HospitalInspections.org

Based on observation and interview the facility failed to ensure a business occupancy was separated from the health care occupancy by construction having a minimum two hour fire resistance rating in accordance with Chapter 8.

Findings:

On 06/21/17 at 1:11 pm 12 patient rooms located on the east end section of the second floor of the facility were observed to be repurposed into offices. The maintenance manager was asked to describe the repurposed area and he stated it was leased for behavioral counseling. The surveyor asked if the group is a part of the hospital and the maintenance manager stated it was not.

Reference:
NFPA 101, 2012 Edition, Chapter 8 and Chapter 19.1.3.3
42 CFR 482.41 and 42 CFR 485.623

Based on observation and interview the facility failed to ensure the means of egress was continuously maintained free of all obstructions to full use in case of emergency as required.

Findings:

On 06/21/17 at 4:05 pm the surveyor observed the exit door leading north from the surgical suite opens to a medical records storage room. A metal bookcase was observed to be lying across the egress pathway blocking it. The maintenance manager stated the bookcase should not be there.

Based on observation and interview the facility failed to ensure doors in a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress as required in accordance with NFPA 101, 2012 Edition, Chapter 19.2.2.2.6. Also, the facility failed to ensure each staff member working in permitted door locked units were provided with a key as required per NFPA 101, 2012 Edition, Chapter 19.2.2.2.5.1.

Findings:

On 06/21/17 at 10:34 am a deadbolt was observed to be on the door leading to the southeast stairwell on the second floor. There were multiple deadbolt locks observed on corridor doors throughout the facility.

On 06/21/17 at 11:03 am the door to the geriatric locked area on the second floor had a deadbolt installed on the egress door leading to the emergency egress stairwell. A staff person was asked to open the door, and she said she did not have a key.

Based on observation and interview the facility failed to ensure illumination of means of egress to include exit discharge is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention in accordance to NFPA 101, 2012 Edition Chapter 19.2.8.

Findings:

On 06/20/17 at 1:20 pm, each of the designated exit discharges from the facility were observed to have lighting fixtures on normal power. The maintenance manager was asked if the exit discharge lighting would always illuminate when the emergency generator came on and there was no normal electrical power. The maintenance manager stated he did not know and could not confirm which lights would illuminate under generator power.

Based on observation and interview the facility failed to ensure their hazardous areas were protected as required in Chapter 8.7.1 and Chapter 19.3.2.1.

Findings:

On 06/21/17 at 10:51 am a hazardous area storage hazardous area closet had one wall which was observed to have non-fire rated plywood covering one wall within the closet. The maintenance manager was asked to explain the raw plywood which was installed. He stated he did not know why it was installed but would remove it or cover it with fire rated gypsum board.

On 06/21/17 at 4:05 pm a medical records hazardous storage area containing over 50 bankers boxes stored on wood frame shelves located near the surgical suite was observed to have a fire rated wall that did not terminate to the roof deck. There was an approximate 30X2 feet area of wall missing which would allow fire, and smoke back into the facility. The maintenance manager was asked to explain why they did not have the wall built up to the roof deck, and he stated he did not know how it got that way or why it happened.

Based on record review, observation and interview the facility failed to ensure ventilation within the surgical suite was in accordance with ASHRAE 170 as required.

Findings:

On 06/20/17 at 2:23 pm during record review the facility temperature and humidity logs showed the facility's range to be 20-60% and not 30-60% as required. The surgical manager was asked why the facility's starting range number for RH was 20%. She stated it was because they are using CMS's categorical waiver to lower RH to 20%. The surveyor stated the CMS categorical waiver does allow states to go to 20% as long as the state they operate in does not have a stricter requirement. The surveyor explained Oklahoma by statute has the RH range of 30% to 60%.

On 06/21/17 at 3:49 pm a tissue test was performed on the following rooms within the surgical suite: high level disinfectant decontamination room, soiled storage, and operating room #5. Each of the rooms tested were observed to be positively ventilated and not negatively ventilated as required. The manager of surgical services accompanied the surveyor and saw the results of the tissue tests for each area. She stated she did not know why the areas were not properly ventilated but would get them corrected.

Based on observation and interview the facility failed to ensure smoke detection devices were fully inspected, operational and maintained as required.

Findings:

On 06/22/17 at 2:57 pm a ceiling mounted smoke detector was observed in a patient room repurposed into EMS staff sleeping room to have a smoke detector dust cover installed on it. The application of the smoke detector dust cover made it non-operational. The maintenance manager was asked if there was construction being done within the room and he stated no. A facility EMS staff member was asked why the dust cover was installed on the smoke detector in the room. The EMS staff person stated the cover was placed on the smoke detector because when the shower is used in the room it sets off the smoke detector.

On 06/22/17 at 3:17 pm a ceiling mounted smoke detector was observed to be within three feet of an air diffuser in the corridor near radiology. The maintenance manager stated they would get the smoke detector installed correctly.

