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Based on observation and staff interviews, on September 1, 2015 during a verification visit, the facility failed to construct, install and maintain the building systems to ensure life safety to patients. The cumulative effect of the environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.


Findings:

The facility was found to contain the following 2 deficiencies.
K 33: exit stairs opening to unoccupied rooms
K 48: that staff were not familiar with their responsibilities in the event of a fire
Refer to the the full description at the cited K tags.

Based on observation and staff interviews, the facility did not construct, install and maintain a proper ventilation and temperature control system in operating rooms and sterile processing areas. The facility did not have a ventilation system that was installed and maintained in accordance with state regulations and manufacturer recommendations. This deficiency occurred in 1 of the 6 smoke compartments and had the potential to affect the operating room patients within these smoke compartments.

FINDING INCLUDE:

1. On 09/01/2015 at 1:50 PM, observation revealed in the Sterile Processing area, that cleaning of endoscopy scopes and other surgical equipement was done in the same room as the sterilizing and packaging of sterile equipment. The cleaning of the dirty equipment requires the room to be negative pressure and the processing of clean equipment requires the room to have positive pressure. The air flow into this room is negative. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director Facilities).

Based on observation and staff interviews, on September 1, 2015 during a verification visit, the facility failed to construct, install and maintain the building systems to ensure life safety to patients. The cumulative effect of the environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.


Findings:

The facility was found to contain the following 2 deficiencies.
K 33: exit stairs opening to unoccupied rooms
K 48: that staff were not familiar with their responsibilities in the event of a fire
Refer to the the full description at the cited K tags.