HospitalInspections.org

Based on observation and policy review, the facility failed to ensure outdated drugs were not available for patient use. This had the potential to affect all of the facility's 122 active patients.

Findings include:

A tour of the facility's emergency department was conducted on 05/11/15 at 1:30 PM. A Rapid Response Box was identified as having the following expired medications:
1. Nitrostat (used for preventing or relieving a sudden attack of chest pain) 0.4 milligrams Lot # V120492 expired 02/2015
2. 0.9% Sodium Chloride (an electrolyte) Lot 250 milliliters # C918805 expired 04/2015

An Emergency Room Trauma Box was identified having the following expired medications:
1. Morphine (an opioid pain medication) 10 milligrams/milliliters Lot #013350 expired 01/2015
2. Vecuronium Bromide (a muscle relaxant) 10 milligrams Lot # 7005762 expired 01/2014
3. Fentanyl Citrate (a pain medication) 50 micrograms/milliliter Lot # 22-C31-DK expired 04/01/2014

The facility's Outdated Medication Control policy #PH 100-35 was reviewed. The policy stated drugs which have reached their expiration date will be removed from active stock and sequestered in an appropriate location. Any stock which has reached its expiration date or is within one month of expiring is removed from stock and placed in the pharmacy's expired medication area for holding.

Based on observation, record review, and interview, the facility failed to maintain a two hour rated barrier between different occupancies, failed to ensure all doors protecting corridor openings were free of impediments to their closing, failed to maintain the stated rating of fire barriers protecting stairways and other vertical openings, failed to ensure each door in stairway completely self closed, failed to maintain the ratings of smoke barriers, failed to ensure each door in a smoke barrier closed completely, failed to maintain the stated rating of the fire barriers protecting its hazardous areas in each of its buildings, failed to maintain the rating of the fire barriers protecting each of the exit components, failed to ensure emergency illumination was provided in accordance with 7.9 and failed to test annually for not less than 90 minutes in each of its buildings, failed to ensure all personnel are familiar with the signals and emergency actions to take in a simulation of emergency fire conditions, failed to maintain an automatic sprinkler system in accordance with NFPA 25 and 13, failed to ensure dampers in each of its buildings were tested in accordance with National Fire Protection Association 90A, 1999 edition, section 3-4, failed to have a remote annunciator for its generator in a location readily observed by operating personnel in accordance with National Fire Protection Association 99 Chapter 3-4, failed to ensure the medical gas room in the building had one hour fire resistive construction, failed to maintain a one hour rating the wall separating it from the other tenant in the building, failed to maintain the integrity of its one hour rated smoke barrier and failed to ensure the surgery center's generator is maintained to a reasonable degree to supply service when needed, failed to ensure the sensitivity of the smoke detectors in the smoke detection system was tested, and failed to ensure each building's generator was inspected weekly and electrical transfer times documented. (A709) and failed to maintain the facility's heating,ventilation and cooling system to acceptable level of quality.(A724)

Based on observation, interview, and record review, the facility failed to meet requirements for life safety, specifically, the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association.This deficient practice has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 122 patients.

Findings include:

Building 1, main campus

K11 Failed to maintain two hour rated barrier between different occupancies
K18 Failed to ensure all doors protecting corridor openings were free of impediments to their closing
K20 Failed to maintain the stated rating of its fire barriers protecting its stairways and other vertical openings
K21 Failed to ensure each door in stairway completely self closed
K25 Failed to maintain the ratings of its smoke barriers
K27 Failed to ensure each door in a smoke barrier closed completely
K29 Failed to maintain the stated rating of the fire barriers protecting its hazardous areas
K33 Failed to maintain the rating of the fire barriers protecting each of its exit components
K46 Failed to ensure emergency illumination was provided in accordance with 7.9 and be tested annually for not less than 90 minutes.
K50 Failed to ensure all personnel are familiar with the signals and emergency actions to take in a simulation of emergency fire conditions
K62 Failed to maintain an automatic sprinkler system in accordance with NFPA 25 and 13
K67 Failed to ensure its dampers were tested in accordance with National Fire Protection Association 90A, 1999 edition, section 3-4.
K106 Failed to have a remote annunciator for its generator in a location readily observed by operating personnel in accordance with National Fire Protection Association 99 Chapter 3-4.


Building 2, Surgery Center

K29 Failed to maintain the stated rating of the fire barriers protecting its hazardous areas
K46 Failed to ensure emergency illumination was provided in accordance with 7.9 and be tested annually for not less than 90 minutes.
K67 Failed to ensure its dampers were tested in accordance with National Fire Protection Association 90A, 1999 edition, section 3-4.
K76 Failed to ensure the medical gas room in the building had one hour fire resistive construction
K114 Failed to maintain a one hour rating the wall separating it from the other tenant in the building
K130 Failed to maintain the integrity of its one hour rated smoke barrier and failed to ensure the ambulatory surgery center's generator is maintained to a reasonable degree to supply service when needed


Building 3, detached

K29 Failed to maintain a one hour fire rated barrier to protect its hazardous areas
K46 Failed to ensure emergency illumination was provided in accordance with 7.9 and be tested annually for not less than 90 minutes.
K51 Failed to ensure the sensitivity of the smoke detectors in its smoke detection system was tested
K144 Failed to ensure the building's generator was inspected weekly and electrical transfer times documented

Building 4, sleep laboratory

K29 Failed to ensure door protecting a hazardous area closed completely

Based on observation and interview, the facility failed to maintain its heating, ventilation and cooling system to acceptable level of quality. This deficient practice has the potential to affect all patients, staff and visitors to the facility. The facility had a census of 122 patients.

Findings include:

On 05/11/15 at 11:21 AM a tour was taken of the sixth floor with Staff Q and R.

1.On 05/11/15 at 2:08 PM observation of the return air vents in the bathrooms to patient rooms 637 and 636 revealed the louvers and heating, ventilation and cooling tube had thick layers of dust.

On 05/11/15 at 2:08 PM in an interview, Staff R confirmed the observation.

2. On 05/11/15 at 2:42 PM observation of the return air vents in the bathroom to patient room 618 revealed the louvers and heating, ventilation and cooling tube had thick layers of dust.

On 05/12/15 at 2:42 PM in an interview, Staff R confirmed the observation.

On 05/12/15 at 9:48 AM a tour was conducted of the third floor with Staff Q and R.

3. On 05/12/15 at 10:48 AM observation of the return air vent louvers in the bathroom to patient room 316 revealed it was almost completed occluded by dust.

On 05/12/15 at 10:48 AM in an interview, Staff R confirmed the observation.

4. On 05/12/15 at 10:56 AM observation of the return air vent louvers in the bathroom to patient room 318 revealed it to have a thick layer of dust.

On 05/12/15 at 10:56 AM in an interview, Staff R confirmed the observation.