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1) Based on observation and interview with staff, the facility failed to protect openings of a suite with doors, such as those constructed of 1¾ inch solid-bonded core wood, capable of resisting fire for at least 20 minutes, and with a means suitable for keeping the door closed, NFPA 101 2000,19.3.6.3. Findings include:

i) Double egress doors, west exit to the corridor and to south door to Radiology waiting are not provided with latching hardware that protects the suite from the egress corridor.


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1) Based on observation and interview with staff, the facility failed to place, store or stage Soiled linen or trash collection receptacles greater than 32 gal (121 L) in a room protected as a hazardous area when not attended. NFPA 101 19.7.5.5. Findings include:

i) Blue 5 x 5 x 3 feet blue mobile receptacles used for trash and soiled linen are located in Radiology corridor, GI Lab Suite and other areas of the hospital to numerous to document. Receptacles were not being attended and are not located in a room protected as a hazardous area.

1) Based on observation and interview with staff, the facility failed to protect Anesthetizing locations in accordance with NFPA 99, Standard for Health Care Facilities. Findings include:

a) Based on observation and interview with Director of the GI Lab, the Director stated that the facility is providing Inhalation Anesthesia in two of the three rooms located in the Out Patient GI lab. The Policy Document Number MMS-SS-FS-0036, Revision#:v2 identifies area in which inhalation anesthetics agents are administered, OR'S 1 through 6, LDR 1 through 5, ASC 1 through 3, the GI Lab is not identified as area for Anesthesia. Purchasing ordered equipment for a non anesthetizing location and Bio- Medical Department allowed equipment to be used without flagging or notifying that this was not a anesthetizing location in accordance with Policy and Procedure Document MMS-SS-FS-0036.

b) NFPA 99 1999 edition chapter 12-4.1.2 requires all anesthesia locations to meet chapter 5.
i) Chapter 5-4.1 requires rooms that inhalation anesthesia locations are provided with mechanical ventilation systems to be capable of controlling the relative humidity at a level greater than 35%. Humidity logs provided, depict chronic levels of humidity less than the 30% as established by the Mercy Memorial Health Center , Temperature/Humidity Log for Endoscope Department that describe ranges from 30-60 %. The month of January, 2014 logs depict all of the days of the month, which were less than the 30-60% range. No corrective action documentation was available or shown. This was verified by the Director of Engineering.

ii) Chapter 5-4.1.2 requires supply and exhaust systems for windowless anesthesia locations be provided with a means that will automatic remove products of smoke and combustion. The rooms in the GI Lab are not provided with automatic smoke evacuation.

iii) Chapter 5-6.1.1 requires Ventilating and humidifying equipment for anesthetizing locations be kept in operable condition and be continually operating during procedures. The facility failed to verify the condition of ventilating equipment or the lack of humidity and smoke evacuation equipment.

iv) Medical gas and Medical Gas Alarms in accordance with NFPA 99 1999 edition chapter 4-3.1.2.2 (1) ( c ) requires actuating switches between the switch and outlet with a individual shut off valve at each specific location. This equipment is not provided

v) NFPA 99 1999 edition CHAPTER 12-4.1.1.4 requires Rules and Regulations to be posted in the room. These rules and regulations for the control of personal in anesthesia location are not posted. Fire Loss prevention as required for anesthesia locations in NFPA 99, chapter 12-4.1.2.10, Fire Loss Prevention for anesthetizing locations, are not being conducted in this area.

1) Based on observation, review of the Policy and Procedure MMM-SS-0035, last updated 6 / 16 / 2011 and interview with staff, the facility failed to identify rooms used as critical care areas in accordance with NFPA 99 1999 edition chapter 12-2.6 , Patient Care Areas. Findings include :

i) GI Lab, Recovery for Inpatient &Outpatient Surgery, Cardiac Catherization Lab are not on the Policy describing Critical Care Areas.

1) Based on observation and interview with staff, the facility failed to protect openings of a suite with doors, such as those constructed of 1¾ inch solid-bonded core wood, capable of resisting fire for at least 20 minutes, and with a means suitable for keeping the door closed, NFPA 101 2000,19.3.6.3. Findings include:

i) Double egress doors, west exit to the corridor and to south door to Radiology waiting are not provided with latching hardware that protects the suite from the egress corridor.


.

1) Based on observation and interview with staff, the facility failed to place, store or stage Soiled linen or trash collection receptacles greater than 32 gal (121 L) in a room protected as a hazardous area when not attended. NFPA 101 19.7.5.5. Findings include:

i) Blue 5 x 5 x 3 feet blue mobile receptacles used for trash and soiled linen are located in Radiology corridor, GI Lab Suite and other areas of the hospital to numerous to document. Receptacles were not being attended and are not located in a room protected as a hazardous area.

1) Based on observation and interview with staff, the facility failed to protect Anesthetizing locations in accordance with NFPA 99, Standard for Health Care Facilities. Findings include:

a) Based on observation and interview with Director of the GI Lab, the Director stated that the facility is providing Inhalation Anesthesia in two of the three rooms located in the Out Patient GI lab. The Policy Document Number MMS-SS-FS-0036, Revision#:v2 identifies area in which inhalation anesthetics agents are administered, OR'S 1 through 6, LDR 1 through 5, ASC 1 through 3, the GI Lab is not identified as area for Anesthesia. Purchasing ordered equipment for a non anesthetizing location and Bio- Medical Department allowed equipment to be used without flagging or notifying that this was not a anesthetizing location in accordance with Policy and Procedure Document MMS-SS-FS-0036.

b) NFPA 99 1999 edition chapter 12-4.1.2 requires all anesthesia locations to meet chapter 5.
i) Chapter 5-4.1 requires rooms that inhalation anesthesia locations are provided with mechanical ventilation systems to be capable of controlling the relative humidity at a level greater than 35%. Humidity logs provided, depict chronic levels of humidity less than the 30% as established by the Mercy Memorial Health Center , Temperature/Humidity Log for Endoscope Department that describe ranges from 30-60 %. The month of January, 2014 logs depict all of the days of the month, which were less than the 30-60% range. No corrective action documentation was available or shown. This was verified by the Director of Engineering.

ii) Chapter 5-4.1.2 requires supply and exhaust systems for windowless anesthesia locations be provided with a means that will automatic remove products of smoke and combustion. The rooms in the GI Lab are not provided with automatic smoke evacuation.

iii) Chapter 5-6.1.1 requires Ventilating and humidifying equipment for anesthetizing locations be kept in operable condition and be continually operating during procedures. The facility failed to verify the condition of ventilating equipment or the lack of humidity and smoke evacuation equipment.

iv) Medical gas and Medical Gas Alarms in accordance with NFPA 99 1999 edition chapter 4-3.1.2.2 (1) ( c ) requires actuating switches between the switch and outlet with a individual shut off valve at each specific location. This equipment is not provided

v) NFPA 99 1999 edition CHAPTER 12-4.1.1.4 requires Rules and Regulations to be posted in the room. These rules and regulations for the control of personal in anesthesia location are not posted. Fire Loss prevention as required for anesthesia locations in NFPA 99, chapter 12-4.1.2.10, Fire Loss Prevention for anesthetizing locations, are not being conducted in this area.

1) Based on observation, review of the Policy and Procedure MMM-SS-0035, last updated 6 / 16 / 2011 and interview with staff, the facility failed to identify rooms used as critical care areas in accordance with NFPA 99 1999 edition chapter 12-2.6 , Patient Care Areas. Findings include :

i) GI Lab, Recovery for Inpatient &Outpatient Surgery, Cardiac Catherization Lab are not on the Policy describing Critical Care Areas.