HospitalInspections.org

K700 - Operating Features - Building Automation

Findings: APPLICABLE TO ALL CAMPUSES
The surveyor observed, while accompanied by the Regional Facility Manager, Facility Manager, 'Quality and Patient Safety Director' and 'Director of Safety & Emergency Preparedness Safety Officer', during the hours of the survey from 9AM - 3:00 PM on 8/17/18 at Christus Santa Rosa Hospital - Westover Hills, that there were the following issues:

1) Based on observation at patient room B1053 in Westover Hills campus, the ball-in-wall airflow indicator did not agree with the handheld manometer device.
2) The four campuses utilize a similar set of building automation system (BAS) to view, adjust, and gather data on temperature and relative humidity through their facility. BAS has its problem like the ball-in-wall issue when total reliance on one system or tool without secondary check can lead to complacency and inaccurate diagnosis. As it was observed at Medical Center, inside kitchen cooler no. 3, there were two non-agreeing thermometers. Failure of BAS and data gathering methodology should be a point of consideration for comprehensive risk assessment.

Findings: APPLICABLE TO ALL CAMPUSES
The surveyor observed, while accompanied by the Regional Facility Manager, Facility Manager, 'Quality and Patient Safety Director' and 'Director of Safety & Emergency Preparedness Safety Officer', during the hours of the survey from 9AM - 3:00 PM on 8/17/18 at Christus Santa Rosa Hospital - Westover Hills, that there were the following issues:

1) Based on a review of the fire drill records at the Alamo Heights and Westover Hills campuses, it was conducted without regular consistency. For example, in the first and second quarter of 2018, fire drills were not held at unexpected times for both campuses. Fire drill records indicated same deficiency occurred in 2017 for the Alamo Heights campus.

Findings: APPLICABLE TO ALL CAMPUSES
The surveyor observed, while accompanied by the Regional Facility Manager, Facility Manager and 'Quality and Patient Safety Director, during the hours of the survey from 2:30 PM - 9:00 PM on 8/15/18 that there were the following issues:

1) Based on review of the records, facility does not perform any receptacle maintenance and testing at all of its campuses. NFPA 99-2012, section 6.3.3.2 lists the minimum requirements for receptacle testing regardless of hospital-grade or not. Describe the facility justification of testing frequency (e.g. appropriate testing intervals) based on documented performance data. For example, experiential data shows that retention force of the grounding blade of each electrical receptacle decreases over time due to repeated usage. Thus, the failure rate has a direct correlation to time and usage. What data does the facility collect or will implement that could provide the kind of indication of pending failures or reveal non-conformance receptacles such that it could take pre-emptive action before the onset of failure?