HospitalInspections.org

1. Based on observation, it was determined the facility did not properly seal penetrations in the smoke barrier walls to prevent the passage of smoke at four of seven locations inspected. The failed practice had the potential to affect 17 of 17 patients on the day of the first day of the survey, and all patients admitted to the facility. The findings follow:

A. On a tour of the surgical suite on 06/29/10 at 1330 with the Director of Engineering, unsealed penetrations of the smoke barrier walls were observed at the following locations in the surgical suite:
1) Above the ceiling at the smoke barrier doors near Dietary separating Smoke Zone 1 and Smoke Zone 4.
2) Above the ceiling at the smoke barrier doors near Surgery separating Smoke Zone 3 and Smoke Zone 2.
3) Above the ceiling at the smoke barrier door to the Outpatient Clinic separating Smoke Zone 2 and Smoke Zone 1.
4) Above the ceiling at the smoke barrier doors near Physical Therapy separating Smoke Zone 1 and Smoke Zone 2.
B. The Director of Engineering verified the unsealed penetrations during the tour of the facility on 06/29/10 at 1330.

2. Based on fire drill documentation review and staff interview, it was determined the facility failed to conduct four (1st, 2nd and 4th 2009 and 1st 2010) of five required quarterly fire drills for the 2nd shift (night shift) from January 2009 to March 2010). The failed practice had the potential to affect 17 of 17 patients in the facility on the first day of the survey and all patients admitted to the facility. The findings follow:

A. Review of the facility fire drill records on 06/28/10 at 1430 revealed there was no documentation of fire drills for the 2nd shift (night shift) for the 1st, 2nd, and 4th quarters in 2009 and for the 1st quarter in 2010.
B. In an interview conducted on 06/28/10 at 1530 the Director of Engineering stated he was aware that several fire drills had not been performed on the 2nd shift within the past year. The Director of Engineering stated there was no further fire drill documentation available for review.

3. Based on review of the "Operating Room History" Log and staff interview, it was determined the humidity level was not maintained above 35% as required in two of two Operating Rooms in the facility for 2009 and 2010; the facility failed to take corrective action in response to the low humidity levels. The failed practice had the potential to affect two of two patients admitted for surgery on the second day of the survey and all patients admitted for surgery. The findings follow:

A. A review of the "Operating Room History" Log on 06/29/10 at 1000 revealed Humidity levels below 35% were recorded as follows:
1) In Operating Room #1, humidity levels below 35% were recorded for 25 of 41 days from 01/01/09 to 03/04/09 and 28 of 39 days from 12/15/09 to 02/11/10.
2) In Operating Room #2, humidity levels below 35% were recorded for 30 of 41 days from 01/01/09 to 03/04/09 and 30 of 39 days from 12/15/09 to 02/11/10.
B. In an interview conducted on 06/29/10 at 1030, the Director of Engineering stated no work orders for repairs or adjustments to the air conditioning system had been produced in response to the low humidity levels in the operating rooms.
C. On 06/29/10 at 1040, the Director of Engineering verified the humidity levels recorded "Operating Room History" Log and that there was no further documentation related to the low humidity levels available for review.

1. Based on observation, it was determined the facility did not properly seal penetrations in the smoke barrier walls to prevent the passage of smoke at four of seven locations inspected. The failed practice had the potential to affect 17 of 17 patients on the day of the first day of the survey, and all patients admitted to the facility. The findings follow:

A. On a tour of the surgical suite on 06/29/10 at 1330 with the Director of Engineering, unsealed penetrations of the smoke barrier walls were observed at the following locations in the surgical suite:
1) Above the ceiling at the smoke barrier doors near Dietary separating Smoke Zone 1 and Smoke Zone 4.
2) Above the ceiling at the smoke barrier doors near Surgery separating Smoke Zone 3 and Smoke Zone 2.
3) Above the ceiling at the smoke barrier door to the Outpatient Clinic separating Smoke Zone 2 and Smoke Zone 1.
4) Above the ceiling at the smoke barrier doors near Physical Therapy separating Smoke Zone 1 and Smoke Zone 2.
B. The Director of Engineering verified the unsealed penetrations during the tour of the facility on 06/29/10 at 1330.

2. Based on fire drill documentation review and staff interview, it was determined the facility failed to conduct four (1st, 2nd and 4th 2009 and 1st 2010) of five required quarterly fire drills for the 2nd shift (night shift) from January 2009 to March 2010). The failed practice had the potential to affect 17 of 17 patients in the facility on the first day of the survey and all patients admitted to the facility. The findings follow:

A. Review of the facility fire drill records on 06/28/10 at 1430 revealed there was no documentation of fire drills for the 2nd shift (night shift) for the 1st, 2nd, and 4th quarters in 2009 and for the 1st quarter in 2010.
B. In an interview conducted on 06/28/10 at 1530 the Director of Engineering stated he was aware that several fire drills had not been performed on the 2nd shift within the past year. The Director of Engineering stated there was no further fire drill documentation available for review.

3. Based on review of the "Operating Room History" Log and staff interview, it was determined the humidity level was not maintained above 35% as required in two of two Operating Rooms in the facility for 2009 and 2010; the facility failed to take corrective action in response to the low humidity levels. The failed practice had the potential to affect two of two patients admitted for surgery on the second day of the survey and all patients admitted for surgery. The findings follow:

A. A review of the "Operating Room History" Log on 06/29/10 at 1000 revealed Humidity levels below 35% were recorded as follows:
1) In Operating Room #1, humidity levels below 35% were recorded for 25 of 41 days from 01/01/09 to 03/04/09 and 28 of 39 days from 12/15/09 to 02/11/10.
2) In Operating Room #2, humidity levels below 35% were recorded for 30 of 41 days from 01/01/09 to 03/04/09 and 30 of 39 days from 12/15/09 to 02/11/10.
B. In an interview conducted on 06/29/10 at 1030, the Director of Engineering stated no work orders for repairs or adjustments to the air conditioning system had been produced in response to the low humidity levels in the operating rooms.
C. On 06/29/10 at 1040, the Director of Engineering verified the humidity levels recorded "Operating Room History" Log and that there was no further documentation related to the low humidity levels available for review.