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OKLAHOMA SURGICAL HOSPITAL, LLC
Hazardous Areas - Enclosure
Tag No.: K0321
Based on observation and staff interview it was determined the facility failed to ensure protection of hazardous soiled linen/biohazard waste was protected in a area protected as a hazardous area.
Findings:
On 2/6/17 at 12:38 p.m., while on tour of the facility a plastic wheeled container of soiled linen/biohazard waste over 64 gallons was observed to be stored open to the corridor in post-op next to a wheeled 4 shelf metal rack with clean linens stored on each shelf.
The director of support services acknowledged the area where soiled and clean linen were stored next to each other in post-op open to the corridor.
At 12:40 p.m., a housekeelping/soiled linen/biohazard waste room door was obseved to not be closed in a positively latched position. The door was observed to not fully close, and did not have self-closing hardware.
The director of support services acknowledged the door was hard to close, and did not have self-closing hardware.
Anesthetizing Locations
Tag No.: K0323
Based on observation and staff interview it was determined the facility failed to ensure heating, cooling, and ventilation were in accordance with ASHRAE 170.
Findings:
On 2/6/17 test & balance annual inspection reports for the hospital were requested for 2016, 2015, and 2014. They were not provided.
The director of support services acknowledged the missing test & balance inspection reports.
On 2/7/17 at 12:57 p.m., while on tour of the facility in the surgical suite the central sterile supply room could not be determined to be positively ventilated as required.
The director of support services acknowledged the surgical suite central sterile supply could not be determined to be positively mechanically ventilated.
Fire Alarm System - Testing and Maintenance
Tag No.: K0345
Based on observation and staff interview it was determined the facility failed to ensure their fire alarm system was maintained in working order.
Findings:
On 2/6/17 at 12:05 p.m., while on tour of the facility a yellow tag was observed to be on the fire alarm system dated 12-29-16.
The director of support services acknowledged the existing yellow tagged fire alarm system.
Utilities - Gas and Electric
Tag No.: K0511
Based on observation and staff interview it was determined the facility failed to ensure electrical wiring and equipment was compliant with NFPA 70 of the National Electric Code.
Findings:
On 2/6/17 at 11:59 a.m., while on tour of the facility one (1) multiplug was observed to be in use at the reception desk in administration, One (1) power tap was observed to be in use in the pre-op area and two (2) multiplugs were observed to be in use in the pre and post op areas respectively.
At 12:54 p.m., while on tour of the facility a power strip was observed to be in the procedure room located on the 3rd floor.
The director of support services acknowledged the multiplugs and power strip in the procdure room.
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Based on observation and staff interview it was determined the facility failed to ensure current inspections on laboratory equipment in service.
Findings:
On 2/8/17 while on tour of the facility laboratory located on the 1st floor the following equipment was observed to not have current inspection labels: fume hood, and two refrigerators storing laboratory supplies.
The laboratory manager was asked for the inspection reports for the fume hood, and two refrigerators. She said she doesn't have them and they have not been inspected since they were installed.
Soiled Linen and Trash Containers
Tag No.: K0754
Based on observation and staff interview it was determined the facility failed to protect soiled linen/biohazard waste in a protected hazardous area.
Findings:
On 2/7/17 at 12:43 p.m., while on tour of the facility a plastic wheeled container of soiled/biohazard linens over 64 gallons was observed to be stored open to the corridor in post-op next to a wheeled four (4) shelf metal rack with clean linens. It could not be determined if the area where the soiled linens was negatively ventilated, and it could not be determined if the area where the clean linens were stored was positively ventilated.
The director of support services acknowledged the area where soiled and clean linen were stored next to each other in the post-op area open to the corridor was negatively vented for soiled- positively ventilated for clean storage.
Gas and Vacuum Piped Systems - Inspection and
Tag No.: K0908
Based on staff interview it was determined the facility failed to ensure the facility medical gas systems were inspected as required.
Findings:
On 2/6/17 at 12:47 p.m., the medical gas system inspection reports were requested for 2016, 2015, and 2014. They were not provided.
The director of support services acknowledged not having the medical gas system annual inspection reports.