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1) Based on observation and interview with staff, the facility failed to provide all sleeping rooms with a door leading to a corridor providing access to an exit or have a door leading directly to grade in accordance with 19.2.5.1. 19.2.5.9 Findings include:

a) The exit on the north end of the building did not terminate to a public way. NFPA 101 2000 edition chapter 7.5.4.3 requires that all accessible means of egress shall be continuous from each accessible occupied area to a public way or area of refuge in accordance with 7.2.12.2.2.

1) Based on observation and interview with staff, the facility failed to provide and maintain the fire alarm system required for life safety , that is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. Findings include:

a) The fire alarm was not on a annual testing program. The last Fire Alarm Test was in January of 2013.

All equipment connected to the fire alarm system was not tested.

1) Based on observation and interview with staff, the facility failed to provide and maintain an automatic sprinkler system, it is installed in accordance with NFPA 13. Findings include:

a) The fire alarm system was not on an annual testing Program. The Fire alarm was last tested on September 12, 2014

b) The loading dock and storage area for soiled linen carts was not sprinkled.

1) Based on observation and interview with staff, the facility failed to provide Heating, ventilating, and air conditioning systems that comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2 Findings include:

a) 12 of the 14 exhaust fans were not working

b) The facility could not provide documentation that the following rooms met minimun air exchanges: the Operating Room, Procedure Room, Decontamination Room, clean storage, and central supply. The sterilizer room was not exhausting air on this date.

1) Based on observation and interview with staff, the facility failed to provide Piped in medical gas systems that comply with NFPA 99, Chapter 4. Findings include:

a) Bulk Oxygen Fill site ws not provided with 8 foot cement surface. The existing fill site was oil based asphalt. The Bulk Oxygen System was not installed in accordance with NFPA 55 2005 EDITION chapter 9.3.2.3, the fill site did not have a noncombustible surfacing provided under liquid mobile supply equipment with a width not less than the full width of the delivery vehicle and a length not less than 8 ft (2.5 m) in the direction of the vehicle axis.

b) The Bulk Oxygen Tank was not provided with alarms in accordance with NFPA 99 1999 edition chapter 4-3.1.1.7 Bulk Manifold Gas Systems. The wiring from the tank was disconnected.

1) Based on observation, interview, and review of the Humidity logs, the facility failed to provide Anesthetizing locations that are protected in accordance with Standard for Health Care Facilities NFPA 99 1999 edition chapter 5.4.1.1, and NFPA 101 2000 edition chapter 19.3.2.3. Findings include:

a) Based on interview with Operating Room Staff, the Operating Room staff had not conducted or made a hazard evaluation or conducted a Fire Drill to evaluate hazards that could be encountered during surgical procedures 12-4.1.2.10. The evaluation shall include hazards associated with the properties of electricity, hazards associated with the operation of surgical equipment, and hazards associated with the nature of the environment. Periodic reviews of surgical operations and procedures was not conducted with special attention given to any change in materials, operations, or personnel.

b) The Operating Room staff did not have a humidity logged.

c) Operating Room staff failed to have a fire drill located and dedicated to an operating room fire with Physicians participating.

d) The Operating Room staff did monitor or have manometers installed. Manometers shall be installed and monitored to determine that life of the HEPA Filters.

e) Ventilating and humidifying equipment was not maintained and operating during surgical procedures in accordance with NFPA 99 1999 edition chapter 5-6.1.1. There was no humidifier installed on the HVAC unit supplying air to the Operating Room.

1) Based on observation and interview with staff, the facility failed to provide a Type I Essential Electrical System powered by a generator with a transfer switch and separate power supply in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4.. Findings include:

a) The emergency generator was not provided with a remote enunciator.

b) There was no battery back up light over the transfer switch and generator room.

c) The door to the Emergency Generator room was not working (broken)

1) Based on observation and interview with staff, the facility failed to maintain design features initially approved for construction. The building must be maintained in accordance with approved design specifications. Any variations shall require the approval of the authority having jurisdiction prior to the actual change NFPA101 2000 Life Safety Code 5.1.7.

a) Patient Rooms located on the surgery hallway 1 & 2 were re-purposed and now being used as Recovery.

1) Based on observation and interview with staff, the facility failed to provide Master alarm panels that are in two separate locations and have audible and visible signals. There alarms shall operate at high/low alarms for +/- 20% operating pressure. NFPA 99, 4.3.1.2.2. Findings include:

a) Master and area alarms required for the Operating Room, Procedure Room, Nurses Station, and Recovery Area are not in compliance with NFPA 99 1999 edition chapter 4-3.1.2.2. Area alarm monitors shall indicate 20% rise or fall from normal pressure. Arcuating Switches for recovery were not down stream of the zone valve. Actuating Switches for anesthetizing locations were not placed in an individual line upstream of the room shutoff valve supplying the outlets in the room for each piped in medical gas and vacuum system. Alarms were not installed in the suites identified above connected to the actuating switches that monitor pressure. .

