HospitalInspections.org

Based on review of Fire Drill Records and interview with the Director of Engineering, the facility failed to ensure that staff is familiar with fire drill procedures and is aware that drills are part of established routine. Finding:

The records did not document what staff participated in the drills, that staff was familiar with procedures, and that there were corrective actions for deficiencies identified.

Based on review of the Operating Room logs and interview with the Director of the Operating Suite and the Director of Engineering, the facility failed to provide anesthetizing locations with relative humidity equal to or greater than 35%. Findings:

Operating room logs for the months of January and February recorded humidity levels in the 20's.

Based on review of Fire Drill Records and interview with the Director of Engineering, the facility failed to ensure that staff is familiar with fire drill procedures and is aware that drills are part of established routine. Finding:

The records did not document what staff participated in the drills, that staff was familiar with procedures, and that there were corrective actions for deficiencies identified.

Based on review of the Operating Room logs and interview with the Director of the Operating Suite and the Director of Engineering, the facility failed to provide anesthetizing locations with relative humidity equal to or greater than 35%. Findings:

Operating room logs for the months of January and February recorded humidity levels in the 20's.