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Based on observation, interview with staff, the facility failed to provide Doors protecting corridor , exits, or hazardous areas are substantial doors, such as those constructed of 1¾ inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes and the doors are provided with a means suitable for keeping the door closed (latching hardware). Findings include:

The doors to Operating Room Suite and Repertory are not provided with latching hardware.

Based on observation and interview with staff, the facility failed to provide an exit and directional signs that are displayed in accordance with section 7.10 with continuous illumination and are served by the emergency lighting system. 19.2.10.1 Findings include:

Exit signs are not installed on the west end of the nurses station outside the Psychiatric Unit. Throughout the facility exit signs shall be installed as to provide two ways of egress.

Based on observation, interview with staff, the facility failed to verify that staff is familiar with procedures in case of fire at unexpected times under varying conditions. NFPA 101 2000 edition chapter 19.7.1.2. Findings include:

Staff were questioned in the presence of the Director of Engineering what action they would take if smoke or fire was detected. Staff were unable to demonstrate clearly and efficiently in a timely manner the established routine adopted by the facility. The facility shall plan and provide the following: Use of the alarms (RACE) RESCUE, ALARM, CONFINE, EXTINGUISH.

Based on observation and interview with staff the facility failed to provide a maintenance and testing program complying with applicable requirements of NFPA 70 and 72. 9.6.1.4 Findings include:

The annual inspection of the fire alarm system was not signed.

All equipment connected to the fire alarm system was not tested. Combination fire and smoke dampers were not shown as equipment tested on the fire alarm report.

Based on observation and interview with staff, the facility failed to provide piped in medical gas systems that comply with NFPA 99, Chapter 4. Findings include:

The was no intervening wall between the zone valves of the recovery area located in the first room adjacent to the male locker room.

The vacuum equipment in the Operating Room was in the floor. The procedures that require multiple suction outlets must be hung on the wall or extra outlets be installed.

Based on observation and interview with staff, the facility failed to provide Anesthetizing locations that are protected in accordance with NFPA 99, NFPA 99, 4.3.1.2.3(n) and 5.4.1.1, 19.3.2.3 Findings include:

The governing body failed to designate anesthetizing locations. 12-2.7

The facility failed to post rules and regulations for the control of personal concerned with anesthetizing locations 12-4.1.1.4.

The facility failed to maintain the humidifying equipment. Ventilation and Humidifying equipment shall be kept in operation during surgical procedures 5-6.1.1.

The Operating Rooms were not provided with smoke evacuation in accordance with NFPA 12-4.1.2 and 5-4.1.2

The Operating Room ventilation system shall be positive in relation to the sterile corridor. The facility failed to document air exchanges that depicted a positive relationship to adjacent areas.

The facility was not monitoring and maintaining Humidity between 35 and 60 percent.

Based on observation and interview with staff, the facility failed to provide life support equipment that has a Type I Essential Electrical System powered by a generator with a transfer switch and separate power supply. The EES is in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4. Findings include:

Emergency power receptacles are not installed on the existing patient wing.

Emergency power receptacles are not installed in the recovery.

The receptacles that the blood bank was plugged into were not marked.

Provide a one line drawing that depicts the distribution of the emergency power. Panels in the facility were not labeled and staff could not identify distribution.

Based on observation and interview with staff, the Governing Body responsible for the structure that has the elements of hospital operation for Building Design, Purchasing, inspection,maintenance schedules,and training programs failed to oversee implementation of said responsibilities. NFPA 99 1999 edition chapter 12-2.1 Findings include:

The facility has failed to Implement a Preventive Maintenance Program that covers all equipment and building services. .A preventive maintenance program shall be established and approved by the governing body

Based on observation and interview with staff, the facility failed to provide Specific Area Requirements for Anesthesia NFPA 99 1999 edition chapter 12-4 . Findings include:

The facility failed to schedule and conduct a fire drill orientated to the hazards in the Operating Room Suite. 12-4.1.2 10

Policies and Procedures that deal with how the Staff, including physicians shall practice medicine and prepare for alarming, evacuation, and shutdown of equipment were not available. 12-4.1.2.10

Rules and Regulations jointly agreed upon between the Medical Staff and Hospital Authorities were not available 12-4.1.1.4

Incidents shall be documented monthly and reviewed annually 12-4.1.2.10.

