HospitalInspections.org

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Based on observation and staff interview, the facility did not ensure that the physical plant and the overall hospital environment is maintained in such a manner that the safety and well-being of patients are assured.

Findings include:

1- On 09/02/2020, during the physical tour of the ED (Emergency Department), at approximately 10:53 am, two of the exit signs at the ED exits were not illuminated as per the requirement of NFPA 101, both exit signs should have been continuously illuminated.
NFPA 101 2010: 7.8.1.1, 21.2.8

2- On 09/02/2020, during the physical tour of the ED, approximately at 11:00 am, In multiple locations, portable fire extinguishers were obstructed and obscured from view.

Examples include;

Fire extinguisher was obstructed by a garbage can with no signage near the ED's door.
Fire extinguisher was obstructed by a garbage can outside Pediatric ED near adult ED's waiting room.
Fire extinguisher was placed in a cabinet without signage in the corridor outside adult waiting room.

As per NFPA 101, all portable fire extinguishers should be visible and readily accessible in the event of fire.
NFPA 101 2010: 21.3.5.3, 9.7.4.1, 6.1.3.1, 6.1.3.3.1


3- On 09/02/2020, during the physical tour of the ED of the hospital, at approximately 11:45am,
Two exit stairs were found to have contradicting signage.
Examples include:
Stairwell 5 Exit door had contradicting signage with one indicating Exit and another indicating no exit
Stairwell 6 Exit door was being blocked by debris.
NFPA 101 2010: 21.7.3.1

The above findings were identified in the presence of Staff B, Associate Director of Nursing and Staff C, ED Director and were brought to the attention of the facility's leaders during the exit conference.
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Based on observation, staff interviews, and document review, the facility failed to employ methods for preventing and controlling the transmission of infections within the hospital. Specifically, the facility failed to:
1) Ensure the Emergency Department (ED) triage area was designed and ventilated to reduce the exposure of staff, patients, and families to airborne infectious diseases;
2) Maintain an acceptable range of Relative Humidity (RH) in two (2) of 12 Operating Rooms in accordance with its policy and procedures and generally acceptable standards of practice;
3) Maintain ventilation pressure requirements in special rooms (Soiled Utility Room, Clean Utility Room and Medication Room).

Findings include:

1. During the tour of the ED on 9/3/2020 at approximately 10:30 AM, the following was observed:

A patient in a stretcher was brought into the ED via the ED ambulance entrance escorted by two (2) Emergency Medical Staff (EMS) and two (2) family escorts. The patient was then triaged at the triage station which was an open area located in the Main ED Entrance/Hallway.

The Main ED Entrance/Hallway had four (4) workstations; one station was assigned to the triage nurse, two were assigned to two staff members who were responsible for checking employees and visitors' temperature, and the fourth station was a security post. Patients, visitors and staff members were seen walking by the triage station located in the hallway.

During interview with Staff A, ED Charge Nurse at the time of observation, she stated that the ED never had a designated Triage room.

As per The Facility Guidelines Institute (FGI) 2010 Edition:
*(3) The triage area requires special consideration.
(a) The area shall be visible from the reception, triage, or control station to permit observation of patients waiting for treatment.
(b) As the point of entry and assessment for patients with undiagnosed and untreated airborne infections, the triage area shall be designed and ventilated to reduce the exposure of staff, patients, and families to airborne infectious diseases. For requirements, see Part 6 American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) 170.

FGI 2010: 2.2-3.1.3.3, 3a,3b, Part 6, Table 7-1 notes that Adult ED is a point of entry and assessment for patients with undiagnosed and untreated airborne infections, the triage area shall be designed and ventilated to reduce the exposure of staff, patients, and families to airborne infectious diseases.

The facility's practice of triaging ED patients in an open area (ED Hallway/Entrance) place patients, visitors and staff at risk for infection specifically, patients with undiagnosed and untreated respiratory infections.

This finding was acknowledged by Staff B, ED Assistant Director of Nursing, and Staff C, ED Director who were present during the tour.


2. Review of the Relative Humidity (RH) Log for March 2020 to September 3, 2020 showed that two (2) Operating Rooms (OR) in the facility were used when the Relative Humidity were out of acceptable range (Normal RH range 30-60%).

On 08/12/2020, RH for OR #1 was 74.3% when a C-section was performed.
6/3/2020, RH in OR #1 was 67%
6/3/2020, RH in OR #2 was 64%
7/1/2020, RH in OR #1 was 65%
7/6/2020, RH in OR #2 was 66.6%

Similar examples of abnormal RH levels were noted on 7/29, 7/22, 8/15, 8/17 and 8/24/20 when the two ORs were used for emergency procedures.

Based on the facility's Plan of Correction to the failure to maintain RH levels within acceptable range in its ORs, OR #s 1 & 2 should have been immediately taken out of service when the RH levels were abnormal. The RH logs did not reflect that this action was taken.

It should be noted that the facility has 10 other ORs that could be used for the required procedures and avoid utilizing the two ORs (OR #s 1& 2) when their RH levels are out of range.

During interview on 9/3/20 with the Director of Maternal & Child Services, the staff member acknowledged that the two ORs 1 and 2 are used mainly for Cesarean Section and that those two ORs were used repeatedly for emergency procedures and that prior to their use a risk assessment was performed and documented.


3. On 09/02/2020, during the physical tour of the ED at approximately 11:30 am, several rooms with ventilation pressure requirements had neutral ventilation pressure. This finding was observed in the following locations;

Soiled Utility Room near Cubicle 5-8 was found to have a neutral air pressure contrary to the required negative air pressure.

Soiled Utility Room A1-562K in Pediatric ED was found to have a neutral air pressure contrary to the required negative air pressure.

Clean Utility Room near Cubicle 5-8 was found to have a neutral air pressure contrary to the required positive air pressure.

Medication Room A1-562H in Pediatric ED was found to have a neutral air pressure contrary to the required positive air pressure.

As per FGI 2010, Part 6, Table 7-1: Soiled Utility room should have negative ventilation pressure and Clean Utility should have positive pressure. In addition, the medication room should have positive pressure.
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