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Based on observation, interview with staff and review of records, the facility failed to provide documentation of anesthetizing locations that record the Relative Humidity is maintained equal to or greater than 35%. Finding:

The facility did not maintain logs of the humidity levels for the OR Suites.

(1) Based upon observation, interview with staff and review of records, the facility failed to implement established policies and protocols that requires equipment in the surgery suite found defective, be taken out of service and tagged. NFPA 99 7-6.2.2.4 Finding:

After the Stryker Neptune equipment activated an alarm on the Line Isolation Monitor, the equipment was taken out of service but not tagged as defective.

(2) Based on observation and interview with staff, the facility failed to provide Operating Room Physicians and Surgeons with periodic review of surgical operations and procedures for Fire Loss Prevention in accordance with NFPA 99 12-4.1.2.10. Finding:

The facility failed to provide documentation of periodic review of surgical operations and procedures for Fire Loss Prevention for the Operating Room Physicians and Surgeons.

Based on observation and interview with staff, the facility failed to provide a fume hood room designed for negative air pressure relative to other occupancies. NFPA 99 5-4.2.1,
Finding:

There is not a door to the room housing the fume hood which results in the required negative air pressure relative to the area outside the room not being maintained.

Based on observation, interview with staff and review of records, the facility failed to document the percentage of load for the monthly Generator test as required by NFPA 99 3-4.4.1