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

a) The Static Ground Detector located in both the Procedure room and Operating Room is installed, however the Visual alarms were not working. No preventive maintenance program

b) Operating Room staff could not identify or explain the function of the lamps/ equipment located in the Operating Room and in the Procedure Room.

c) Facility failed to have a Patient Care Area Impedance and Receptacle Testing program for existing, new receptacles and power service supply's for patient care areas in accordance with NFPA 99 199 edition chapter 3-3.3.1 through 3-4.4.3

d) Operating Room staff could not identify the two sources of power required in the operating room. Receptacles in the operating room were all
marked emergency, not one normal power receptacle / circuit was provided could be identified or marked.

e) Through out the facility, receptacles have been replaced or installed with non-hospital grade receptacles.

f) Electrical panels through out the building were not labeled. The following Panels were not labeled or could be identified; Life Safety, Critical Care and Equipment Branch along with normal power panels.

g) Based on observation, interview with staff, the facility failed to provide a program that provides an environment that is reasonably safe from the shock and burn caused from the use of electrical appliances in patient care areas in accordance with NFPA 99 chapter 7-6.5. The facility did not have a program that identifies equipment that being used and training a program that includes Doctors, nurses and other staff, to make them aware of the safety guidelines and periodic review of manufacture guidelines.

h) The facility failed to ensure that the Bio-Medical Test Contractor is providing a safe and effective program. The facility did not reviewed test results from the contractor against the manufactures requirements for comparison or any other method that would ensure safe and effective operation in accordance with manufacture requirements. The governing body did not assure that hospital services are provided in compliance with the Medicare Conditions of participation and according to acceptable standards of practice, by contract. The governing body must take actions through the hospital ' s QAPI program to: assess the services furnished directly by hospital staff and those services provided under contract, identify quality and performance problems, implement appropriate corrective or improvement activities, and to ensure the monitoring and sustainability of those corrective or improvement activities.

i) The Bio -Medical Equipment Program does not meet NFPA 99 chapter 7-6.2.1.2 (b). Equipment in Critical Care areas are required to be tested semi annually. All equipment in Critical Care areas at this facility (Emergency Department) were tested annually, EKG Machine located in the Operating Room Suite was only check yearly, last documented test was on October of 2013.

1) Based on observation and interview with staff, the facility failed to provide all sleeping rooms with a door leading to a corridor providing access to an exit or have a door leading directly to grade in accordance with 19.2.5.1. 19.2.5.9 Findings include:

a) The exit on the north end of the building did not terminate to a public way. NFPA 101 2000 edition chapter 7.5.4.3 requires that all accessible means of egress shall be continuous from each accessible occupied area to a public way or area of refuge in accordance with 7.2.12.2.2.

1) Based on observation and interview with staff, the facility failed to provide and maintain the fire alarm system required for life safety , that is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. Findings include:

a) The fire alarm was not on a annual testing program. The last Fire Alarm Test was in January of 2013.

All equipment connected to the fire alarm system was not tested.

1) Based on observation and interview with staff, the facility failed to provide and maintain an automatic sprinkler system, it is installed in accordance with NFPA 13. Findings include:

a) The fire alarm system was not on an annual testing Program. The Fire alarm was last tested on September 12, 2014

b) The loading dock and storage area for soiled linen carts was not sprinkled.

1) Based on observation and interview with staff, the facility failed to provide Heating, ventilating, and air conditioning systems that comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2 Findings include:

a) 12 of the 14 exhaust fans were not working

b) The facility could not provide documentation that the following rooms met minimun air exchanges: the Operating Room, Procedure Room, Decontamination Room, clean storage, and central supply. The sterilizer room was not exhausting air on this date.

1) Based on observation and interview with staff, the facility failed to provide Piped in medical gas systems that comply with NFPA 99, Chapter 4. Findings include:

a) Bulk Oxygen Fill site ws not provided with 8 foot cement surface. The existing fill site was oil based asphalt. The Bulk Oxygen System was not installed in accordance with NFPA 55 2005 EDITION chapter 9.3.2.3, the fill site did not have a noncombustible surfacing provided under liquid mobile supply equipment with a width not less than the full width of the delivery vehicle and a length not less than 8 ft (2.5 m) in the direction of the vehicle axis.

b) The Bulk Oxygen Tank was not provided with alarms in accordance with NFPA 99 1999 edition chapter 4-3.1.1.7 Bulk Manifold Gas Systems. The wiring from the tank was disconnected.