The governing body shall adopt a policy that dictates were anesthesia will be conducted 12-2.7

Based on observation and interview with staff, the facility failed to maintain the Eye Wash located in the Laboratory. Findings include:

The eye wash in the lab was not being flushed on a monthly basis and logged .

Based on observation and interview with staff the facility failed to inspect weekly and exercise the emergency generator under load for 30 minutes per month in accordance with NFPA 99. 3.4.4.1. Findings include:

The emergency generator was run, however, the name plate rating of 30% was not on the document (generator logs).

Staff associated with the operating and maintaining the emergency power system had not been trained.

Staff stated that they could not start the generator and transfer power manually.
.

Based on observation, interview with staff, the facility failed to provide and maintain electrical wiring and equipment in accordance with NFPA 70, National Electrical Code. 9.1.2

Findings include:

The Line Isolation Monitors in the Operating Rooms and in the C section room did not have a Preventive Maintenance Program in accordance with NFPA 99 1999 edition chapter 3-3.3.4.1

The Line Isolation Monitors in the Operating Rooms were not functional. The Fuses were removed to prevent the Audible and Visual alarms from functioning.

The GOVERNING BODY FAILED to require the facility to provide safety performance criteria testing, maintenance, Qualifications and Training of all Personnel and equipment used in Patient Care Areas. The program shall include periodic review of manufacturing safety guidelines and usage requirements for electrometric units and similar appliances. Facility could not provide documentation that Doctors, Nurses, and other staff associated with the useage, matenance, testing, and cleaning had periodic review and an in service.

The facility failed to monitor and track medical equipment that requires Biomedical Safety Check. Equipment in the Operating Room Suite to have an annual Bio Medical Equipment check. Staff were not trained to check and take out of service equipment not properly tested in accordance with adopted policy and procedures.

Based on observation, interview with staff, the facility failed to provide Doors protecting corridor , exits, or hazardous areas are substantial doors, such as those constructed of 1¾ inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes and the doors are provided with a means suitable for keeping the door closed (latching hardware). Findings include:

The doors to Operating Room Suite and Repertory are not provided with latching hardware.

Based on observation and interview with staff, the facility failed to provide an exit and directional signs that are displayed in accordance with section 7.10 with continuous illumination and are served by the emergency lighting system. 19.2.10.1 Findings include:

Exit signs are not installed on the west end of the nurses station outside the Psychiatric Unit. Throughout the facility exit signs shall be installed as to provide two ways of egress.

Based on observation, interview with staff, the facility failed to verify that staff is familiar with procedures in case of fire at unexpected times under varying conditions. NFPA 101 2000 edition chapter 19.7.1.2. Findings include:

Staff were questioned in the presence of the Director of Engineering what action they would take if smoke or fire was detected. Staff were unable to demonstrate clearly and efficiently in a timely manner the established routine adopted by the facility. The facility shall plan and provide the following: Use of the alarms (RACE) RESCUE, ALARM, CONFINE, EXTINGUISH.

Based on observation and interview with staff the facility failed to provide a maintenance and testing program complying with applicable requirements of NFPA 70 and 72. 9.6.1.4 Findings include:

The annual inspection of the fire alarm system was not signed.

All equipment connected to the fire alarm system was not tested. Combination fire and smoke dampers were not shown as equipment tested on the fire alarm report.

Based on observation and interview with staff, the facility failed to provide piped in medical gas systems that comply with NFPA 99, Chapter 4. Findings include:

The was no intervening wall between the zone valves of the recovery area located in the first room adjacent to the male locker room.

The vacuum equipment in the Operating Room was in the floor. The procedures that require multiple suction outlets must be hung on the wall or extra outlets be installed.

