HospitalInspections.org

Based on observation and interview, the hospital does not meet the applicable provisions of the Life Safety Code of the National Fire Protection Agency (NFPA), as evidenced by:

1) The hospital does not conform to NFPA 241 Standard for Safeguarding Construction, Alterations and Demolition Operations related to Temporary Construction Barriers.
2) The hospital does not provide fire safety to patients and staff during construction related to access of fire hydrants.

Findings include:

Findings #1:
- Observation during facility tour on 8/21/14 at 11:00 AM revealed a Tyvek construction curtain used as a construction barrier in the operating room corridor adjacent to room number D-348 restroom; the purpose of the construction was to tie in the plumbing for the construction zone on floor 4 above.

This finding was verified with Director of Facility Engineering Staff #5 on 8/21/14.

Findings #2:
- Observation during facility tour on 8/21/14 at 2:30 PM revealed a construction dumpster located in front of the fire hydrant adjacent to the generator building.

This finding was verified with Staff #5 on 8/21/14.

Based on observation and interview, the hospital does not maintain the surgical services cart washer and carts, related to hard water residuals on the washer and carts.

Findings include:

Observation during tour of the Sterile Processing Department's soiled and clean processing areas on 8/21/14 at 11:30AM revealed a white powdery residual on the exterior of the cart washer and the interior and exterior of the case carts on the clean side of the department. During interview at that time, Operating Room Support Supervisor Staff #68 confirmed this and indicated that the facility has hard water, and as a result, these "calcium deposits" have been a problem for some time.

Based on observation, interview, document review and policy and procedure review, the hospital does not ensure maintenance of facilities and supplies to ensure an acceptable level of safety and quality, as evidenced by:

1) Not all facilities and equipment are maintained.
2) The hospital does not consistently ensure that emergency code cart supplies are available for patient care, as evidenced for 2 of 11 crash carts inspected.

Findings include:

Findings #1:
- During tour of the emergency department on 8/19/14, it was observed that there was a hole in the wall of the clean storage linen alcove.

This finding was verified with System Director for Patient Experience & Accreditation Staff #4 on 8/19/14.

- During tour of the 26 Pump Room on 8/19/14, it was observed that the condensate return pit had a large amount of standing water and what appeared to be algae growth. System Director for Facilities Engineering Staff #6 verified this and stated that there may be a clogged drain.

- During tour of the S-4 Pump Room on 8/19/14, it was observed that there was water leaking from the trap, and the water was pooling on the floor due to poor drainage at the drain.

This finding was verified with Director of Facility Engineering Staff #5 on 8/19/14.

- During tour of the laboratory on 8/19/14, it was observed that in the corridor near the refrigerators, there were two ceiling tiles that were water stained and wet to the touch, indicating an active leak.

This finding was verified with Staff #5 on 8/19/14.

During the tour of the kitchen on 8/19/14, the following was observed, and verified by Director of Dietary Staff #25 at the time of observation:
- Four of the shelving units in Dry Storage were not at least six inches above the floor.
- Both door seals of the silver double door cooler had mold growth on them.
- Approximately six inches of seal was missing from the door seal of the cooks' cooler.
- The fan guard of the main walk-in cooler had dust build up on it.
- In the area where the steam kettle was located, there were two water leaks from piping to the existing steam kettle, three pieces of ceramic tile were missing from the floor, and the exhaust hood had a large amount of condensation from the existing steam kettle, which at the time of inspection had water boiling in it. There was air being drawn by the exhaust hood, but based on observation of the amount of condensation on the hood and steam escaping from the area into adjacent space, it did not appear to be a sufficient volume of exhaust.
- In the two-bay sink pots and pans area, the area underneath the sink had a large quantity of standing water with gray slime.
- During interview, Staff #25 indicated that the system for cleaning pots and pans was to utilize a two-bay sink to first wash, second to rinse, then put the items into a machine to sanitize utilizing high temperature. The wash cycle requires a minimum temperature of 150° Farenheit and a final rinse at a minimum of 180°. Review of the "Washer Temperature Log" revealed that the minimum temperatures were not achieved for 11 of the 13 days documented for August 2014. Staff #25 indicated that there is an alternative method of bringing pots and pans to the dish washer for sanitization. The process was not observed during the inspection.

- During tour of the Garbage Room on 8/19/14, it was observed that garbage cans were stored directly in front of the "208/120" electrical panel box. This does not allow for the minimum working space that must be clear at all times.

This finding was verified with Staff #6 on 8/19/14.

Findings #2:
Review on 8/21/14 of policy #NS-340 "Code Team (formerly Code Blue)" (last revised 11/2013) revealed that the code cart shall be inspected once every 24 hours when a clinical area is open for patient care and compliance will be noted by signing on the appropriate date.

Review of current Code Cart Integrity Checklists for 11 crash carts revealed that the AED, Defibrillator and Lock for Integrity are not checked once every 24 hours on all patient care/clinical units, as follows:
- Review on 8/19/14 at 1:00 PM of the Code Cart Integrity Checklist in the emergency department revealed no documentation (which was verified by Manager of Emergency Services Staff #12 at that time) that the code cart had been checked on 7/4/14 or 7/29/14.
- Review on 8/19/14 at 3:00 PM of the Code Cart Integrity Checklist on 4B, a medical/surgical patient unit, revealed no documentation (which was verified by System Coordinator for Risk Management and Regulation Staff #1 at that time) that the code cart had been checked on the following days:
--- April 2014: on 4/4, 4/25 and 4/27;
--- May 2014: on 5/10, 5/11 and 5/27;
--- June 2014: on 6/6, 6/20 and 6/21;
--- July 2014: on 7/2 and 7/6.