HospitalInspections.org

Based on observation and interview with staff, the facility failed to provide a fire alarm system required for life safety that is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. The system has an approved maintenance and testing program complying with applicable requirements of NFPA 70 and 72. 9.6.1.4 Findings include:

1. The smoke evacuation system installed in the operating room suite has not been
documented as being tested on an annual basis.

2. The smoke detector in the south 300 corridor is not greater than 3 feet from the air
conditioning diffuser, this has not been shown as a deficiency.

Based on observation and interview with staff, the facility failed to provide an automatic sprinkler system that is installed in accordance with NFPA 13. Findings include:

The dock located in back of the hospital where soiled linen carts are stored under the overhang, along with a wooden pallet at the time of survey (8-05-2013) was not provided with automatic sprinkler coverage.

Based on observation and interview with staff, the facility failed to provide Heating, Ventilating, and Air-Conditioning that complies with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2 Findings include:

1. The clean storage area was not provided with humidity control . The hummidity can not be above 70%.

2. The sterile equipment room is not positive air flow.

3. The soiled work room for scopes is not negative air flow.

4. There is no documentation that the clean work room for scopes is positive and that the room has 4 air exchanges per hour.

5. The HVAC Equipment Room is also a return plenum, the room on this day 08/05/2013 had chemicals stored, and a container used for spraying chemicals. The room shall be kept clean , with no storage.

Based on observation and interview with staff, the facility failed to provide Soiled linen or trash collection receptacles that do not exceed 32 gallon size. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) shall be located in a room protected as a hazardous area when not attended. 19.7.5.5 Findings include:

A receptacle staged outside the general storage area/ maintenance area shall be removed and located in a room protected from the corridor and with an automatic fire suppression system.

Based on observation and interview with staff, the facility failed to provide Anesthetizing locations that are protected in accordance with NFPA 99, Standard for Health Care Facilities. Findings include:

1. Facility failed to provide a policy that dictates what rooms anesthesia will be conducted in. It shall be the responsibility of the governing body of the hospital to designate anesthetizing locations chapter 12-2.7.

2. The humidity for Operating Rooms were out of range and below 30% in January, February, March of 2013. In June when the humidity is naturally high the humidity was above the 60% . There shall be a written policy to deal with humidity and staff orientated on what the Interim Policy is when humidity is out of range.

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

1. The reserve fuel is a 55 gal barrel located in the generator room (not in approved container and stored combustibles in the hospital) . The reserve shall have a capability of 96 hours of fuel on site stored in an approved container. The reserve fuel shall be logged and reported in accordance to policy and procedures adopted by the facility

2. The electrical trickle charge required for the battery was plugged in using a extension cord supplied from the boiler room.

3. The block heater was not plugged in.

4. The receptacle for the charger and block heater located on the west side of the generator room was dead and lying on the floor.

Surveyor: Thomas, Terry M.
Based on observation and interview with staff, the facility failed to provide a comprehensive
evaluation of safety hazards that could be encountered during procedures and treatment.
Also, continuing education for personnel concerned with the application and maintenance of
electric appliances; including, physicians, nurse's, nurse aids, engineers, technicians, and
orderlies. These staff members shall be cognizant of the risks associated with electrical
equipment and procedures conducted
in their environment in accordance with NFPA 99, 1999 EDITION chapter 7-6.5 and 12-4.1.2.10 and to
provide documentation .

Findings include:

1. Staff was not provided with training that included all of the electrical fixtures in the operating room. The Line Isolation Monitors were installed; however, staff did not know the function of the equipment. The switch outside each operating room was for a manual smoke evacuation fan; staff did not know what the buttons controlled or the function.

2. The light over the endo-scope room was out of date on the bio-medical inspection sticker since 2010, staff did not know protocol to remove equipment from service that did not have a current bio-med inspection sticker.









Surveyor: Thomas, Terry M.
Based on observation and interview with staff, the facility failed to provide a comprehensive
evaluation of safety hazards that could be encountered during procedures and treatment.
Also, continuing education for personnel concerned with the application and maintenance of
electric appliances; including, physicians, nurse's, nurse aids, engineers, technicians, and
orderlies. These staff members shall be cognizant of the risks associated with electrical
equipment and procedures conducted
in their environment in accordance with NFPA 99, 1999 EDITION chapter 7-6.5 and 12-4.1.2.10 and to
provide documentation .

Findings include:

1. Staff was not provided with training that included all of the electrical fixtures in the operating room. The Line Isolation Monitors were installed; however, staff did not know the function of the equipment. The switch outside each operating room was for a manual smoke evacuation fan; staff did not know what the buttons controlled or the function.

