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SACRED HEART MEDICAL CENTER - RIVERBEND
Anesthetizing Locations
Tag No.: K0323
Based on observations and interview during the survey, it was determined through on-going dialog with the Maintenance Staff that the facility failed to ensure that humidity levels within areas of piped-in medical gas complied with NFPA 99 for the facility (NFPA 99, 5.1.4.8.7, 5.1.9.3, 6.4.2.2.4.2 & LSC 8.7, 19.3.2.3, S&C 13-58 and S&C 15-27). This resulted in the potential for injury to patients during medical procedures. Findings include, but were not limited to:
1. On 11/15/2016, during record review between 8:00 a.m. and 5:00 p.m., the humidity policy presented to the surveyor specified the humidity range at the facility to be maintained between 20% - 60%. Surveyor asked for IFU's (Instructions for Use) for equipment that was used or existed within the facilities Operating Rooms and Procedures Rooms. IFU's supplied by the facility showed that certain equipment within the OR's and PR's could not tolerate humidity levels below 30%.
Surveyor was accompanied by the Maintenance Staff who acknowledged the existence of these conditions.
Anesthetizing Locations
Tag No.: K0323
Based on observations and interview during the survey, it was determined through on-going dialog with the Maintenance Staff that the facility failed to ensure that humidity levels within areas of piped-in medical gas complied with NFPA 99 for the facility (NFPA 99, 5.1.4.8.7, 5.1.9.3, 6.4.2.2.4.2 & LSC 8.7, 19.3.2.3, S&C 13-58 and S&C 15-27). This resulted in the potential for injury to patients during medical procedures. Findings include, but were not limited to:
1. On 11/15/2016, during record review between 8:00 a.m. and 5:00 p.m., the humidity policy presented to the surveyor specified the humidity range at the facility to be maintained between 20% - 60%. Surveyor asked for IFU's (Instructions for Use) for equipment that was used or existed within the facilities Operating Rooms and Procedures Rooms. IFU's supplied by the facility showed that certain equipment within the OR's and PR's could not tolerate humidity levels below 30%.
Surveyor was accompanied by the Maintenance Staff who acknowledged the existence of these conditions.