HospitalInspections.org

Based on observations made during tour and staff interview, it was determined that the facility failed to protect one hazardous area, the laboratory, with a one hour fire-rated barrier and 3/4 hour doors on closers. This could affect all individuals utilizing the services of the affected smoke compartment.

Findings include:

Tour of the facility was conducted on 2/23/10 from 2:00 PM until 5:50 PM with the Director of Plant Engineering (staff Q) and the Safety Officer (staff R.) The laboratory was noted to have three doors in the one-hour barrier that separated it from the rest of the hospital that were not at least 3/4 hour rated and were not automatic closing or on self-closers.

Observation of the one-hour barrier above the ceiling tiles revealed the following:

There was an unsealed opening around a red pipe and a sprinkler pipe above the entry door.
There were unsealed openings around two conduits and around two pipes in the barrier near the entry door.
Above the two blood drawing rooms, there were unsealed openings around a pipe and a duct, and an open-ended conduit with wires had not been sealed.

These findings were confirmed by staff Q during the tour.

Based on review of sprinkler inspection reports and staff interview, it was determined that the facility failed to perform required quarterly inspections and tests of the sprinkler system, and to ensure that the annual inspection and test was performed within one year of the previous test. This could affect all individuals in the facility.

Findings include:

Inspection and test records of the sprinkler system were reviewed on 2/23/10 and 2/25/10. It was noted that the most recent inspection of the sprinkler system was performed on 1/23/09, prior to occupancy of the new hospital building, and there were no quarterly inspections of the sprinkler system available for review. It was confirmed by the Director of Plant Engineering (staff Q) on 2/23/10 at 2:00 PM that no quarterly inspection and testing of the sprinkler system had been done. It was confirmed by the Safety Officer (staff R) on 2/25/10 at 11:30 AM that there were no further inspections done after the initial inspection on 1/23/09.

Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that the pulmonary function laboratory was protected in accordance with NFPA 99, in a room where there were medical gases stored that were less than 3000 cubic feet. This could affect all individuals utilizing the services of this smoke compartment.

Findings include:

Tour of the facility was conducted on 2/24/10 from 9:20 AM until 11:15 AM with the Director of Plant Engineering (staff Q) and the Safety Officer (staff R.) The pulmonary function laboratory was observed to have three large tanks of medical gases: one large tank of oxygen, one large tank of helium, and one large tank of an oxygen mix (0.5 per cent neon, 21 per cent oxygen, 0.3 per cent carbon monoxide, and 78.2 per cent nitrogen) used for the pulmonary function machine. The room in which these tanks were stored had a door that was not on a self-closer, and the room had one light switch and two electrical outlets that were located less than five feet above the floor. These findings were confirmed by staff Q during the tour.

Based on observations made during tour of the facility, review of humidity logs, observations of actual humidity levels at return air and set points for humidity on the main computer terminal, and staff interview, it was determined that the facility failed to maintain relative humidity (RH) equal to or greater than 35 per cent in two of two operating rooms during the months of January and February, 2010.

Findings include:

Tour was conducted on 2/23/10 from 2:00 PM until 5:50 PM with the Director of Plant Engineering (staff Q) and the Safety Officer (staff R.) Relative humidity (RH) was observed at 3:23 PM to be 30 per cent in OR #1 and 26.1 per cent in OR #2. Review of the RH record kept by nursing for January, 2010 and February, 2010 revealed that in January the RH was less than 35 per cent on two days in OR #1 and on 13 days in OR #2. The RH in OR #1 on the days noted ranged from 22 per cent to 32 per cent; the RH in OR #2 on the days noted ranged from 26 per cent to 33 per cent. In February the RH was less than 35 per cent on three days in OR #1 and on 13 days in OR #2. The RH in OR #1 on the days noted ranged from 21 to 25 per cent; the RH in OR #2 on the days noted ranged from 20 per cent to 33.4 per cent.

Observation of the actual RH levels at return air from the OR's at the main computer terminal in the maintenance department confirmed that the RH in both OR's was less than 35 per cent, and it was also noted that the low end set point for RH was 20 per cent.

These findings were confirmed by staff Q during the tour.

Based on review of generator records and staff interview, it was determined that the facility failed to record weekly inspections of the generator as required by NFPA 99. This could affect all individuals in the hospital.

Findings include:

Review of the generator log was completed on 2/23/10. Monthly load testing was recorded as performed as required; however, there was no record available for review for the weekly inspections of the generator. The Director of Plant Engineering (staff Q) stated in an interview on 2/25/10 at 9:30 AM that the generator was inspected daily, but there was no record kept of the inspections.

