The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

JACKSON MEMORIAL HOSPITAL 1611 NW 12TH AVE MIAMI, FL 33136 Feb. 5, 2019
VIOLATION: Gas and Vacuum Piped Systems - Modifications Tag No: K0910
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observations and interview the facility failed to maintain the medical gas equipment and system in accordance with National Fire Protection Association (NFPA) 99 (2012 edition) 5.1.5.16.1 and 5.1.10.2.3.1. Improper use and management of medical gas systems could result in failure of the system to perform as designed. This could result in failure of the system, creating the potential for harm to patients and staff and increasing the risks associated with anesthetizing medical gasses.

The findings included:

Observations and interviews with the Associate Director of Environmental and Safety and the Director of Engineering on [DATE] between 10:00AM. And 3:00p.m. Inspection of the operating rooms (ORs) in West Wing ( 15 ORs), DTC (20 ORs) and the 4th floor East (2 ORs) revealed that the anesthesia equipment in the operating rooms had a color coded purple hose with the coupling in white connected to the vacuum connection. This hose is dedicated to Waste Anesthetic Gas Disposal (WAGD). The current connectors are field modifications to connect to a vacuum inlet which is prohibited by 5.1.5.16.1.
VIOLATION: Electrical Systems - Wet Procedure Locations Tag No: K0913
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation and interview the facility failed to comply with the requirements of National Fire Protection Association (NFPA) 99 for wet locations in the Operating Rooms. The facilities Wet/ Dry Risk Assessment states that all the Operating Rooms are considered to be wet locations and there are some Operating Rooms that are not protected with isolated power.

The Findings Include:

Observations and interviews with the Associate Director of Environmental and Safety and the Director of Engineering on [DATE] between 10:00AM and 3:00 PM revealed the facility does not have isolated power protection in the Operating Rooms (OR) in the Ryder Trauma Center (6 ORs ), East Tower 5th floor (2 ORs), and DTC (20 ORs) . Inspection of the operating rooms (ORs) in the facility failed to provide the required electrical protection in accordance with National Fire Protection Association (NFPA) 99 (2012 edition) 6.3.2.2.8.2.