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1) Based on observation and interview with staff, the facility failed to provide doors protecting corridor openings, constructed of 1¾ inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. There is no impediment to the closing of the doors and doors are provided with a means suitable for keeping the door closed. 19.3.6.3.6 19.3.6.3 Findings include:

a) The door to maintenance shop was not provided with a closure that kept door closed.

b) Door to kitchen across from COO Office was not provided with Latching Hardware.

1) Based on observation and interview with staff, the facility failed to provide Exit and directional signs that are displayed in accordance with section 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 Findings include:

a) there is no exit sign in the ceiling adjacent to to room 200.

1) Based on observation and interview with staff, the facility failed to conduct fire drills that are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9 PM and 6 AM a coded announcement may be used instead of audible alarms. 19.7.1.2 Findings include:

a) Fire drill for the night shift for last quarter of 2013 was missing.

1) Based on observation and interview with staff, the facility failed to provide a fire alarm system required for life safety that is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. The system failed to have an approved maintenance and testing program complying with applicable requirements of NFPA 70 and 72. 9.6.1.4 Findings include:

a) The combination fire and smoke dampers located through out the building and connected to the smoke alarm was not tested.

b) Facility failed to have a directory of points for the alarm system. The facility could not verify that the contractor tested all components such as smoke dampers annually.

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

a) The room constructed to house the Sterilizer was not provided with sprinkler protection.

1) Based on observation and interview with staff, the facility failed to provide Heating, ventilating, and air conditioning 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) The facility failed to maintain equipment that provides Temperature and Humidity with accepted practices. Findings include:

a-1) The manometers on the HVAC Equipment were disconnected and not working for the Operating Room.

a-2) The humidifier used to maintain humidity in the Operating Rooms was not working. Historical Records for Humidity were not taken. Facility failed to maintain Equipment needed for ventilating and humidifying during surgical procedures in accordance with 5-6.1.1.

a-3) The HVAC Equipment was not keeping the room cool . The facility relied on a box fan setting on the floor. Fans can not be used to re-circulate air with out filtration.

a-4) Documentation was not available to show how many air exchanges, outside air exchanges per hour the Operating Room and supporting spaces has, nor was there documentation available to show if the room was positive or negative. The outside air damper was closed on the roof that provided air to the Operating Room. The Director of maintenance was asked about the outside air damper position, he indicated that he never had check the outside air damper.

a-5) The facility could not show life of or condition of the HEPA Filters, the filters were changed out on a time basis, instead of when pressure drop across the filters indicate to be changed by a manometer. No reading were taken from the Manometers, and the Director of Maintenance indicated that manometers were not used to determine filter life.

b) The sterilizer was not provided with an exhaust or tied into an exhaust duct.

c) The decontamination room in the Operating Room Suite was not negative.

d) The room used as central sterile did not have a positive air flow and provided with humidity control. Central Sterile room door was propped open, holes in sheet rock and space around the sterilizer allowed for unfiltered air to travel in.

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

a) The bottled reserve system, located at the bulk oxygen site is not protected with a cover and the bottom of the bottles are not protected from rusting in accordance with 4-3.5.2.2.

b) Based on observation, review of Building Plans and interview with staff, the internal governing structure, responsible for elements of hospital operation, building design, purchasing specifications, inspection procedures, and maintenance schedules, failed to delegate to staff for hiring of consultants, architects, engineers, to submit remodeling, modification, renovation plans or to change room use to Authority Having Jurisdiction. The design of the building was altered in the following areas that impacted the Performance Design of the medical gas systems in accordance with NFPA 101 2000 Life Safety Code 5.8.14. Findings include:

b1) The three rooms 200, 202, 204 and room adjacent to these rooms, used as a procedure room, did not have medical gas area alarms immediately outside the rooms in accordance with 4-3.1.2.2

b2) The three rooms 200, 202, 204 and room adjacent to these rooms, used as a procedure room, did not have medical gas zone valves immediately outside the rooms in accordance with 4-3.1.2.3 (m).

1) Based on observation and interview with staff, the facility failed to provide Anesthetizing locations that are protected in accordance with NFPA 99, Standard for Health Care Facilities. Findings include:


a) Based on interview with Operating Room Staff, the facility failed to adopted Rules and Regulations and to Post Rules and Regulations that are in accordance with NFPA 99 1999 edition Chapter 12- 4.1.1.4 for the control of personal in Anesthetizing Locations. Operating Room Staff had not been thoroughly in-serviced for Specific Area Requirements for Anesthetizing Locations in accordance with 12-4.1.1 through 12-4.1.2.10. Also staff has not practiced a fire drill in the operating room that simulated a Operating Room Fire. Operating Room Staff including, Physicians, and Support Staff has not had periodic review of manufactures 'safety guidelines and usage requirements for electrosurgical units and similar appliances. Physicians, nurses nurse aids,engineers, technicians, and orderlies shall be cognizant of the risks associated with their use and to achieve this end result, the hospital shall provide appropriate programs of continuing education for its personnel in accordance with NFPA 99 1999 edition chapter 7-6.5. Facility did not provide such program for all its personal and could not provide required documentation.

b) The operating room is not provided with a smoke removal system that removes products of fire and smoke in accordance with NFPA 99 5-4.2.

