HospitalInspections.org

Based on hospital policy and procedure reviews, anesthesia cart content list review, observations and staff interviews, the facility's staff failed to ensure controlled substances medications were kept secure in 2 of 5 anesthesia carts (Carts #1 and Cart #2) in the operating room.

The findings include:

Review of policy and procedure on 06/14/2017 titled "Handling of Controlled Medications" revealed "...Policy...The hospital will comply with all state and federal laws governing the handling of controlled substances....Purpose...To assign responsibility for the...storage,...and control of controlled substances and to minimize the potential for diversion of controlled substances....Storage...All controlled substances are to be locked in the controlled substance cabinets in the pharmacy department....Controlled substances are also stored throughout the hospital as stock in locked boxes and automated dispensing machines....The Pharmacy department will supply controlled substances to the Anesthesia Department....The Anesthesia Department maintains two safes for holding the locked boxes..."

Review of policy and procedure on 06/14/2017 titled "Medication Storage" revealed "...Policy...All medications (including sample medications) are properly stored throughout the hospital and departments of the hospital....All medications (including non prescription medications) are stored in a locked container in a closed room, or under constant surveillance....Controlled Substances are stored under locked conditions to prevent diversion and in accordance with state and federal regulations....Security of medications should be maintained at all times.

Review on 06/15/2017 of a hand written document titled "Anesthesia Cart" revealed a list of the contents in the anesthesia cart. The list included medications as well as supplies. The handwritten list had illegible medication listings however the following medications were listed: Morphine, Dilaudid, Fentanyl and Versed.

1. Observations during tour of the operating suite on 06/13/2017 at 1230 revealed in O.R. (Operating Room) #3, the anesthesia cart (cart #1) had two drawers pulled open and was not locked or secured. Observation of the two opened drawer's contents revealed the presence of controlled substances medications. Observation revealed the assigned CRNA (Certified Registered Nurse Anesthetist) #1 was not present in O.R. #3 or near the cart. Observation revealed the unlocked anesthesia cart with controlled substances was not under continuous surveillance.

Interview on 06/13/2017 at 1235 with the CRNA #1 revealed she locked the cart when she left the room to transport a patient to the PACU (Post Anesthesia Care Unit). CRNA #1 stated "the nurse was in the room".

Interview on 06/13/2017 during tour AS (Administrative Staff) #4 revealed, "It was not locked." Interview confirmed the observation findings.

2. Observations during tour of the operating suite on 06/13/2017 at 1440 revealed in O.R. #4, the anesthesia cart (Cart #2) drawers appeared to be closed. When the Surveyor pulled on the anesthesia cart drawers they opened indicating the cart was not locked and the contents were not secure. Observation of the drawer's contents revealed controlled substances medications were present. Observation revealed the assigned CRNA (Certified Registered Nurse Anesthetist) #2 was not present in O.R. #4 or near the cart. Observation revealed the unlocked anesthesia cart with controlled substances was not under continuous surveillance.

Interview 06/13/2017 at 1445 with the CRNA #2 revealed the anesthesia cart was not locked but should have been locked. Interview revealed he should have pressed the button on the cart to lock the cart before he left the O.R. to transport a patient to PACU. Interview revealed "but I did not." Interview confirmed the observation findings.

Based on review of the hospital's policy, observation , review of inspection sheets of apron/thyroid shields, interviews with staff, the hospital failed to ensure maintenance of personal radiation protective equipment in 1 of 8 thyroid collars.

The findings include:

Review on 06/14/2017 of the hospital's policy titled, "Pain Management," revision date of 01/2017, revealed " ...The protective devices are located in x-ray and checked annually. If you notice or suspect defect, notify RSO (radiation safety officer)."

Observation on 06/14/2017 at 1145 in outpatient clinic A's treatment room revealed a thyroid collar with a tear in the fabric. Further observation revealed a 0.5 inch tear, with frayed edges in the cloth border of the apron. Further observation revealed Tech #1 was wearing the defective collar as the surveyor entered room prior to a scheduled radiological procedure. Tech #1 attempted to place the defective collar on the surveyor for protection from radiation during the procedure.

Interview on 06/14/2017 at 1145 with x-ray technician (Tech #1) revealed the thyroid collar should be removed from use due to a tear in the cloth of collar.

Based on observation as referenced in the Life Safety report of survey completed June 13, 2017 through June 14, 2017, the hospital staff failed to develop and maintain the facilities in a manner to ensure the health and safety of patients, staff and visitors.

The findings include:

The hospital failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association assuring the safety and well-being of patients.

