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Based on observation and interview, the facility failed to maintain protection of 2 of 6 ceiling barriers in accordance of 19.3.1. (see tag K311), failed to ensure 36 of over 1000 hard wired smoke detectors were not installed where air flow would adversely affect its operation (see tag K341), failed to ensure 1 of 1 oxygen storage location where transfilling occurs was provided with proper signage, a concrete or ceramic floor, and proper distance from combustible items (see tag K927). .

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that all locations from which it provides services are constructed, arranged and maintained to ensure the provision of quality health care in a safe environment.

Based on observation and interview, the facility failed to maintain protection of 2 of 6 ceiling barriers in accordance of 19.3.1. LSC 19.3.1 requires protection of vertical opening 39.3.1. LSC 19.3.1 requires vertical opening shall be enclosed or protected in accordance with Section 8.6. LSC 8.6.1 requires every floor that separates stories in a building shall be constructed as a smoke barrier. LSC 19.3.1.1 requires where an enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating. This deficient practice could affect patients, staff, and visitors on the 4th, 5th, and 6th floors. The facility failed to ensure 36 of over 1000 hard wired smoke detectors were not installed where air flow would adversely affect its operation. NFPA 72, 2010 edition, 17.7.6.3.2 requires that smoke detectors shall not be located directly in the airstream of supply registers. Section 17.7.4.1 requires in spaces served by air handling systems, detectors shall not be located where air flow prevents operation of the detectors. A.17.7.4.1 states detectors should not be located in a direct airflow or closer than 36 inches from an air supply diffuser or return air opening. This deficient practice could affect up to 20 patients, as well as staff and visitors throughout the facility.

Findings include:

Based on observations with the Director of Facility Services and Maintenance Coordinator on 04/09/19 between 8:30 a.m. and 12:15 p.m., a four inch conduit penetrated the floor/ceiling assembly between the 6th and 5th floor, and the 5th and 4th floor in the Telecom Room on each floor. The conduit was mostly open with only two small wires running through. Based on interview at the time of observation, the Director of Facility Services agreed the four inch conduit penetrating both floors was not properly fire stopped.

Based on observations on 04/08/19 between 11:00 a.m. and 4:15 p.m. and on 04/09/19 between 8:30 a.m. and 12:30 p.m. during a tour of the facility with the Director of Facility Services and the Maintenance Coordinator, the following was observed:
a. The Cardiovascular office/EKG file room had a smoke detector within 16 inches of an air supply vent
b. The Heart failure room had a smoke detector within 16 inches of an air supply vent
c. The Prosolo room had a smoke detector within 16 inches of an air supply vent
d. The 6th floor stairwell landing had a smoke detector within 16 inches of an air supply vent
e. The Cardiac back hallway had a smoke detector within 16 inches of an air supply vent
f. The Cath lab holding hall near Holding room #6 had a smoke detector within 16 inches of an air supply vent
g. The Cath lab holding room #8 had a smoke detector within 16 inches of an air supply vent
h. The Cath lab holding room #7 had a smoke detector within 16 inches of an air supply vent
i. The Cath lab holding room #6 had a smoke detector within 16 inches of an air supply vent
j. The Cath lab holding room #5 had a smoke detector within 16 inches of an air supply vent
k. The Cath lab holding room #4 had a smoke detector within 16 inches of an air supply vent
l. The Cath lab holding room #3 had a smoke detector within 16 inches of an air supply vent
m. The Cath lab holding room #2 had a smoke detector within 16 inches of an air supply vent
n. The Cath lab holding room #1 had a smoke detector within 16 inches of an air supply vent
o. Cath lab holding nurses station had a smoke detector within 16 inches of an air supply vent
p. The 6th floor soiled utility room had a smoke detector within 16 inches of an air supply vent
q. The Cath lab equipment room had a smoke detector within 16 inches of an air supply vent
r. The Cath lab Clean storage room had a smoke detector within 16 inches of an air supply vent
s. The Cath lab outside the women's locker room had a smoke detector within 16 inches of an air supply vent
t. The Cath Lab ACC/QI office had a smoke detector within 16 inches of an air supply vent
u. The O.B. room #3458 had a smoke detector within 16 inches of an air supply vent
v. The Surgery Pre-Operative/Post-Operative Room #1 had a smoke detector within 16 inches of an air supply vent
w. The Surgery Pre-Operative/Post-Operative Room #2 had a smoke detector within 16 inches of an air supply vent
x. The Surgery Pre-Operative/Post-Operative Room #3 had a smoke detector within 16 inches of an air supply vent
y. The Surgery Pre-Operative/Post-Operative Room #4 had a smoke detector within 16 inches of an air supply vent
z. The Surgery Pre-Operative/Post-Operative Room #5 had a smoke detector within 16 inches of an air supply vent
aa. The Surgery Pre-Operative/Post-Operative Room #6 had a smoke detector within 16 inches of an air supply vent
bb. The Surgery Pre-Operative/Post-Operative Room #7 had a smoke detector within 16 inches of an air supply vent
cc. The Surgery Pre-Operative/Post-Operative Room #8 had a smoke detector within 16 inches of an air supply vent
dd. The Surgery care nurses station had a smoke detector within 16 inches of an air supply vent
ee. The west end of the Surgical supply room had two smoke detectors within 16 inches of an air supply vent
ff. The 4th floor Nourishment room had a smoke detector within 16 inches of an air supply vent
gg. The 1st floor soiled utility room #1533 near the MRI Center suite had a smoke detector within 12 inches of an air supply vent
hh. The Lower level trash chute room had a smoke detector within 12 inches of an air supply vent
ii. The Lower level Doctors lounge had a smoke detector within 12 inches of an air supply vent
jj. The Lower level BC Storage room had a smoke detector within 12 inches of an air supply vent
Based on interview at the time or each above mentioned observation, the Director of Facility Services and the Maintenance Coordinator agreed each aforementioned smoke detector as being within 36 inches of an air supply vent.

