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Based on observation, staff interview and record review it was determined the facility failed to separate non-health occupancies from health care occupancies.

Findings:

On 11/02/2016 at 11:14 a.m., while on tour of the facility's 3rd floor a group of health care occupancy patient rooms were observed to not be separated from non-health care occupancy outpatient exam/treatment rooms with 2 hour fire resistance-rated construction. A review of the provided facility floor plans indicated there was no fire wall separation of each outpatient exam/treatment area(s).

The facility manager acknowledged there was no fire wall barrier separation between the inpatient and outpatient areas.

Based on observation and staff interview it was determined the facility failed to ensure alcohol based hand rub dispensers (ABHR) were not installed over an ignition source. Findings:

On 11/02/2016 at 11:24 a.m., an ABHR was observed installed over an ignition source in the soiled work room in pod 3-C.

On 11/03/2016 at 11:31 a.m., an ABHR was observed installed over an ignition source in an equipment room located in the surgery suite.

At 14:14, an ABHR was observed installed over an ignition source in patient room 267.

The facility manager acknowledged the ABHR dispensers installed over ignition sources.

Based on observation, staff interview, and record review it was determined the facility failed to ensure protection of electrical wiring and equipment as required.

Findings:

On 11/02/2016 at 12:52 p.m., a power tap was observed to be in use in the PCCU office.

At 14:30, while on tour of the endoscopic procedure room located on the 2nd floor of the facility 2 duplex red electrical receptacles were observed in the procedure room but could not be determined if they were GFCI. On review of the facility construction drawings, it could not be determined if the receptacles were GFCI.

The facility manager acknowledged the power tap and electrical receptacles.

Based on observation, staff interview and record review it was determined the facility failed to ensure heating, ventilation and air conditioning complied with 9.2 and shall be installed in accordance with the manufacturer's specifications.

Findings:

On 11/02/2016 at 11:47 a.m., the negative ventilation for the endoscopic procedure room located on the 2nd floor of the facility could not be verified. On review of the test & balance report the endoscopic procedure room on the 2nd floor was not included.

The facility manager acknowledged the endoscopic procedure room needing to be negatively ventilated.

At 11/03/2016 at 11:27 a.m., while on tour of the surgical suite, steel storage racks with sterile equipment packs were observed to be stored in the surgical corridor.

The facility manager was asked if there was documentation to indicate the surgical corridor where the sterile equipment was being stored was positively ventilated. The facility manager said that the surgical corridor was not included on the test and balance inspection.

Based on observation and staff interview it was determined the facility failed to ensure any means of egress in any area within the facility undergoing construction, repair, or improvements to be inspected daily to ensure its ability to be used instantly in case of emergency and compliance with NFPA 241 Standards for Safeguarding Construction, Alteration, and Demolition Operations.
Findings:
On 11/04/2016 at 14:15, while on tour of the facility it was observed new construction was in progress on the 3rd floor.
At 14:16, the facility manager was interviewed. Was asked for the facility construction log or documentation indicating the areas under current construction have been inspected daily since the start of construction to ensure the areas could be used instantly in case of an emergency. He said the facility does not have documentation regarding inspection of construction areas in the facility.

Based on staff interview it was determined the facility failed to categorize building systems by documenting risk assessments for each of the areas as outlined in NFPA 99, 2012 Edition, Chapter 4.

Findings:

On 11/04/2016 at 14:17, risk assessments were requested for the following areas: electrical systems, medical gas systems, and patient care areas.

The facility manager acknowledged the missing risk assessments.

Based on observation, and record review it was determined the facility failed to ensure wet procedure locations were protected.

Findings:

On 11/01/2016 at 15:10, while on tour of the facility the electrical receptacles in the endoscopic procedure room located on the 2nd floor could not be identified as having GFCI or isolated power. On review of the facility construction drawings, it could not be determined if the receptacles were GFCI.

Based on observation it was determined the facility failed to ensure using the CMS categorical waiver for power strips was approved by the facility for use of having approval and power strips

Findings:

On 11/02/2016 at 09:44 a.m., while on tour of the facility a daisy chained extension cord was observed to be plugged into a power tap connected to a desktop computer which was located in the infection control office.

On 11/03/2016 at 11:50 a.m., a refrigerator was observed to be plugged into a power tap in the materials management purchasing office.

At 13:40, on tour of the IT room in the basement, an extension cord was observed to be in use. The extension cord was hanging from a ceiling tile, and on inspection was observed to be plugged into a power tap which was located in the plenum space of the drop ceiling.

Based on observation and staff interview it was determined the facility failed to ensure trans filling from liquid oxygen was in a protected hazardous area.

Findings:

On 11/02/2016 at 14:33, while on tour of the facility a liquid oxygen reservoir container with wheels was observed to be stored in a room that was not protected. The door to this room was open, had no self-closing hardware, and had electrical receptacles/light switches installed below 5 feet from the floor of the room. The room was not negatively mechanically vented. This room contained a wooden cabinet, and 4 patient walkers with 4 oxygen delivery devices.

The facility manager was asked if trans filling of oxygen was being done in the observed room. He said yes, the large liquid oxygen tank is used to fill the smaller portable liquid oxygen units on each of the walkers.