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Tag No.: K0067
1) Based on observation and interview with staff, the facility failed to provide Heating, ventilating, and air conditioning systems that comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2. Findings include:
a) The facility failed to ensure that the condition of the physical plant and overall hospital environment is developed and maintained in a manner to ensure the safety and well being of patients.
a-1) The mobile cath lab humidity was not logged. There was no way to confirm if determined humidity levels were within acceptable parameters, and that corrective that corrective actions was performed in a timely manner to achieve acceptable levels.
a-2) The facility failed to ensure proper ventilation, light, and temperature controls were installed and verified. Air exchanges in the unit require 15 total air exchanges, 3 outside air exchanges, also maintenance staff could not identify the location of outside air intakes. The room/space requires a positive air flow out of the mobile unit. A Report was not available at the time of the visit, nor did staff have information regarding a Commissioning of or a Test and Balance Report.
b) The manometers installed to monitored the HEPA Filters was not being logged. Cath Lab Manager was not in-serviced or could identify the purpose of the manometers. Pre filters required upstream of the HEPA filter could not be found nor could staff show location of the fresh air intakes.
Tag No.: K0075
1) Based on observation and interview with staff, the facility failed to provide Soiled linen or trash collection receptacles that do not exceed 32 gal (121 L) in capacity.
a) Mobile soiled linen / trash collection receptacles (the 50 gallon trash receptacle located at the foot of the bed ) that is greater than
32 gal (121 L), located in the Mobile Cath Lab bed location, in conjunction with other receptacles, was not protected as a hazardous area 19.7.5.5. Combined with all of the trash containers in the room, the trash collection receptacles exceeded the 32 gallon per 64 square feet.
Tag No.: K0078
1) Based on observation and interview with staff, the facility failed to provide for or designate Anesthetizing locations and protected in them accordance with NFPA 99, Standard for Health Care Facilities. Findings include:
a) Governing Body failed to designate anesthetizing locations in accordance with NFPA 99 1999 edition chapter 12.2.7
Tag No.: K0130
1) Based on observation and interview with staff, the facility failed to maintain design features initially approved for construction. The building was not maintained in accordance with approved design specifications. Any variations shall require the approval of the authority having jurisdiction prior to the actual change NFPA101 2000 Life Safety Code 5.1.7. and in accordance with Interruptive Guidelines Appendix A ?482.41(b)(8)
a) There was no written evidence of submittal through this office or inspection and approval by State or local fire control agencies that the facility installed the mobile Cath Lab adjacent to the Emergency Generator. The emergency converter was not located in a separate service room separated from the remainder of the mobile unit by a fire separation wall having a minimum of a 2 hour fire resistance rating in accordance with NFPA 99 1999 edition chapter 3-4.1.1.6. The fresh air intake and the door openings to the mobile unit is compromised by the heat generated from the radiator and fan blowing onto the mobile unit
Tag No.: K0144
1) Based on observation and interview staff, the facility failed to logged and inspect the Emergency Generator weekly and exercised under load for 30 minutes per month, in accordance with NFPA 99. 3.4.4.1. Findings include:
a) The emergency generator was not exercised under load and logged monthly.
b) The emergency generator was not inspected weekly and documented.
c) The emergency battery back up light over the Cath Lab Table and the Battery Back up light over the Transfer Switch was not tested monthly and documented.
d) Cath Lab manager was not in-serviced on internal workings of the emergency transfer switch nor was her staff. Staff was not trained to trouble shoot the transfer equipment in an emergency.
e) Maintenance staff indicated that the emergency generator was repaired shortly after the mobile unit was placed for service. Facility did not have the repair documentation available for review and staff could not verify or ensure that the services performed under a contract was provided in a safe and effective manner. The hospital did not have the mechanism to evaluate the quality of contracted service and ensure that the contracted service was provided in a safe and effective manner in accordance with ?482.12(e)(1) .
Tag No.: K0147
1) Based on observation and interview with staff, the facility failed to provide and maintain Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2 Findings include:
a) The Line Isolation Monitor was not put on a monthly preventive maintenance check list and documented.
b) Cath Lab manager was asked to describe function of equipment in the Mobile Cath Lab. Surveyor pointed to the Line Isolation Monitor, Cath Lab manager indicated that she had not been in-serviced on said equipment and did not know function of the equipment.
c) Staff could not point to or describe the two sources of power in the Cath Lab. Staff pointed to the emergency power outlets/ receptacles, but could not point to or describe where the required normal circuit/ receptacle was located in the event of the transfer switch failure .
d) The Bio Medical Equipment testing intervals for equipment does not meet minimum requirements. Ohio Suction Machine (GE Number 402669714) was tested October of 2013, however it was not due for re-testing until October of 2014. Cath Labs is considered a Critical Care Areas and require testing intervals semi annually in accordance with NFPA 99 1999 edition chapter 7-6.2.1.2.
e) Patient Ground Testing for patient care areas was not conducted. Impedance Testing for patient care areas was not preformed and record keeping was not maintained in accordance with NFPA 99 19999 edition chapter -3.3.2.1 through 3-3.4.3