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AIA, (American Institute of Architects) Guidelines for Design and Construction of Health Care Facilities 2.1 General Hospitals 8.2 General Standards for Details and Finishes 8.2.3.4 Ceilings

(3) Semirestricted areas

(a) Ceiling finishes in semirestricted areas such as airborne infection isolation rooms, protective environment rooms, clean corridors, central sterile supply spaces, specialized radiographic rooms, and minor surgical procedure rooms shall be smooth, scrubbable, nonabsorptive, non perforated, capable of withstanding cleaning with chemicals, and without crevices that can harbor mold and bacterial growth.

(b) If lay-in ceiling is provided, it shall be gasketed or clipped down to prevent the passage of particles from the cavity above the ceiling plane into the semirestricted environment. Perforated, tegular, serrated, or highly textured tiles shall not be used.

Based on tour of the surgical suites on 11/2/11 with Staff A (Manager of Surgical Services) it was observed that the facility failed to maintain an environment that is safe for the patients' well-being.

Findings include:

During tour of the surgical suite on 11/2/11 it was observed and shown to Staff A that the ceiling tiles located in the semi-restricted corridor adjoining operating rooms 1, 2 and 3, and in the clean sterile storage failed to have smooth, scrubbable, nonabsorptive, non perforated surfaces capable of withstanding cleaning with chemicals, and without crevices that can harbor mold and bacterial growth.

2010 Guidelines for the Design and Construction of Heath Care Facilities Chapter 2 Hospitals Section 2.1-8.6 Electronic Safety and Security Systems 2.1-8.6.2 Electronic Surveillance Systems "Electronic surveillance systems include but are not limited to patient elopement systems, door access/control systems, video/audio monitoring systems, patient location systems, and infant abduction prevention systems."

Based on interview the facility fails to have proper security for the safety of patients and employees for the provisions of direct services.

Findings include:

During the facility tour with Staff B (Microbiology) and Staff C (Director of Radiology) it was determined by interview that the following departments are not secured during the 11-7 shift and therefore have the potential for access of unauthorized persons to the department during the 11-7 shift:

1) Radiology
2) Laboratory services

The Radiology department has an access door off of the staff corridor that is not locked at night. The radiology technician does leave the area during the 11-7 shift and the department is unlocked and unattended. The Laboratory department has two doors off of the staff corridor that are not locked at night. The laboratory technician does leave the department during the 11-7 shift and the department is accessible to unauthorized personnel.

Staff B and Staff C confirmed that the doors as indicated above are not locked and therefore have the potential for access of unauthorized persons to the department during the 11-7 shift.

ANSI [American National Standard Institute] /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 tour of the surgical suite on 11/2/11 with Staff A (Manager of Surgical Services) it was observed that the facility failed to monitor the pressurization of the three surgical rooms.

Findings include:

During tour on 11/2/11 of the surgical suite it was observed and shown to Staff A that the three surgical rooms failed to have visual air pressurization monitoring devices to show the appropriate air pressurization in the surgical room.

Based on observation, review of the facility glucometer control documentation and interview it was determined that the facility failed to have documented evidence of the expiration date after opening the solution bottle on three glucometer units in three different facility departments.

Findings include:

Observation on 11/1/11 on the Medical Surgical Unit showed that the opened Blood Glucose Monitoring control solution bottle had no documented evidence of a date for the opening of the solution bottle and no documented evidence of the expiration date after opening the solution bottle.

Interview with Staff D (Unit Manager) on 11/1/11 confirmed that the Blood Glucose Monitoring control solution bottle unit was not labeled with an opening date or expiration date.

Observation on 11/2/11 in the Emergency Department showed that the opened Blood Glucose Monitoring control solution bottle had no documented evidence of a date for the opening of the solution bottle and no documented evidence of the expiration date after opening the bottle.

Interview with Staff E (Emergency Manager) on 11/1/11 confirmed that the Blood Glucose Monitoring control solution bottle on the unit was not labeled with an opening date or expiration date.

Observation on 11/2/11 in the Pediatric Office practice showed that the opened Blood Glucose Monitoring control solution bottle had no documented evidence of a date for the opening of the solution bottle and no documented evidence of the expiration date after opening the bottle.

Interview with Staff F (Office Practice Manager) on 11/2/11 confirmed that the Blood Glucose Monitoring control solution bottle on the unit was not labeled with an opening date or expiration date.