HospitalInspections.org

Based on observation and interview the facility failed to ensure opening doors to access to the emergency egress pathway would only take one action to open as required.

Findings:

On 03/31/21 at 9:54am the surveyor observed a one deadbolt lock on each of the procedure room doors in the surgery area which would require two actions to open to gain access to the emergency egress pathway.

On 03/31/21 at 9:54am the surveyor asked staff I why they had deadbolt locks on each of the procedure doors. Staff I stated they were wanting to control traffic but can install the correct locks which are compliant to code.

Based on observation and interview the facility failed to ensure hazardous areas are properly protected from other use spaces.

Findings:

On 03/31/21 at 2:44 pm the surveyor observed an IT closet with multiple combustible items stored within it. There was a wooden combustible shelf, multiple corrugated boxes, multiple combustible plastic items which are not to be stored in the hazardous area IT closet.

On 03/31/21 at 2:44 pm the surveyor asked staff O stated why combustible items were stored within the IT closet. Staff O stated they did not know and that the IT staff were not aware it was against fire code.

Based on record review, observation and interview the facility failed to ensure ASHRAE 170-2008 ventilatory standards were maintained as required.

Findings:

Record review showed the facility policy for relative humidity was 20-60% and the range for Oklahoma is 30-60% for relative humidity. Further record review showed the facility test and balance inspection report dated 01/31/20 did not include the following areas: semi-restricted corridor which had four wheeled shelves storing sterile supplies, and sub-sterile ante room between OR 1 and 2 which housed a small amount of sterile supplies.

On 03/30/21 at 10:27am the surveyor asked staff I why their relative humidity was 20-60%. Staff I stated the relative humidity policy has been that way for a few years per AORN who allows it but will change it to be compliant.

On 03/30/21 at 2:42pm the surveyor observed the semi-restricted corridor in the surgical area to have hour steel storage shelves with sterile supplies, and a sub-sterile ante room between OR 1 and 2 which was observed to have a small amount of sterile supplies. Both of these areas would need to be tested and verified to be positively ventilated to be in compliance per ASHRAE 170-2008 ventilatory standards as required.

On 3/30/21 at 2:45pm the surveyor asked staff I why the substerile area, sterile storage, soiled utility were not tested on the annual test and balance inspection report. Staff I stated they will correct it and those areas must not have been added as they should have.

Based on observation and interview the facility failed to ensure fire extinguisher(s) located in the kitchen had placard(s) displayed next to each one as required.

Findings:

On 03/31/21 at 12:22pm the surveyor observed one ABC class fire extinguisher in the kitchen with no placard posted next to it as required.

On 03/31/21 at 12:22pm the surveyor asked asked staff O why there was no placard on the ABC fire extinguisher when it was installed. Staff O stated they had inhouse staff install it and they probably were not aware of the requirement. Staff O stated they would get the appropriate placard for the fire extinguisher which was installed within the kitchen.


NFPA 96, 2011 Edition
Chapter 10 Fire Extinguishing Equipment
10.2 Types of Equipment
10.2.2* A placard shall be conspicuously placed near each extinguisher that states that the fire protection system shall be activated prior to using the fire extinguisher.

Based on record review and interview the facility failed to ensure fire drills conducted included the transmission of a fire alarm signal as required.

Findings:

Record review of the facility fire drill documentation showed each fire drill did not include verification of a transmission of a fire alarm signal.

On 03/30/21 at 10:32 am staff O was asked to show the surveyor where they document how they verify the transmission of a fire alarm signal. Staff O stated they did not document it on the fire drill report forms but will add it from this point on.

Based on record review and interview the facility failed to ensure the emergency generator fuel testing was completed as required.

Findings:

Record review showed generator fuel testing was not completed for 2020, 2019 and 2018.

On 03/31/21 at 1:52pm Staff O was asked to provide the emergency generator fuel testing for 2020, 2019 and 2018. Documentation for generator fuel testing was not provided for those three years.

On 03/31/21 at 1:54pm the surveyor asked staff O why generator fuel testing was not done for 2020, 2019 and 2018. Staff O stated it will be placed on their generator program.