HospitalInspections.org

Based on observation and interview, the facility failed to maintain fire extinguishers in accordance with NFPA 10. This could result in the failure of a fire extinguisher to function as designed.

The findings include:

On 9/9/2015 at 9:52 a.m. a.m. while on tour of the UF Florida Surgical Center with the facility maintenance director in the surgical suites sub-sterile rooms, water based fire extinguishers were observed. The verification of service collar indicated that the last internal inspection and hydrostatic testing was performed in January 2008. The maintenance director contacted the fire extinguisher service company and they confirmed that the extinguishers were beyond their service interval.

According to NFPA 10 (1998 edition) 5-2; " At intervals not exceeding those specified in Table 5-2, fire extinguishers shall be hydrostatically retested. The hydrostatic retest shall be conducted within the calendar year of the specified test interval. In no case shall an extinguisher be recharged if it is beyond its specified retest date. " Table 5-2 indicates that " Stored-pressure water, loaded stream, and/or antifreeze- 5 years "

Based on observations and interviews, the facility failed proper storage of compressed medical gas cylinders in accordance with NFPA 99, Standard for Health Care Facilities. Improper storage of medical gas cylinders could result in the rupture of the cylinders and subsequent accelerated development of fire, smoke and fire gasses in a fire situation.

The findings include:
On 9/8/2015 at 1:35 PM while on tour of the UF Endoscopy Center with the facility maintenance director at the oxygen manifold and storage room, H-size oxygen tanks were observed in use and in storage. A light switch was observed inside the room and was located 4 feet above the floor. The maintenance director confirmed the observation.
On 9/9/2015 at 10:10 a.m. while on tour of the UF Florida Surgical Center with the facility maintenance director in the medical gas manifold and storage room, the pull station for the fire alarm was observed installed at 4 feet above the floor. The maintenance director confirmed the observation.
According to NFPA 99 (1999 edition) 8-3.1.11(f) "Electrical fixtures in storage locations shall meet 4-3.1.1.2(a)11d 'Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft (1.5 m) above the floor to avoid physical damage'."

South Tower/Cancer
Based on observation and interviews, the facility failed to properly document the testing intervals for biomedical equipment used in critical care and wet locations, including operating rooms as required by NFPA 99 (1999 edition) chapter 7-6.2.1.2. While the maximum listed intervals for these areas is six months, the biomedical equipment used in the operating rooms in the North and South tower operating rooms, including line voltage equipment, are labeled as valid for one year. Records review found the actual testing intervals to be less than six months. However, the labels are misleading and could lead to injury or death of a patient due to misuse of the equipment. Interviews with the staff in the North Tower operating rooms confirmed the staff is unaware the maximum testing interval for biomedical equipment in the operating rooms is six months.
The findings include:
While on tour September 9, 2015 at 9:30 AM in the South tower open operating rooms and at 2:30 PM in the North Tower open operating rooms, with the Maintenance Director, all the biomedical equipment, including line voltage equipment, was observed labeled to be re-inspected 12 months from the inspection date. The Maintenance Director acknowledged the dates and notes on the inspection label An interview with the Charge Nurse during a tour of the open operating rooms in the North Tower confirmed the staff is unaware of maximum testing interval for biomedical equipment used in the operating rooms is six months. At the exit conference the Director of the biomedical equipment section acknowledged the labeling of the biomedical equipment used in the operating rooms required re-inspection to be done in 12 months from the inspection date.
UF Endoscopy Center
Based on observation and interviews, the facility failed to test electrical equipment in accordance with NFPA 99 and maintain electrical equipment in accordance with manufacturer ' s specifications and with NFPA 70. Failure to maintain electrical equipment could result in the loss of power or the failure of the equipment to operate as designed. This could endanger patients from electric shock hazards.

Findings include:

On 9/8/2015 2015 at 1:45 PM while on tour of the UF Endoscopy Center with the facility maintenance director in room 1166 a manometer testing device was observed. The device had an inventory label that was dated 10/8/2012. A staff member said that the device was used on patients to study gastric and intestinal processes. The maintenance director said that the device was owned by the University and not the facility and was not in the facility inventory for maintenance and testing. He stated that he was not aware of any policy for devices not owned by the facility. According to NFPA 99 (1999 edition) 7-6.2.1.2 (a); " The facility shall establish policies and protocols for the type of test and intervals of testing for each appliance. " and 7-6.2.1.11; " Policies shall be established for the control of appliances not supplied by the facility. "

Based on observation and interview, the facility failed to maintain fire extinguishers in accordance with NFPA 10. This could result in the failure of a fire extinguisher to function as designed.