Based on observation and interview with staff, the facility failed to provide Anesthetizing locations that are protected in accordance with NFPA 99, NFPA 99, 4.3.1.2.3(n) and 5.4.1.1, 19.3.2.3 Findings include:

The governing body failed to designate anesthetizing locations. 12-2.7

The facility failed to post rules and regulations for the control of personal concerned with anesthetizing locations 12-4.1.1.4.

The facility failed to maintain the humidifying equipment. Ventilation and Humidifying equipment shall be kept in operation during surgical procedures 5-6.1.1.

The Operating Rooms were not provided with smoke evacuation in accordance with NFPA 12-4.1.2 and 5-4.1.2

The Operating Room ventilation system shall be positive in relation to the sterile corridor. The facility failed to document air exchanges that depicted a positive relationship to adjacent areas.

The facility was not monitoring and maintaining Humidity between 35 and 60 percent.

Based on observation and interview with staff, the facility failed to provide life support equipment that has a Type I Essential Electrical System powered by a generator with a transfer switch and separate power supply. The EES is in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4. Findings include:

Emergency power receptacles are not installed on the existing patient wing.

Emergency power receptacles are not installed in the recovery.

The receptacles that the blood bank was plugged into were not marked.

Provide a one line drawing that depicts the distribution of the emergency power. Panels in the facility were not labeled and staff could not identify distribution.

Based on observation and interview with staff, the Governing Body responsible for the structure that has the elements of hospital operation for Building Design, Purchasing, inspection,maintenance schedules,and training programs failed to oversee implementation of said responsibilities. NFPA 99 1999 edition chapter 12-2.1 Findings include:

The facility has failed to Implement a Preventive Maintenance Program that covers all equipment and building services. .A preventive maintenance program shall be established and approved by the governing body

Based on observation and interview with staff, the facility failed to provide Specific Area Requirements for Anesthesia NFPA 99 1999 edition chapter 12-4 . Findings include:

The facility failed to schedule and conduct a fire drill orientated to the hazards in the Operating Room Suite. 12-4.1.2 10

Policies and Procedures that deal with how the Staff, including physicians shall practice medicine and prepare for alarming, evacuation, and shutdown of equipment were not available. 12-4.1.2.10

Rules and Regulations jointly agreed upon between the Medical Staff and Hospital Authorities were not available 12-4.1.1.4

Incidents shall be documented monthly and reviewed annually 12-4.1.2.10.

The governing body shall adopt a policy that dictates were anesthesia will be conducted 12-2.7

Based on observation and interview with staff, the facility failed to maintain the Eye Wash located in the Laboratory. Findings include:

The eye wash in the lab was not being flushed on a monthly basis and logged .

Based on observation and interview with staff the facility failed to inspect weekly and exercise the emergency generator under load for 30 minutes per month in accordance with NFPA 99. 3.4.4.1. Findings include:

The emergency generator was run, however, the name plate rating of 30% was not on the document (generator logs).

Staff associated with the operating and maintaining the emergency power system had not been trained.

Staff stated that they could not start the generator and transfer power manually.
.

Based on observation, interview with staff, the facility failed to provide and maintain electrical wiring and equipment in accordance with NFPA 70, National Electrical Code. 9.1.2

Findings include:

The Line Isolation Monitors in the Operating Rooms and in the C section room did not have a Preventive Maintenance Program in accordance with NFPA 99 1999 edition chapter 3-3.3.4.1

The Line Isolation Monitors in the Operating Rooms were not functional. The Fuses were removed to prevent the Audible and Visual alarms from functioning.

The GOVERNING BODY FAILED to require the facility to provide safety performance criteria testing, maintenance, Qualifications and Training of all Personnel and equipment used in Patient Care Areas. The program shall include periodic review of manufacturing safety guidelines and usage requirements for electrometric units and similar appliances. Facility could not provide documentation that Doctors, Nurses, and other staff associated with the useage, matenance, testing, and cleaning had periodic review and an in service.

The facility failed to monitor and track medical equipment that requires Biomedical Safety Check. Equipment in the Operating Room Suite to have an annual Bio Medical Equipment check. Staff were not trained to check and take out of service equipment not properly tested in accordance with adopted policy and procedures.