1) Based on observation, interview, and review of the Humidity logs, the facility failed to provide Anesthetizing locations that are protected in accordance with Standard for Health Care Facilities NFPA 99 1999 edition chapter 5.4.1.1, and NFPA 101 2000 edition chapter 19.3.2.3. Findings include:

a) Based on interview with Operating Room Staff, the Operating Room staff had not conducted or made a hazard evaluation or conducted a Fire Drill to evaluate hazards that could be encountered during surgical procedures 12-4.1.2.10. The evaluation shall include hazards associated with the properties of electricity, hazards associated with the operation of surgical equipment, and hazards associated with the nature of the environment. Periodic reviews of surgical operations and procedures was not conducted with special attention given to any change in materials, operations, or personnel.

b) The Operating Room staff did not have a humidity logged.

c) Operating Room staff failed to have a fire drill located and dedicated to an operating room fire with Physicians participating.

d) The Operating Room staff did monitor or have manometers installed. Manometers shall be installed and monitored to determine that life of the HEPA Filters.

e) Ventilating and humidifying equipment was not maintained and operating during surgical procedures in accordance with NFPA 99 1999 edition chapter 5-6.1.1. There was no humidifier installed on the HVAC unit supplying air to the Operating Room.

1) Based on observation and interview with staff, the facility failed to provide a Type I Essential Electrical System powered by a generator with a transfer switch and separate power supply in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4.. Findings include:

a) The emergency generator was not provided with a remote enunciator.

b) There was no battery back up light over the transfer switch and generator room.

c) The door to the Emergency Generator room was not working (broken)

1) Based on observation and interview with staff, the facility failed to maintain design features initially approved for construction. The building must be maintained in accordance with approved design specifications. Any variations shall require the approval of the authority having jurisdiction prior to the actual change NFPA101 2000 Life Safety Code 5.1.7.

a) Patient Rooms located on the surgery hallway 1 & 2 were re-purposed and now being used as Recovery.

1) Based on observation and interview with staff, the facility failed to provide Master alarm panels that are in two separate locations and have audible and visible signals. There alarms shall operate at high/low alarms for +/- 20% operating pressure. NFPA 99, 4.3.1.2.2. Findings include:

a) Master and area alarms required for the Operating Room, Procedure Room, Nurses Station, and Recovery Area are not in compliance with NFPA 99 1999 edition chapter 4-3.1.2.2. Area alarm monitors shall indicate 20% rise or fall from normal pressure. Arcuating Switches for recovery were not down stream of the zone valve. Actuating Switches for anesthetizing locations were not placed in an individual line upstream of the room shutoff valve supplying the outlets in the room for each piped in medical gas and vacuum system. Alarms were not installed in the suites identified above connected to the actuating switches that monitor pressure. .

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

a) The Static Ground Detector located in both the Procedure room and Operating Room is installed, however the Visual alarms were not working. No preventive maintenance program

b) Operating Room staff could not identify or explain the function of the lamps/ equipment located in the Operating Room and in the Procedure Room.

c) Facility failed to have a Patient Care Area Impedance and Receptacle Testing program for existing, new receptacles and power service supply's for patient care areas in accordance with NFPA 99 199 edition chapter 3-3.3.1 through 3-4.4.3

d) Operating Room staff could not identify the two sources of power required in the operating room. Receptacles in the operating room were all
marked emergency, not one normal power receptacle / circuit was provided could be identified or marked.

e) Through out the facility, receptacles have been replaced or installed with non-hospital grade receptacles.

f) Electrical panels through out the building were not labeled. The following Panels were not labeled or could be identified; Life Safety, Critical Care and Equipment Branch along with normal power panels.

g) Based on observation, interview with staff, the facility failed to provide a program that provides an environment that is reasonably safe from the shock and burn caused from the use of electrical appliances in patient care areas in accordance with NFPA 99 chapter 7-6.5. The facility did not have a program that identifies equipment that being used and training a program that includes Doctors, nurses and other staff, to make them aware of the safety guidelines and periodic review of manufacture guidelines.

h) The facility failed to ensure that the Bio-Medical Test Contractor is providing a safe and effective program. The facility did not reviewed test results from the contractor against the manufactures requirements for comparison or any other method that would ensure safe and effective operation in accordance with manufacture requirements. The governing body did not assure that hospital services are provided in compliance with the Medicare Conditions of participation and according to acceptable standards of practice, by contract. The governing body must take actions through the hospital ' s QAPI program to: assess the services furnished directly by hospital staff and those services provided under contract, identify quality and performance problems, implement appropriate corrective or improvement activities, and to ensure the monitoring and sustainability of those corrective or improvement activities.

i) The Bio -Medical Equipment Program does not meet NFPA 99 chapter 7-6.2.1.2 (b). Equipment in Critical Care areas are required to be tested semi annually. All equipment in Critical Care areas at this facility (Emergency Department) were tested annually, EKG Machine located in the Operating Room Suite was only check yearly, last documented test was on October of 2013.