2. The light over the endo-scope room was out of date on the bio-medical inspection sticker since 2010, staff did not know protocol to remove equipment from service that did not have a current bio-med inspection sticker.









Based on observation and interview with staff, the facility failed to provide a comprehensive evaluation that can be made of hazards that could be encountered during procedures and treatment. Also continuing education for personnel concerned with the application and maintenance of electric appliances, including physicians, nurse' s nurse aids, engineers, technicians, and orderlies. These staff members shall be cognizant of the risks associated with electrical equipment and procedures conducted in there environment. In accordance with NFPA 99 1999 EDITION chapter 7-6.5 and 12-4.1.2.10 and documented . Findings include:

1 Staff was not provided with training that included all of the electrical fixtures in the operating room. The Line Isolation Monitors were installed , however staff did not know the function of the equipment. The switch outside each operating room was for a manual smoke evacuation fan; staff did not know function.
2 The light over the endo-scope room was out of date since 2010, staff did not know protocal to remove equipment from service that did not have a current sticker.


Based on observation and interview with staff, the facility failed to provide a comprehensive
evaluation of safety hazards that could be encountered during procedures and treatment.
Also, continuing education for personnel concerned with the application and maintenance of
electric appliances; including, physicians, nurse's, nurse aids, engineers, technicians, and
orderlies. These staff members shall be cognizant of the risks associated with electrical
equipment and procedures conducted in their environment in accordance with NFPA 99,
1999 EDITION chapter 7-6.5 and 12-4.1.2.10 and to provide documentation.

Findings include:

1. Staff was not provided with training that included all of the electrical fixtures in the operating room. The Line Isolation Monitors were installed; however, staff did not know the function of the equipment. The switch outside each operating room was for a manual smoke evacuation fan; staff did not know what the buttons controlled or the function.

2. The light over the endo-scope room was out of date on the bio-medical inspection sticker since 2010, staff did not know protocol to remove equipment from service that did not have a current bio-med inspection sticker.

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

1. The Recovery Rooms were not provided with emergency Power from the Critical Care Branch in accordance with NFPA 99 chapter 3-4.2.2.2 (c)

2. The Line Isolation Monitors were not on a preventive maintenance program in accordance with 3-3.3.4.1

3. The Over Head Light in the Operating Room had not had a bio-med inspection since 2010

Based on observation and interview with staff, the facility failed to provide a fire alarm system required for life safety that is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. The system has an approved maintenance and testing program complying with applicable requirements of NFPA 70 and 72. 9.6.1.4 Findings include:

1. The smoke evacuation system installed in the operating room suite has not been
documented as being tested on an annual basis.

2. The smoke detector in the south 300 corridor is not greater than 3 feet from the air
conditioning diffuser, this has not been shown as a deficiency.

Based on observation and interview with staff, the facility failed to provide an automatic sprinkler system that is installed in accordance with NFPA 13. Findings include:

The dock located in back of the hospital where soiled linen carts are stored under the overhang, along with a wooden pallet at the time of survey (8-05-2013) was not provided with automatic sprinkler coverage.

Based on observation and interview with staff, the facility failed to provide Heating, Ventilating, and Air-Conditioning that complies with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2 Findings include:

1. The clean storage area was not provided with humidity control . The hummidity can not be above 70%.

2. The sterile equipment room is not positive air flow.

3. The soiled work room for scopes is not negative air flow.

4. There is no documentation that the clean work room for scopes is positive and that the room has 4 air exchanges per hour.

5. The HVAC Equipment Room is also a return plenum, the room on this day 08/05/2013 had chemicals stored, and a container used for spraying chemicals. The room shall be kept clean , with no storage.

Based on observation and interview with staff, the facility failed to provide Soiled linen or trash collection receptacles that do not exceed 32 gallon size. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) shall be located in a room protected as a hazardous area when not attended. 19.7.5.5 Findings include:

A receptacle staged outside the general storage area/ maintenance area shall be removed and located in a room protected from the corridor and with an automatic fire suppression system.

Based on observation and interview with staff, the facility failed to provide Anesthetizing locations that are protected in accordance with NFPA 99, Standard for Health Care Facilities. Findings include:

1. Facility failed to provide a policy that dictates what rooms anesthesia will be conducted in. It shall be the responsibility of the governing body of the hospital to designate anesthetizing locations chapter 12-2.7.

2. The humidity for Operating Rooms were out of range and below 30% in January, February, March of 2013. In June when the humidity is naturally high the humidity was above the 60% . There shall be a written policy to deal with humidity and staff orientated on what the Interim Policy is when humidity is out of range.