~cross-refer to 482.41(b)(1)(2)(3) Physical Environment: Life Safety from Fire - Standard Tag A0710

Based on observation as referenced in the Life Safety report of survey completed June 13, 2017 through June 14, 2017, the hospital failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association.

The findings include:

A. Based on observations, on June 13, 2017 at approximately 9:00 AM onward, the following deficiencies were noted:

1. Floor/ceiling assembly improperly fire stopped at pneumatic tube system penetration - located on fourth floor beside elevator lobby.

2. PVC conduit improperly fire stopped at fourth floor mechanical room MR400 - staff could not provide installation instructions for firestop assembly provided at penetration.

3. Steel roof beam is not equipped with fireproofing above elevator equipment in penthouse near stair #3 - Penthouse enclosure rating shall be maintained equivalent to rating of elevator shaft.

4. There is an unsealed penetration in the floor/ceiling assembly in ice machine room.(kitchen area)

NFPA 101 2012 ed, Sect 19.1.6.1, 8.3.5
This deficiency effected one of two smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~cross refer to Life Safety Code Standard - NFPA 101, Tag K 0161.

B. Based on observations, on June 13, 2017 at approximately 9:00 AM onward, the following deficiencies were noted:

1. Means of egress is obstructed by wall mounted clerical pad - located beside room 336. Device is not self-closing when opened and released.

2. There is no guardrail at exit discharge adjacent to loading dock - dock is greater than thirty inches above grade.

3. Horizontal door between serving area and dining room is locked against egress from inside serving area.

4. Doors between dining room and corridor do not swing in the direction of egress - room is sized to seat 50 or more occupants.

5. Enclosed courtyard is not equipped with remote second exit discharge - discharge to public way is not a smooth transition at intersection of curb and fence gate. Located at right of loading dock.

NFPA 101, 19.2.1, 7.1.10.1
This deficiency effected one of two smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~cross refer to Life Safety Code Standard -NFPA 101, Tag K 0211.

C. Based on observations, on June 13, 2017 at approximately 9:00 AM onward, the following deficiencies were noted:

1. Electromagnetic locks on exit discharge doors are incomplete - system is not equipped with delayed egress or on/off switches at each door with master on/off switch at supervised station. Locks are located on door to stair #4, beside room 225; and other exit doors on the same floor.

Note: Electromagnetic locks, as installed, did release with loss of power and activation of fire alarm system.

NFPA 101, 7.2.1.6.1, 19.2.2.2.6
This deficiency effected one of two smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~cross refer to Life Safety Code Standard - NFPA 101, Tag K 0222.

D. Based on observations, on June 13, 2017 at approximately 9:00 AM onward, the following deficiencies were noted:

There are holes in exit passageway enclosure - located in PACS Room in Radiology Suite.

NFPA 101 2012 ed, Sect 19.2.2.3, 19.2.2.4, 7.2
This deficiency effected one of two smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~cross refer to Life Safety Code Standard - NFPA 101, Tag K 0225.

E. Based on observations, on June 13, 2017 at approximately 9:00 AM onward, the following deficiencies were noted:

1. There is no exit sign at cross corridor smoke barrier doors - located near volunteer work room.

NFPA 101, Sects 19.2.10.1, 7.10
This deficiency effected one of two smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~cross refer to Life Safety Code Standard - NFPA 101, Tag K 0293.

F. Based on observations, on June 13, 2017 at approximately 9:00 AM onward, the following deficiencies were noted:

1. There is a wedge under door to respiratory therapy storage room.

2. Dumbwaiter doors are observed in the open position - room enclosure is incomplete and area is used for storage of combustibles. (Dispatch Room)

3. General storeroom doors are not self-closing - doors are equipped with hold-open feature not connected to release with activation of fire alarm system.

4. There is no self-closing device on door to environmental services storage - located in basement level.

NFPA 101, Sects 19.3.2.1, 8.7.1
This deficiency effected one of two smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~cross refer to Life Safety Code Standard - NFPA 101, Tag K 0321.

G. Based on observations, on June 13, 2017 at approximately 9:00 AM onward, the following deficiencies were noted:

Note: This facility utilizes special locking arrangements therefore requiring fully sprinklered/smoke detection thru-out per NFPA 101, 2012 Ed, Sect 7.2.1.6. (The auto Supervised Sprinkler option has been installed to meet this requirement)

1. There is no sprinkler in electrical room - located in 2 East electrical room.

2. There is no sprinkler in CT IV station - located in Radiology Unit.

3. There are no sprinklers for ER exit discharge enclosure - bound by three walls and enclosing ramp.

NFPA 101, 2012 Ed, Sects 19.5.3, 7.2.1.6, 9.7, NFPA 13, 2010 Ed.
This deficiency effected one of two smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~cross refer to Life Safety Code Standard - NFPA 101, Tag K 0351.

