fire Protection Association (NFPA) 99 (2012 ed.) 6.3.4.

Findings include:

-- Review of the facility's annual LIM tests, from 1/2024 - 12/2024, revealed that the annual tests for the following LIMs at Upstate Hospital SUNY Health Science Center were not completed at the start of the survey on 12/10/2024:
- LIM B02 - UH East Wing 3rd Floor - Task due date 7/1/2024.
- LIM B03 - UH East Wing 3rd Floor - Task due date 7/1/2024.
- LIM B04 - UH East Wing 3rd Floor - Task due date 7/1/2024.
- LIM B05 - UH East Wing 3rd Floor - Task due date 7/1/2024.
- LIM A09 - UH East Wing 3rd Floor - Task due date 7/1/2024.
- LIM B011 - UH East Wing 2nd floor - Task due date 10/31/2024.
- LIM B06 - UH East Wing 3rd floor - Task due date 10/31/2024.
- LIM A01 - UH East Wing 3rd floor - Task due date 10/31/2024.
- LIM A02 - UH East Wing 3rd floor - Task due date 10/31/2024.
- LIM Test 5 East OR 9 - UH East Wing 5th Floor - Task due date 1/31/2024.
- LIM Test 5 East OR 11 - UH East Wing 5th Floor - Task due date 3/2/2024.
- LIM Test 5 East OR 1 - UH East Wing 5th Floor - Task due date 5/1/2024.
- LIM Test 5 East OR 4 - UH East Wing 5th Floor - Task due date 7/1/2024.
- LIM Test 5 East OR 2 - UH East Wing 5th Floor - Task due date 7/1/2024.
- LIM Test 6 West Endovascular - UH2 6th Floor - Task due date 10/31/2024.
- LIM Test 6 West Cath Lab - UH2 6th floor - Task due date 10/31/2024.
- LIM Test 2 East Treatment Room - UH East Wing 2nd Floor - Task due date 5/14/2024.
- LIM Test 2 East Exam Room - UH East Wing 2nd Floor - Task due date 5/14/2024.

-- Per correspondence with Staff A, on 12/30/2024 at 11:51 am, they acknowledged the above findings