HospitalInspections.org

Based on observation the hospital failed to ensure that doors in exit passageways or hazardous area enclosures are held open by devices that will only automatically close the doors upon activation of the fire alarm system and the sprinkler system.

Failure to ensure that wooden door wedges and unapproved door hold devices are not used places the patients and staff at risk for injury from possible smoke from a hazardous area enclosure and smoke exposure in exit hallways in the case of a fire.

Finding:

On 5/17/2012 during a tour of the endoscopy unit at 3:45 PM the surveyor observed the 1 hour fire rated door for the scope wash area was held open by a wooden door wedge. The scope wash area was where the scope washer and scope disinfectant chemicals were stored. The door had a closure, but the door wedge at the base of the door restricted the door from closing. The wooden door wedge under the 1 hour fire rated door was later removed by hospital staff.

Based on observation, log record review, and interview of staff the hospital failed to maintain relative humidity equal to or greater than 35% in anesthetizing location.

Failure to maintain safe humidity levels in the operating rooms places the patients at risk for a possible fire from an electrostatic discharge in an oxygen enriched environment.

Finding:

1. On 5/16/2012 at 3:55 PM the surveyor toured two of the three operating rooms and observed relative humidity monitors in operating rooms # 1 and #3 which were unoccupied at the time. The relative humidity in operating room #1 was 34% and in operating room #3 it was 37%.

2. During a tour of the surgery area on 5/16/2012 the surveyor also reviewed the "OR Humidity Record" dated from January 2, 2012 through May 16, 2012. The percent relative humidity in the three operating rooms was monitored, but it was not consistently maintained at recommended fire safety levels. The number of days the relative humidity was recorded at safe levels, equal to or greater than 35% in the three operating rooms were as follows:

OR#1 OR#2 OR#3

January 0 of 21 days (0%) 0 of 21 days (0%) 0 of 21 days (0%)
February 2 of 21 days (9%) 1 of 21 days (5%) 1 of 21 days (5%)
March 1 of 22 days (5%) 4 of 22 days (18%) 4 of 22 days (18%)
April 6 of 21 days (29%) 8 of 21 days (38%) 9 of 21 days (43%) May 3 of 12 days (25%) 2 of 12 days (17%) 4 of 12 days (30%)

3. During an interview by the surveyor with hospital staff on 5/16/2012 (S 1) and (S 2) confirmed the relative humidity monitoring log and reported to the surveyor that the hospital was taking action by installing humidity control equipment to correct the low humidity in the three operating rooms.

Based on observation the hospital failed to ensure that doors in exit passageways or hazardous area enclosures are held open by devices that will only automatically close the doors upon activation of the fire alarm system and the sprinkler system.

Failure to ensure that wooden door wedges and unapproved door hold devices are not used places the patients and staff at risk for injury from possible smoke from a hazardous area enclosure and smoke exposure in exit hallways in the case of a fire.

Finding:

On 5/17/2012 during a tour of the endoscopy unit at 3:45 PM the surveyor observed the 1 hour fire rated door for the scope wash area was held open by a wooden door wedge. The scope wash area was where the scope washer and scope disinfectant chemicals were stored. The door had a closure, but the door wedge at the base of the door restricted the door from closing. The wooden door wedge under the 1 hour fire rated door was later removed by hospital staff.

Based on observation, log record review, and interview of staff the hospital failed to maintain relative humidity equal to or greater than 35% in anesthetizing location.

Failure to maintain safe humidity levels in the operating rooms places the patients at risk for a possible fire from an electrostatic discharge in an oxygen enriched environment.

Finding:

1. On 5/16/2012 at 3:55 PM the surveyor toured two of the three operating rooms and observed relative humidity monitors in operating rooms # 1 and #3 which were unoccupied at the time. The relative humidity in operating room #1 was 34% and in operating room #3 it was 37%.

2. During a tour of the surgery area on 5/16/2012 the surveyor also reviewed the "OR Humidity Record" dated from January 2, 2012 through May 16, 2012. The percent relative humidity in the three operating rooms was monitored, but it was not consistently maintained at recommended fire safety levels. The number of days the relative humidity was recorded at safe levels, equal to or greater than 35% in the three operating rooms were as follows:

OR#1 OR#2 OR#3

January 0 of 21 days (0%) 0 of 21 days (0%) 0 of 21 days (0%)
February 2 of 21 days (9%) 1 of 21 days (5%) 1 of 21 days (5%)
March 1 of 22 days (5%) 4 of 22 days (18%) 4 of 22 days (18%)
April 6 of 21 days (29%) 8 of 21 days (38%) 9 of 21 days (43%) May 3 of 12 days (25%) 2 of 12 days (17%) 4 of 12 days (30%)

3. During an interview by the surveyor with hospital staff on 5/16/2012 (S 1) and (S 2) confirmed the relative humidity monitoring log and reported to the surveyor that the hospital was taking action by installing humidity control equipment to correct the low humidity in the three operating rooms.