H. Based on observations, on June 13, 2017 at approximately 9:00 AM onward, the following deficiencies were noted:

1. There is no positive latching hardware on doors to dining room -these dining room doors provide required separation of dish conveyor opening at kitchen/dining room from corridor.

NFPA 101, 2012 ed Sect 19.3.6.3.5
This deficiency effected one of two smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~cross refer to Life Safety Code Standard - NFPA 101, Tag K 0363.

I. Based on observations, on June 13, 2017 at approximately 9:00 AM onward, the following deficiencies were noted:

1. There are holes in the rated smoke barrier that are not sealed - located above ceiling near room 244.

NFPA 101, 19.3.7.3, 8.6.7.(1)
This deficiency effected one of two smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~cross refer to Life Safety Code Standard - NFPA 101, Tag K 0372.

J. Based on observations, on June 13, 2017 at approximately 9:00 AM onward, the following deficiencies were noted:

1. There is no identification of circuit breaker and panelboard serving fire alarm panel in PACS Room fire alarm panel - located in Radiology Suite.

2. Fire alarm panel is wired to Critical Branch of Essential Electrical System - located in PACS Room.

3. Receptacle is wired improperly in clean utility room - located in birthing center. Receptacle wires are not enclosed in conduit or other protective jacket in louvered box.

4. There is no ground fault interrupter protection for receptacles beside sinks in kitchen serving area.

NFPA 101, Sections 19.5.1.1, 9.1.2, NFPA 70, 2011 ed.
This deficiency potentially affects all smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~cross refer to Life Safety Code Standard - NFPA 101, Tag K 0511.

K. Based on observations, on June 13, 2017 at approximately 9:00 AM onward, the following deficiencies were noted:

1. There is no service access opening for duct smoke detector - air handling unit located in MR400.

NFPA 101, 19.5.2.1, 9.2, NFPA 90A, 2012 ed
This deficiency effected one of two smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~refer to Life Safety Code Standard - NFPA 101, Tag K 0521.

L. Based on observations, on June 13, 2017 at approximately 9:00 AM onward, the following deficiencies were noted:

1. Oxygen cylinders are stored less than five feet from combustibles in clean utility room - located on fourth floor.

NFPA 99 2012 ed, 11.6.2
This deficiency effected one of two smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~cross refer to Life Safety Code Standard - NFPA 101, Tag K 0906.

M. Based on observations, on June 13, 2017 at approximately 9:00 AM onward, the following deficiencies were noted:

1. There is no remote manual stop switch for all emergency generators. NFPA 110, 2010 ed, Sect 5.6.5.6

2. Generator annunciator panel did not read emergency power system supplying load with loss of normal power to automatic transfer switch serving Life Safety Branch - Generators 1, 2, and 3.NFPA 110, Sect 5.6.6

3. There is no visual indicator for battery charger failure on annunciator panel serving generators 1, 2, and 3. NFPA 110, Sect 5.6.4.6

4. There are no specific gravity readings for generator battery electrolyte not Battery Conductance test documentation - documentation shall occur weekly in accordance with NFPA 110, 2010 ed, Sect 8.3.7.1.

NFPA 99, NFPA 110, Sect 8.3
This deficiency effected one of two smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~cross refer to Life Safety Code Standard - NFPA 101, Tag K 0918.

This Life Safety Code (LSC) survey was conducted utilizing the 2012 Existing edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC) for Business Occupancy; and 2012 edition of the NFPA 99 - Health Care Facilities Code (HCFC) and its referenced publications. The facility plan/construction approval occurred prior to July 5, 2016. In the exit conference all LSC deficiencies noted were discussed and acknowledged with Administration.

Stories: 2 (Facility is located on first floor) Construction Type: V(111)
Constructed: Prior to 7/5/2016
Not Sprinklered

Note: The Pain Management facility is located off campus in a separate county within a Business Occupancy.

N. Based on observations, on June 14, 2017 at approximately 9:00 AM onward, the following deficiencies were noted:

1. There is no air handler manual emergency stop switch, located at or near a supervised station, in pain management center.

NFPA 101 Sect 19.5.2.1, 9.2; NFPA 90A 2012 ed
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~cross refer to Life Safety Code Standard - NFPA 101, Tag K 0521.