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West Virginia Licensure Rule CSR 64-12-5

5.1.b.1 The following documents are adopted as construction, equipment, physical facility, and related procedural standards for all existing hospitals, all new construction and any additions, alterations, renovations, or conversions of existing buildings: The relevant sections of the 2001 edition of The Guidelines for Design and Construction of Hospitals and Health Care Facilities as recognized by the American Institute of Architects Academy of Architecture for Health with assistance from the United States Department of Health and Human Resources shall be used as planning standards;



5.4.a Additions and renovations or alterations of any hospital which are begun after the effective date of this rule shall comply with the General and Psychiatric Hospital sections, as applicable, of the latest edition of Guidelines for Design and Construction of Hospitals and Health Care Facilities.

This Standard is not Met as evidenced by:

Based on observation and staff interview, it was determined the hospital failed to maintain the required ventilation for renovated gross decontamination rooms. This failure has the potential to adversely affect the care of all patients treated in the renovated rooms.

Findings include:

1. During tour of the hospital endoscopy procedure area at approximately 11:30 a.m., the gross decontamination room was found not to have the required negative air pressure and air exchanges as listed in the 2001 Guidelines for Design and Construction of Hospitals and Health Care Facilities.

(Gross Decontamination Room) Ventilation System. Negative pressure shall be maintained and a minimum of 10 air changes per shall be maintained. All air should be exhausted to the outside to avoid recirculation within the facility.

2. During an interview with the facility maintenance director on 10/18/11 at approximately 2:30 p.m., it was revealed that the gross decontamination room was not equipped with the required ventilation system.

Based on observation, staff interview and documentation review during a revisit conducted 10/17/11 to 10/18/11, it was determined the facility failed to complete tags C153, C221, C320 and K077 as listed in the plan of corrections. Therefore, this condition is not met.

Based on observation it was determined the hospital failed to maintain the physical plant in a manner to protect patients that are transported to the magnetic resonance imaging (MRI) trailer unit during inclement weather.

Findings include:

1. On 10/17/11 at approximately 9:00 a.m., an MRI trailer was observed located near the front of the hospital. At this time, there was not an acceptable sheltered access route to protect patients from the elements of weather during transport.

Based on review of documents, observation and staff interview it was determined the hospital failed to ensure the renovations to the Surgical Suite, now called the Endoscopic Procedure Room has been completed as of 8/30/11 per the Plan of Correction. This has the potential to negatively affect all patients under going procedures, by increasing their risk for infections.

Findings include:

1. During a tour of the Endoscopic Procedure Room in the afternoon of 10/17/11 it was discovered a hole had been cut in the wall for a window to use as a pass through to the gross decontamination room. When questioned, the Assistant Chief Clinical Officer stated a window has been ordered, but as of this date had not been delivered.

2. The gross decontamination room and the room used to process the endoscopes did not contain an exhaust fan to enable negative air pressure.

3. During an interview with the Assistant Chief Clinical Officer and the Maintenance Director in the afternoon of 10/17/11, they agreed these rooms were not completed and ready to use for services.