1) Based on observation and interview with staff, the facility failed to maintain design features initially approved for construction. The building was not maintained in accordance with approved design specifications. The variations and room re-assignment required approval from the authority having jurisdiction prior to the actual change, NFPA101 2000 Life Safety Code 5.1.7.

a) Room across from the nurses station, used to conduct endo-scope procedures was not submitted for review and approval.

b) The three rooms north of the procedure room, 204,202, 200 were used as a recovery.

c) The room used to clean endo-scopes failed to have a layout that allowed cleaning area for flow of instruments from the contaminated area to the clean assembly area and then to storage. There was no physical barrier provided to prevent droplet contamination from the dirty side to the clean side.

d) The room that was constructed out of combustible wood was used to house the sterilizer. The room was not provided with a exhaust and a fire sprinkler. The room was not closed off in the central sterilizer room, sheet rock was not finished, voids left in the wall.

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) Based on observation, review of Building Plans and interview with staff, the internal governing structure, responsible for elements of hospital operation, building design, purchasing specifications, inspection procedures, and maintenance schedules, the facility failed to delegate to staff for hiring of consultants, architects, engineers, to submit remodeling, modification, renovation plans or to change room use to Authority Having Jurisdiction. The design of the building was altered in the following areas that impacted the Performance Design in accordance with NFPA 101 2000 Life Safety Code 5.8.14.

a-1) The three rooms 200, 202, 204 and the room adjacent to these rooms, used as a procedure room, did not have dedicated circuits to each bed location in accordance with NFPA 99, chapter 3 and NFPA 70. Each bed location shall be provided with a circuit from the Critical Care Branch and one from the normal branch.

b) The Operating Room was not provided with a Battery Back up lighting that provides light while the emergency generator is starting.

c) The Operating Room is not provided with a receptacle supplied from a dedicated normal circuit, separate from the emergency power system.

d) 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 were tested annually. Life Pac tested in May of 2014 is not set up for re-test until May of 2015. The EKG Machine tested in August of 2013 is not scheduled for re-test until August of 2014, both pieces of equipment were located in the Emergency Room. Also the Anesthesia Machine located in the Operating Room was tested in November of 2013, it was not scheduled for re-test until November of 2014.

c) 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 and in accordance with manufacture requirements.

d) The facility failed to have a preventive maintenance program that conducted Impedance Ground and Receptacle Testing in patient care areas in accordance with NFPA 99 3-3.3.2.4 and 3-3.3.3

1) Based on observation and interview with staff, the facility failed to provide doors protecting corridor openings, constructed of 1¾ inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. There is no impediment to the closing of the doors and doors are provided with a means suitable for keeping the door closed. 19.3.6.3.6 19.3.6.3 Findings include:

a) The door to maintenance shop was not provided with a closure that kept door closed.

b) Door to kitchen across from COO Office was not provided with Latching Hardware.

1) Based on observation and interview with staff, the facility failed to provide Exit and directional signs that are displayed in accordance with section 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 Findings include:

a) there is no exit sign in the ceiling adjacent to to room 200.

1) Based on observation and interview with staff, the facility failed to conduct fire drills that are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9 PM and 6 AM a coded announcement may be used instead of audible alarms. 19.7.1.2 Findings include:

a) Fire drill for the night shift for last quarter of 2013 was missing.

1) Based on observation and interview with staff, the facility failed to provide a fire alarm system required for life safety that is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. The system failed to have an approved maintenance and testing program complying with applicable requirements of NFPA 70 and 72. 9.6.1.4 Findings include:

a) The combination fire and smoke dampers located through out the building and connected to the smoke alarm was not tested.

b) Facility failed to have a directory of points for the alarm system. The facility could not verify that the contractor tested all components such as smoke dampers annually.

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

a) The room constructed to house the Sterilizer was not provided with sprinkler protection.

1) Based on observation and interview with staff, the facility failed to provide Heating, ventilating, and air conditioning 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) The facility failed to maintain equipment that provides Temperature and Humidity with accepted practices. Findings include:

a-1) The manometers on the HVAC Equipment were disconnected and not working for the Operating Room.

a-2) The humidifier used to maintain humidity in the Operating Rooms was not working. Historical Records for Humidity were not taken. Facility failed to maintain Equipment needed for ventilating and humidifying during surgical procedures in accordance with 5-6.1.1.

a-3) The HVAC Equipment was not keeping the room cool . The facility relied on a box fan setting on the floor. Fans can not be used to re-circulate air with out filtration.

a-4) Documentation was not available to show how many air exchanges, outside air exchanges per hour the Operating Room and supporting spaces has, nor was there documentation available to show if the room was positive or negative. The outside air damper was closed on the roof that provided air to the Operating Room. The Director of maintenance was asked about the outside air damper position, he indicated that he never had check the outside air damper.

a-5) The facility could not show life of or condition of the HEPA Filters, the filters were changed out on a time basis, instead of when pressure drop across the filters indicate to be changed by a manometer. No reading were taken from the Manometers, and the Director of Maintenance indicated that manometers were not used to determine filter life.

b) The sterilizer was not provided with an exhaust or tied into an exhaust duct.

c) The decontamination room in the Operating Room Suite was not negative.

d) The room used as central sterile did not have a positive air flow and provided with humidity control. Central Sterile room door was propped open, holes in sheet rock and space around the sterilizer allowed for unfiltered air to travel in.