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

1. The reserve fuel is a 55 gal barrel located in the generator room (not in approved container and stored combustibles in the hospital) . The reserve shall have a capability of 96 hours of fuel on site stored in an approved container. The reserve fuel shall be logged and reported in accordance to policy and procedures adopted by the facility

2. The electrical trickle charge required for the battery was plugged in using a extension cord supplied from the boiler room.

3. The block heater was not plugged in.

4. The receptacle for the charger and block heater located on the west side of the generator room was dead and lying on the floor.

Surveyor: Thomas, Terry M.
Based on observation and interview with staff, the facility failed to provide a comprehensive
evaluation of safety hazards that could be encountered during procedures and treatment.
Also, continuing education for personnel concerned with the application and maintenance of
electric appliances; including, physicians, nurse's, nurse aids, engineers, technicians, and
orderlies. These staff members shall be cognizant of the risks associated with electrical
equipment and procedures conducted
in their environment in accordance with NFPA 99, 1999 EDITION chapter 7-6.5 and 12-4.1.2.10 and to
provide documentation .

Findings include:

1. Staff was not provided with training that included all of the electrical fixtures in the operating room. The Line Isolation Monitors were installed; however, staff did not know the function of the equipment. The switch outside each operating room was for a manual smoke evacuation fan; staff did not know what the buttons controlled or the function.

2. The light over the endo-scope room was out of date on the bio-medical inspection sticker since 2010, staff did not know protocol to remove equipment from service that did not have a current bio-med inspection sticker.









Surveyor: Thomas, Terry M.
Based on observation and interview with staff, the facility failed to provide a comprehensive
evaluation of safety hazards that could be encountered during procedures and treatment.
Also, continuing education for personnel concerned with the application and maintenance of
electric appliances; including, physicians, nurse's, nurse aids, engineers, technicians, and
orderlies. These staff members shall be cognizant of the risks associated with electrical
equipment and procedures conducted
in their environment in accordance with NFPA 99, 1999 EDITION chapter 7-6.5 and 12-4.1.2.10 and to
provide documentation .

Findings include:

1. Staff was not provided with training that included all of the electrical fixtures in the operating room. The Line Isolation Monitors were installed; however, staff did not know the function of the equipment. The switch outside each operating room was for a manual smoke evacuation fan; staff did not know what the buttons controlled or the function.

2. The light over the endo-scope room was out of date on the bio-medical inspection sticker since 2010, staff did not know protocol to remove equipment from service that did not have a current bio-med inspection sticker.









Based on observation and interview with staff, the facility failed to provide a comprehensive evaluation that can be made of hazards that could be encountered during procedures and treatment. Also continuing education for personnel concerned with the application and maintenance of electric appliances, including physicians, nurse' s nurse aids, engineers, technicians, and orderlies. These staff members shall be cognizant of the risks associated with electrical equipment and procedures conducted in there environment. In accordance with NFPA 99 1999 EDITION chapter 7-6.5 and 12-4.1.2.10 and documented . Findings include:

1 Staff was not provided with training that included all of the electrical fixtures in the operating room. The Line Isolation Monitors were installed , however staff did not know the function of the equipment. The switch outside each operating room was for a manual smoke evacuation fan; staff did not know function.
2 The light over the endo-scope room was out of date since 2010, staff did not know protocal to remove equipment from service that did not have a current sticker.


Based on observation and interview with staff, the facility failed to provide a comprehensive
evaluation of safety hazards that could be encountered during procedures and treatment.
Also, continuing education for personnel concerned with the application and maintenance of
electric appliances; including, physicians, nurse's, nurse aids, engineers, technicians, and
orderlies. These staff members shall be cognizant of the risks associated with electrical
equipment and procedures conducted in their environment in accordance with NFPA 99,
1999 EDITION chapter 7-6.5 and 12-4.1.2.10 and to provide documentation.

Findings include:

1. Staff was not provided with training that included all of the electrical fixtures in the operating room. The Line Isolation Monitors were installed; however, staff did not know the function of the equipment. The switch outside each operating room was for a manual smoke evacuation fan; staff did not know what the buttons controlled or the function.

2. The light over the endo-scope room was out of date on the bio-medical inspection sticker since 2010, staff did not know protocol to remove equipment from service that did not have a current bio-med inspection sticker.

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

1. The Recovery Rooms were not provided with emergency Power from the Critical Care Branch in accordance with NFPA 99 chapter 3-4.2.2.2 (c)

2. The Line Isolation Monitors were not on a preventive maintenance program in accordance with 3-3.3.4.1

3. The Over Head Light in the Operating Room had not had a bio-med inspection since 2010