The findings include:

On 9/9/2015 at 9:52 a.m. a.m. while on tour of the UF Florida Surgical Center with the facility maintenance director in the surgical suites sub-sterile rooms, water based fire extinguishers were observed. The verification of service collar indicated that the last internal inspection and hydrostatic testing was performed in January 2008. The maintenance director contacted the fire extinguisher service company and they confirmed that the extinguishers were beyond their service interval.

According to NFPA 10 (1998 edition) 5-2; " At intervals not exceeding those specified in Table 5-2, fire extinguishers shall be hydrostatically retested. The hydrostatic retest shall be conducted within the calendar year of the specified test interval. In no case shall an extinguisher be recharged if it is beyond its specified retest date. " Table 5-2 indicates that " Stored-pressure water, loaded stream, and/or antifreeze- 5 years "

Based on observations and interviews, the facility failed proper storage of compressed medical gas cylinders in accordance with NFPA 99, Standard for Health Care Facilities. Improper storage of medical gas cylinders could result in the rupture of the cylinders and subsequent accelerated development of fire, smoke and fire gasses in a fire situation.

The findings include:
On 9/8/2015 at 1:35 PM while on tour of the UF Endoscopy Center with the facility maintenance director at the oxygen manifold and storage room, H-size oxygen tanks were observed in use and in storage. A light switch was observed inside the room and was located 4 feet above the floor. The maintenance director confirmed the observation.
On 9/9/2015 at 10:10 a.m. while on tour of the UF Florida Surgical Center with the facility maintenance director in the medical gas manifold and storage room, the pull station for the fire alarm was observed installed at 4 feet above the floor. The maintenance director confirmed the observation.
According to NFPA 99 (1999 edition) 8-3.1.11(f) "Electrical fixtures in storage locations shall meet 4-3.1.1.2(a)11d 'Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft (1.5 m) above the floor to avoid physical damage'."

South Tower/Cancer
Based on observation and interviews, the facility failed to properly document the testing intervals for biomedical equipment used in critical care and wet locations, including operating rooms as required by NFPA 99 (1999 edition) chapter 7-6.2.1.2. While the maximum listed intervals for these areas is six months, the biomedical equipment used in the operating rooms in the North and South tower operating rooms, including line voltage equipment, are labeled as valid for one year. Records review found the actual testing intervals to be less than six months. However, the labels are misleading and could lead to injury or death of a patient due to misuse of the equipment. Interviews with the staff in the North Tower operating rooms confirmed the staff is unaware the maximum testing interval for biomedical equipment in the operating rooms is six months.
The findings include:
While on tour September 9, 2015 at 9:30 AM in the South tower open operating rooms and at 2:30 PM in the North Tower open operating rooms, with the Maintenance Director, all the biomedical equipment, including line voltage equipment, was observed labeled to be re-inspected 12 months from the inspection date. The Maintenance Director acknowledged the dates and notes on the inspection label An interview with the Charge Nurse during a tour of the open operating rooms in the North Tower confirmed the staff is unaware of maximum testing interval for biomedical equipment used in the operating rooms is six months. At the exit conference the Director of the biomedical equipment section acknowledged the labeling of the biomedical equipment used in the operating rooms required re-inspection to be done in 12 months from the inspection date.
UF Endoscopy Center
Based on observation and interviews, the facility failed to test electrical equipment in accordance with NFPA 99 and maintain electrical equipment in accordance with manufacturer ' s specifications and with NFPA 70. Failure to maintain electrical equipment could result in the loss of power or the failure of the equipment to operate as designed. This could endanger patients from electric shock hazards.

Findings include:

On 9/8/2015 2015 at 1:45 PM while on tour of the UF Endoscopy Center with the facility maintenance director in room 1166 a manometer testing device was observed. The device had an inventory label that was dated 10/8/2012. A staff member said that the device was used on patients to study gastric and intestinal processes. The maintenance director said that the device was owned by the University and not the facility and was not in the facility inventory for maintenance and testing. He stated that he was not aware of any policy for devices not owned by the facility. According to NFPA 99 (1999 edition) 7-6.2.1.2 (a); " The facility shall establish policies and protocols for the type of test and intervals of testing for each appliance. " and 7-6.2.1.11; " Policies shall be established for the control of appliances not supplied by the facility. "