Based on observation and interview, the facility failed to ensure 1 of 1 oxygen storage location where transfilling occurs was provided with proper signage, a concrete or ceramic floor, and proper distance from combustible items. NFPA 99, Health Care Facilities Code 2012 Edition, Section 11.5.2.3.1 states oxygen transfilling locations shall include the following:
(1) A designated area separated from any portion of a facility wherein patients are housed, examined, or treated by a fire barrier of 1 hour fire resistive construction.
(2) The area is mechanically vented, is sprinklered, and has ceramic or concrete flooring.
(3) The area is posted with signs indicating that transfilling is occurring and that smoking in the immediate area is not permitted.
(4) The individual transfilling the container(s) has been properly trained in the transfilling procedures.
NFPA 99, 11.3.2.3 requires oxidizing gases such as oxygen shall be separated from combustibles by one of the following: (1) a minimum distance of 20 feet. (2) a minimum distance of 5 feet if the required storage location is protected by an automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. (3) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of ½ hour.
This deficient practice could affect all patients, as well as staff and visitors on the second floor ICU.

Findings include:

Based on observation on 04/09/19 at 10:25 a.m. during a tour of the facility with the Director of Facility Services, the following was noted within the second floor ICU oxygen transfilling and storage room where three liquid oxygen tanks and over ten oxygen cylinders were being stored:
a. The floor in the oxygen transfilling room was vinyl tile and not concrete or ceramic tile
b. There was no signage on the door to the oxygen transfilling and storage room indicating that oxygen transfilling is occurring
c. There was a large bunch of papers stored in a open plastic container mounted to the wall within two feet of the liquid oxygen tanks.
Based on interview at the time of observation, the Director of Facility Services acknowledged the large bunch of papers stored in mounted plastic container, and an ICU nurse then removed the papers.

Based on document review, observation and interview, the facility failed to address potential infection control issues in 7 instances and failed to have a system for avoiding Immediate Use Steam Sterilization (IUSS) on a regular basis; for a total of 83 times in a 73 day period, from 01/8/2019 to 3/14/2019.
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1. Policy # 3865758, Environmental Services Cleaning of General Areas, last revised 9/2015, indicated:
A. To insure proper sanitation of all areas of the hospital on a regular basis.

2. Review of Association of periOperative Registered Nurses (AORN), 2016 Edition, indicated:
A. Immediate use steam sterilization (IUSS) should be kept to a minimum and should be used only in selected situations and in a controlled manner.
B. IUSS should not be used as a substitute for sufficient instrument inventory.

3. On 4/9/19, between approximately 1:30 p.m. and 3:30 p.m. during offsite tours, 3 instances were observed, in the following areas, in the presence of S5, Clinical Manager of Outcomes:
A. In a mechanical room of the Medical Arts Building, boxes were noted to be sitting directly on the floor and large dark grayish dust globules were scattered throughout the room.
B. At offsite O2, in exam room 1, dust and dark debris was noted on the foot pedals of the handwashing sink, heavy dust was noted on the patient exam table on the flat surface below the raised mattress and inside drawers of the exam table. In one drawer, a dead appearing insect was observed. On window ledge, behind the exam table, dust and small non-moving insects were noted.
C. At offsite O8, in the exam room behind the nurses station, dust and debris were noted inside the drawers of the exam table.

4. On 4/10/19 between approximately 12:30 p.m. and 2:00 p.m., in the presence of S5, in the oncology center, stacks of patient linens were observed to be stored uncovered in wicker type baskets sitting on top of the patient benches in each of the changing rooms.

5. On 4/8/2019 at 1420 hours, while touring the Emergency Department (ED), accompanied by staff S2, Director ED Services and House Supervision, it was noted that the patient snack refrigerator appeared to have spilled drinks, yellow stain and other substances on shelves.

6. On 4/10/2019 at 1045 hours, while touring Outpatient Surgery offsite, accompanied by staff S15, Director of Women Services and staff 1, manager outpatient services, it was noted in general storage room that 1 box of blankets for kids, 1 box of straws and 3 boxes of disposable cups were sitting directly on the floor.

7. In interview on 4/10/2019, at approximately 1500 hours, staff member S2 indicated agreement with the above findings.

8. On 4/9/2019 at approximately 0800 hours, while touring the main hospital Surgery Department, accompanied by staff member N2, manager surgical services, sterilizer log sheets were examined. On days when cataract removal surgeries are performed, the cataract instrument trays are routinely sterilized by IUSS.

9. Staff member N2 indicated in interview that we have 4 cataract instrument sets, but average 12 cases per day on ophthalmologist days. Cataracts are quick, so there is not enough time in between cases to do full sterilization.

10. Staff member N2 indicated in interview on 4/10, 2019 at approximately 1100 hours, that we use AORN guidelines.