Based on observations made during tour and staff interview, it was determined that the facility failed to protect one hazardous area, the laboratory, with a one hour fire-rated barrier and 3/4 hour doors on closers. This could affect all individuals utilizing the services of the affected smoke compartment.

Findings include:

Tour of the facility was conducted on 2/23/10 from 2:00 PM until 5:50 PM with the Director of Plant Engineering (staff Q) and the Safety Officer (staff R.) The laboratory was noted to have three doors in the one-hour barrier that separated it from the rest of the hospital that were not at least 3/4 hour rated and were not automatic closing or on self-closers.

Observation of the one-hour barrier above the ceiling tiles revealed the following:

There was an unsealed opening around a red pipe and a sprinkler pipe above the entry door.
There were unsealed openings around two conduits and around two pipes in the barrier near the entry door.
Above the two blood drawing rooms, there were unsealed openings around a pipe and a duct, and an open-ended conduit with wires had not been sealed.

These findings were confirmed by staff Q during the tour.

Based on review of sprinkler inspection reports and staff interview, it was determined that the facility failed to perform required quarterly inspections and tests of the sprinkler system, and to ensure that the annual inspection and test was performed within one year of the previous test. This could affect all individuals in the facility.

Findings include:

Inspection and test records of the sprinkler system were reviewed on 2/23/10 and 2/25/10. It was noted that the most recent inspection of the sprinkler system was performed on 1/23/09, prior to occupancy of the new hospital building, and there were no quarterly inspections of the sprinkler system available for review. It was confirmed by the Director of Plant Engineering (staff Q) on 2/23/10 at 2:00 PM that no quarterly inspection and testing of the sprinkler system had been done. It was confirmed by the Safety Officer (staff R) on 2/25/10 at 11:30 AM that there were no further inspections done after the initial inspection on 1/23/09.

Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that the pulmonary function laboratory was protected in accordance with NFPA 99, in a room where there were medical gases stored that were less than 3000 cubic feet. This could affect all individuals utilizing the services of this smoke compartment.

Findings include:

Tour of the facility was conducted on 2/24/10 from 9:20 AM until 11:15 AM with the Director of Plant Engineering (staff Q) and the Safety Officer (staff R.) The pulmonary function laboratory was observed to have three large tanks of medical gases: one large tank of oxygen, one large tank of helium, and one large tank of an oxygen mix (0.5 per cent neon, 21 per cent oxygen, 0.3 per cent carbon monoxide, and 78.2 per cent nitrogen) used for the pulmonary function machine. The room in which these tanks were stored had a door that was not on a self-closer, and the room had one light switch and two electrical outlets that were located less than five feet above the floor. These findings were confirmed by staff Q during the tour.

Based on observations made during tour of the facility, review of humidity logs, observations of actual humidity levels at return air and set points for humidity on the main computer terminal, and staff interview, it was determined that the facility failed to maintain relative humidity (RH) equal to or greater than 35 per cent in two of two operating rooms during the months of January and February, 2010.

Findings include:

Tour was conducted on 2/23/10 from 2:00 PM until 5:50 PM with the Director of Plant Engineering (staff Q) and the Safety Officer (staff R.) Relative humidity (RH) was observed at 3:23 PM to be 30 per cent in OR #1 and 26.1 per cent in OR #2. Review of the RH record kept by nursing for January, 2010 and February, 2010 revealed that in January the RH was less than 35 per cent on two days in OR #1 and on 13 days in OR #2. The RH in OR #1 on the days noted ranged from 22 per cent to 32 per cent; the RH in OR #2 on the days noted ranged from 26 per cent to 33 per cent. In February the RH was less than 35 per cent on three days in OR #1 and on 13 days in OR #2. The RH in OR #1 on the days noted ranged from 21 to 25 per cent; the RH in OR #2 on the days noted ranged from 20 per cent to 33.4 per cent.

Observation of the actual RH levels at return air from the OR's at the main computer terminal in the maintenance department confirmed that the RH in both OR's was less than 35 per cent, and it was also noted that the low end set point for RH was 20 per cent.

These findings were confirmed by staff Q during the tour.

Based on review of generator records and staff interview, it was determined that the facility failed to record weekly inspections of the generator as required by NFPA 99. This could affect all individuals in the hospital.

Findings include:

Review of the generator log was completed on 2/23/10. Monthly load testing was recorded as performed as required; however, there was no record available for review for the weekly inspections of the generator. The Director of Plant Engineering (staff Q) stated in an interview on 2/25/10 at 9:30 AM that the generator was inspected daily, but there was no record kept of the inspections.