Based on observation and interview the facility failed to ensure ceilings within smoke compartments would resist the transfer of smoke in accordance with NFPA 101, 2012 Edition, Chapter 19.3.6.2 and 19.3.6.2.7.

Findings:

On 06/22/17 at 10:38 am ceiling tiles throughout the facility's smoke compartments were observed to have openings which would allow smoke and fire into ceiling spaces. The maintenance manager stated he would correct the openings in the ceiling tiles throughout the facility.

Based on observation and interview the facility failed to ensure corridor doors were not equipped with prohibited roller latches.

Findings:

On 06/22/17 at 10:50 am three roller latches were observed to be installed on doors within the emergency department. Trauma room #1 and #2 both had barrel latches installed. The door going from the ED to X-ray had a deadbolt and barrel latch installed. The maintenance manager was asked why barrel latches were installed on the three doors. He stated they were installed before he was there and did not know they were prohibited.

Based on observation and interview the facility failed to ensure areas undergoing construction, repair, or improvements were inspected daily to ensure its ability to be used instantly in case of emergency as required in NFPA 241.

Findings:

On 06/21/17 at 10:21 am a sheet of plywood with a polyethylene plastic sheeting covering was observed to be installed at what was once a designated exit from the emergency room. The maintenance manager stated they had begun to expand the corridor and then halted construction. He stated they left the temporary construction barrier in place. The maintenance manager was asked if it could be used instantly in case of an emergency. He stated no the plywood barrier is installed where it could not be used instantly in case of an emergency.

Based on record review and interview the facility failed to ensure completing building systems risk assessment for their medical gas systems as required.

Findings:

On 06/20/17 at 11:37 am the maintenance manager was asked for the building systems risk assessments to include medical gas systems. During record review the maintenance manager failed to provide the medical gas risk assessment.

Based on record review and interview the facility failed to ensure all master, area, and local alarm systems used for medical gas and vacuum systems complied with appropriate Category warning system requirements as required in NFPA 99, 2012 Edition, Chapter 5.1.9, 5.2.9, and 5.3.6.2.2.

Findings:

On 06/20/17 at 11:39 am the 2016 annual medical gas inspection report from Airgas dated 09/23/16 was reviewed and outlined the following areas which need repair, replacement, protection and/or labeling: a) Master Alarm(s) b) Area Alarm(s), c) Manifold(s)- The Nitrous Oxide Manifold, Nitrogen Manifold, d) Zone Valve(s), e) Vacuum- Medical Vacuum. The maintenance manager was asked if the recommendations from Airgas have been followed or corrected. He stated they are working on it. He further stated there has been an issue with Airgas being sold to a new company Matheson in which they have to bid new proposals for a vendor contract.

Based on record review and interview the facility failed to ensure that building systems risk assessments for the facility essential electric system were completed as required.

Findings:

On 06/21/17 at 11:32 am the maintenance manager was asked for the building systems risk assessments to include their essential electric system. The maintenance manager failed to provide the essential electric system risk assessment.

Based on observation and interview the facility failed to ensure the essential electric system alarm annunciator was installed in a location readily observed by operating personnel at a regular work station in accordance with NFPA 99, 2012 Edition, Chapter 6.4.1.1.17, and 6.4.1.1.15.5.

Findings:

On 06/20/17 at 12:54 pm the generator annunciator was observed to be installed in a mechanical room which was not readily observable and not a regular work station. The maintenance manager was asked if there was always a staff member in the room where the annunciator was installed and he stated no.

Based on observation and interview the facility failed to ensure electrical receptacles or cover plates supplied from the life safety and critical branches had a distinctive color or marking. The emergency powered electrical receptacles were not labeled as required.

Findings:

On 06/22/17 at 3:40 pm after completing a full tour of the facility many of the patient rooms electrical receptacles were not labeled or distinctively color identifying them as being emergency generator powered receptacles. The maintenance manager was asked why many of the outlets were not labeled or distinctively identified. He stated they have not gotten around to completing all of the labeling and marking.

Based on record review and interview the facility failed to ensure all electrical wiring and equipment in use were inspected, maintained and tested as required.

Findings:

On 06/21/17 at 12:01 pm a Phillips ventilator was observed to have a inspection sticker which indicated its next inspection was due in December of 2016.

On 06/21/17 at 12:03 pm the respiratory supervisor was asked why it had not been inspected and she said she thought the leasing company had completed the inspection.

Based on observation and interview the facility failed to ensure freestanding oxygen cylinders were properly chained or supported in a proper cylinder stand or cart as required in NFPA 99, 2012 Edition, Chapter 11.6.2.3 (11).

Findings:

On 06/21/17 at 2:36 pm eight "H" size free standing oxygen cylinders located at the hospital's east side dock area were observed to not be properly chained. The maintenance manager acknowledged the unsecured oxygen cylinders by shaking his head up and down. He stated they would get the tanks secured.