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1) Based on observation and interview with staff, the facility failed to house containers greater than 32 gallon in capacity. 18.7.5.5 requires that 32 gal (121 L) in capacity is not exceeded within any 64 sq ft (5.9 sq. m) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) shall be located in a room protected as a hazardous area when not attended. 18.7.5.5 . Findings include:

a) Rolling containers located throughout the facility were found housed in a open corridor or in alcoves. Containers that were plastic and looked like deep laundry carts that exceeded 32 gallon in size, on 4 wheels were used to collect trash and were not located in a room protected as a hazardous area. This condition was hospital wide in use.

Based on observation and interview with staff, the facility failed to protect anesthetizing locations in accordance with NFPA 99. Relative humidity shall be maintained equal to or greater than 35%. NFPA 99 4.3.1.2.3(n) and 5.4.1.1, 18.3.2.3 Standard for Health Care Facilities:

A) The facility was protecting anesthetizing locations using a categorical waiver that allows for facilities to use the lower end of compliance ranges, less than 35% . The ranges logged on the facilities Humidity and Temperature Log were in the 20% ranges during the colder month of the year, the categorical waiver letter Ref: S&C: 13-25-LSC & ASC, Dated April 19, 2013, Does Not Apply:
· When more stringent RH control levels are required by State or local laws and regulations", State law, Hospital Standards Chapter 667 Appendix A, requires facilities to meet 30% to 60 % range. Also in the same letter CMS states " : Although not required, CMS recommends that hospitals and CAHs maintain the upper range of relative humidity at less than or equal to 60 percent"

B) The governing body failed to ensure that conditions and practices in anesthetizing locations are provided in a safe and effective manner. Surgical Staff members Z , J, & M in the presence of staff member JJJ were not familiar with function and proper operation of the Line Isolation Monitors and could not explain the function. Surveyor pointed to the LIM and asked what the piece of equipment served and what protection it provided , staff members Z,M,& J did not describe either.

c) Rules and regulation required to be posted in Operating Room Suites in accordance with NFPA 99, 1999 edition, chapter 12-4.1.4, and hazard symbol contained in NFPA 704 were not provided or posted;

1) Based on observation and interview with staff, the facility failed to have Electrical wiring and equipment installed and maintained in accordance with NFPA 70, National Electrical Code. 9.1.2. Findings include:

a) Standby power (Battery Back UPS ) was not installed in the cath lab to meet NFPA 70, 700.12 There was no evidence or documentation that the batteries were suitable rating and capacity to supply and maintain at not less than 87 1/2 % of system voltage, for total load of the circuits supplying legally required stand by power, for a period of not less than 1 1/2 hours. Staff member GG was unaware or was not familiar with the method of monitoring the battery back up system. Staff member GG did not have Functional Narrative/ approval with construction documents that depicted wiring and mechanical equipment installed.

b) Battery testing for Emergency Equipment sytem in accordance with manufacturers recommendations regarding UPS was not conducted. There was no evidence that equipment was tested to be fully operational for the duration of the facilities functional need. Written records of visual inspections and tests were not kept or available by the owner for inspection by the authority having jurisdiction.

1) Based on observation and interview with staff, the facility failed to house containers greater than 32 gallon in capacity. 18.7.5.5 requires that 32 gal (121 L) in capacity is not exceeded within any 64 sq ft (5.9 sq. m) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) shall be located in a room protected as a hazardous area when not attended. 18.7.5.5 . Findings include:

a) Rolling containers located throughout the facility were found housed in a open corridor or in alcoves. Containers that were plastic and looked like deep laundry carts that exceeded 32 gallon in size, on 4 wheels were used to collect trash and were not located in a room protected as a hazardous area. This condition was hospital wide in use.

Based on observation and interview with staff, the facility failed to protect anesthetizing locations in accordance with NFPA 99. Relative humidity shall be maintained equal to or greater than 35%. NFPA 99 4.3.1.2.3(n) and 5.4.1.1, 18.3.2.3 Standard for Health Care Facilities:

A) The facility was protecting anesthetizing locations using a categorical waiver that allows for facilities to use the lower end of compliance ranges, less than 35% . The ranges logged on the facilities Humidity and Temperature Log were in the 20% ranges during the colder month of the year, the categorical waiver letter Ref: S&C: 13-25-LSC & ASC, Dated April 19, 2013, Does Not Apply:
· When more stringent RH control levels are required by State or local laws and regulations", State law, Hospital Standards Chapter 667 Appendix A, requires facilities to meet 30% to 60 % range. Also in the same letter CMS states " : Although not required, CMS recommends that hospitals and CAHs maintain the upper range of relative humidity at less than or equal to 60 percent"

B) The governing body failed to ensure that conditions and practices in anesthetizing locations are provided in a safe and effective manner. Surgical Staff members Z , J, & M in the presence of staff member JJJ were not familiar with function and proper operation of the Line Isolation Monitors and could not explain the function. Surveyor pointed to the LIM and asked what the piece of equipment served and what protection it provided , staff members Z,M,& J did not describe either.

c) Rules and regulation required to be posted in Operating Room Suites in accordance with NFPA 99, 1999 edition, chapter 12-4.1.4, and hazard symbol contained in NFPA 704 were not provided or posted;

1) Based on observation and interview with staff, the facility failed to have Electrical wiring and equipment installed and maintained in accordance with NFPA 70, National Electrical Code. 9.1.2. Findings include:

a) Standby power (Battery Back UPS ) was not installed in the cath lab to meet NFPA 70, 700.12 There was no evidence or documentation that the batteries were suitable rating and capacity to supply and maintain at not less than 87 1/2 % of system voltage, for total load of the circuits supplying legally required stand by power, for a period of not less than 1 1/2 hours. Staff member GG was unaware or was not familiar with the method of monitoring the battery back up system. Staff member GG did not have Functional Narrative/ approval with construction documents that depicted wiring and mechanical equipment installed.

b) Battery testing for Emergency Equipment sytem in accordance with manufacturers recommendations regarding UPS was not conducted. There was no evidence that equipment was tested to be fully operational for the duration of the facilities functional need. Written records of visual inspections and tests were not kept or available by the owner for inspection by the authority having jurisdiction.