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Based upon observation, record review, and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid 42 CFR Subpart 485.623(c), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include:

C-0924 - Failure to maintain a clean environment
C-0926 - Failure to maintain proper ventilation in patient care areas
C-0930 - Failure to comply with applicable provisions of the 2012 edition of the Life Safety Code
C-0944 - Failure to maintain and label the medical gas system and failure to maintain the electrical isolated power system.

Based on observation and interview, the facility failed to maintain a clean environment in patient care storage areas. This deficient practice could result in patients receiving linen and medication from areas that staff failed to keep clean. Failure to keep the pharmacy and clean linen floors clean could result in increased cross contamination of supplies, attraction of pests, and increased spread of diseases resulting in poor patient outcomes for all patients.

1. On 7/19/21 at 1101 observed linen, dirt and debris under the lowest shelf in the clean linen room in the area with the inpatient bedrooms.

2. On 7/19/21 at 1339 observed pill casings, dirt and debris under the lowest storage shelves in the pharmacy medication storage room.

Staff F and Staff G confirmed these observations during interview at the time of observation.

Based upon observation and interview the facility failed to maintain proper ventilation in patient care areas. This deficient practice could result in inadequate ventilation compromising the cleanliness/sterility of storage items in clean rooms as well as allow the spread of hazardous or infectious agents from soiled areas to the detriment of all patients and staff in the area.

Findings include:
1. On 07/19/21 at 1142 observed using the tissue test that the new Triage room was not under a net negative pressure. During interview at this time, Staff F explained that the recently constructed room was provided with a multi speed exhaust fan controlled by a switch in the room. The exhaust fan for the room was not turned on or not turned on high enough to create negative pressure airflow. The triage room must be served by a central exhaust system continuously running while the room is in use. When not in use, the triage room must remain under a net negative pressure.

2. On 07/19/21 at 1352 observed that the sterile processing room was not under a net positive pressure by using notebook paper to see the airflow at the undercut of the door.

3. On 07/19/21 at 1414 observed that the first set of air filters for the air handler unit serving endoscopy had a three inch air gap in between the filters and the access door, allowing air to bypass the filters.

4. On 07/19/21 at 1630 observed that the main sterile storage room was not under a net positive pressure by using notebook paper to see the airflow at the undercut of the door.

5. On 07/19/21 at 1633 observed that the Clean linen room near Operating Room 1 (OR 1) was not under a net positive pressure by using notebook paper to see the airflow at the undercut of the door.

The above findings were confirmed during interview with Staff F at the times of the observations.

Based upon observation, record review, and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 485.623(c), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes up to and including death in the event of a fire for all patients. Findings include

See the individually and below cited K-tags dated July 20, 2021.
K-0222
K-0241
K-0324
K-0341
K-0351
K-0353
K-0363
K-0521
K-0914
K-0918

Based upon observation and interview the facility failed to maintain and label the medical gas system and failed to maintain the electrical isolated power system. The lack of adequate isolated power system maintenance could result in significant harm to those patients undergoing invasive surgical procedures should an electrical fault occur and continue undetected. Improper maintenance and labeling of medical gas valves increases the risk of medical gas failure for the medical gas outlets not maintained with potential adverse outcomes the patient. Without proper labeling of the medical gas shutoff valves, staff may not be able to quickly and accurately isolate the oxygen supply to the patient rooms which may need to have the oxygen turned off in an emergency resulting in serious potential harm to all patients from smoke and fire.

Findings include:
1. On 07/19/21 at 11:35 AM, observed two medical gas zone control valve boxes in the patient wing corridor which were not labeled as to the area(s) served.

2. On 07/19/21 at 11:40 AM, observed a new electrical circuit panel in the patient wing corridor just North of the door to the Emergency Department that did not have any of the circuits labeled.

3. On 07/19/21 at 3:50 PM during document review with Staff F, it was identified that there was no record of any routine annual testing and maintenance of the hospital medical gas outlets. During interview at this time, Staff F explained that he was not aware of this requirement for annual testing of the medical gas system and outlets.

These above findings were confirmed during interview with Staff F at the time of the observation.