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

a) The bottled reserve system, located at the bulk oxygen site is not protected with a cover and the bottom of the bottles are not protected from rusting in accordance with 4-3.5.2.2.

b) Based on observation, review of Building Plans and interview with staff, the internal governing structure, responsible for elements of hospital operation, building design, purchasing specifications, inspection procedures, and maintenance schedules, failed to delegate to staff for hiring of consultants, architects, engineers, to submit remodeling, modification, renovation plans or to change room use to Authority Having Jurisdiction. The design of the building was altered in the following areas that impacted the Performance Design of the medical gas systems in accordance with NFPA 101 2000 Life Safety Code 5.8.14. Findings include:

b1) The three rooms 200, 202, 204 and room adjacent to these rooms, used as a procedure room, did not have medical gas area alarms immediately outside the rooms in accordance with 4-3.1.2.2

b2) The three rooms 200, 202, 204 and room adjacent to these rooms, used as a procedure room, did not have medical gas zone valves immediately outside the rooms in accordance with 4-3.1.2.3 (m).

1) Based on observation and interview with staff, the facility failed to provide Anesthetizing locations that are protected in accordance with NFPA 99, Standard for Health Care Facilities. Findings include:


a) Based on interview with Operating Room Staff, the facility failed to adopted Rules and Regulations and to Post Rules and Regulations that are in accordance with NFPA 99 1999 edition Chapter 12- 4.1.1.4 for the control of personal in Anesthetizing Locations. Operating Room Staff had not been thoroughly in-serviced for Specific Area Requirements for Anesthetizing Locations in accordance with 12-4.1.1 through 12-4.1.2.10. Also staff has not practiced a fire drill in the operating room that simulated a Operating Room Fire. Operating Room Staff including, Physicians, and Support Staff has not had periodic review of manufactures 'safety guidelines and usage requirements for electrosurgical units and similar appliances. Physicians, nurses nurse aids,engineers, technicians, and orderlies shall be cognizant of the risks associated with their use and to achieve this end result, the hospital shall provide appropriate programs of continuing education for its personnel in accordance with NFPA 99 1999 edition chapter 7-6.5. Facility did not provide such program for all its personal and could not provide required documentation.

b) The operating room is not provided with a smoke removal system that removes products of fire and smoke in accordance with NFPA 99 5-4.2.

1) Based on observation and interview with staff, the facility failed to maintain design features initially approved for construction. The building was not maintained in accordance with approved design specifications. The variations and room re-assignment required approval from the authority having jurisdiction prior to the actual change, NFPA101 2000 Life Safety Code 5.1.7.

a) Room across from the nurses station, used to conduct endo-scope procedures was not submitted for review and approval.

b) The three rooms north of the procedure room, 204,202, 200 were used as a recovery.

c) The room used to clean endo-scopes failed to have a layout that allowed cleaning area for flow of instruments from the contaminated area to the clean assembly area and then to storage. There was no physical barrier provided to prevent droplet contamination from the dirty side to the clean side.

d) The room that was constructed out of combustible wood was used to house the sterilizer. The room was not provided with a exhaust and a fire sprinkler. The room was not closed off in the central sterilizer room, sheet rock was not finished, voids left in the wall.

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) Based on observation, review of Building Plans and interview with staff, the internal governing structure, responsible for elements of hospital operation, building design, purchasing specifications, inspection procedures, and maintenance schedules, the facility failed to delegate to staff for hiring of consultants, architects, engineers, to submit remodeling, modification, renovation plans or to change room use to Authority Having Jurisdiction. The design of the building was altered in the following areas that impacted the Performance Design in accordance with NFPA 101 2000 Life Safety Code 5.8.14.

a-1) The three rooms 200, 202, 204 and the room adjacent to these rooms, used as a procedure room, did not have dedicated circuits to each bed location in accordance with NFPA 99, chapter 3 and NFPA 70. Each bed location shall be provided with a circuit from the Critical Care Branch and one from the normal branch.

b) The Operating Room was not provided with a Battery Back up lighting that provides light while the emergency generator is starting.

c) The Operating Room is not provided with a receptacle supplied from a dedicated normal circuit, separate from the emergency power system.

d) 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 were tested annually. Life Pac tested in May of 2014 is not set up for re-test until May of 2015. The EKG Machine tested in August of 2013 is not scheduled for re-test until August of 2014, both pieces of equipment were located in the Emergency Room. Also the Anesthesia Machine located in the Operating Room was tested in November of 2013, it was not scheduled for re-test until November of 2014.

c) 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 and in accordance with manufacture requirements.

d) The facility failed to have a preventive maintenance program that conducted Impedance Ground and Receptacle Testing in patient care areas in accordance with NFPA 99 3-3.3.2.4 and 3-3.3.3