HospitalInspections.org

1) Based on observation and interview with staff, the facility failed to ensure doors to corridors were provided with a means suitable for keeping the door closed tightly in its frame. Roller latches are prohibited by CMS regulations in all health care facilities. Findings include:

a) Door to room 110 was not provided with latching hardware.

1) The Performance-Based Design Option out of NFPA 101 2000 Life Safety Code chapter 5.8.14 requires that anyone involved in the ownership or management of the building notify and document the following upon remodeling, modification, renovation, change in use:

(a) The building was approved as a performance-based design,with certain specified design criteria and assumptions.

(b) Any remodeling, modification, renovation, change in use, or change in the established assumptions will require a re-evaluation and re-approval.

c) Wound Care Supplies are being kept in a Tub Room, tub room is now considered a storage room without a door that has latching hardware. Any Re-purposing of rooms shall be submitted and approved.

Based on observation and interview with staff, the facility failed to make staff familiar with procedures and they are aware that drills are part of established routine; Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift; Responsibility for planning and conducting drills shall be assigned only to competent persons who are qualified to exercise leadership. Findings include:

Cleaning staff, Staff Member MM, does not speak fluent English. Staff member MM when asked to demonstrate what to do if she encountered a fire, failed to exhibit the RACE protocol adopted by the hospital. Staff member MM only went and found the fire extinguisher, she did not alarm, confine, or demonstrate removing occupant. The drill was conducted in front of the Director of Engineering.

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 Performance-Based Design Option out of NFPA 101 2000 Life Safety Code chapter 5.8.14 requires that anyone involved in the ownership or management of the building notify and document the following upon remodeling, modification, renovation, change in use:

The building was approved as a performance-based design,with certain specified design criteria and assumptions. .Any remodeling, modification, renovation, change in use, or change in the established assumptions will require a re-evaluation and re-approval.

The renovation project of 2010, added a Procedure room across the corridor from the CT Scan room and scope processing and sterilization room for the limited procedures planned in accordance with Functional Narrative.

Plans provided did not show location of Processor and at that time, the cleaning room does not allow for flow of instrumentation from the contaminated area to the clean area and, finally, to storage.

The clean equipment room including storage, shall protect the equipment from contamination. There shall be at least two (2) deep utility sinks remote from each other. The Ventilation system shall have a Negative pressure, maintained at least ten (10) air changes per hour with a hood over the work counter. All air shall be exhausted to the outside to avoid re-circulation within the facility.

(a) Bronchoscopes procedures are being conducted in the ICU.
b) Endoscope procedures are being conducted in Procedure room, the room is positive, Endoscope procedures shall have air flow that is negative.
c)The facility failed to provide a Patient holding/prep/recovery area for procedures that are conducted.

2) Respiratory Clean Storage and Cleaning of Dirty Equipment was being combined in Respiratory Storage Room. Cleaning and storing clean supplies requires rooms to be separated and air flow is opposite for each application. Performance-Based Design Option out of NFPA 101 2000 Life Safety Code chapter 5.8.14 requires that anyone involved in the ownership or management of the building, to notify and document the following upon remodeling, modification, renovation, change in use:
re-purposing of rooms requires the facility to submit plans.


3) Mechanical Actuated Smoke Dampers located through out the facility were not documented as being tested, testing dampers cannot be verified,there is no address or location given to dampers.

Based on observation and interview with staff, the facility failed to continuously maintained Means of egress, to be free of all obstructions or impediments to full instant use, in the case of fire or other emergency. Findings include:

The corridor west of procure rooms staged a blue cart for soiled linen. The cart was staged at the time of arrival 10:30 am and was located in the same place at 5:30 pm on March 24, 2014 .

1) Based on observation and interview with staff, the facility failed to install, test, electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2

a) Impedance Testing of circuits and receptacles through out the hospital has not been preformed. Documentation was not maintained in accordance with NFPA 99 1999 edition chapter 3-3.3.2.1, 3-3.4.3


2) Based on observation, review of Bio Medical Equipment and interview with staff, the governing body failed to ensure that contractor of services, comply with all applicable conditions of participation and standards for the contracted services, in accordance with Interruptive Guideline Appendix A, A-0083 §482.12(e) Standard: Contracted Services .

Findings include:

a) The rental equipment brought in was not identified with Bio Medical Test Sticker in accordance with Bio Medical Testing requirements adopted by the facility; preventive maintenance testing results for rental equipment was not available On Line or located on site.

b) The governing body failed to ensure and document that the Bio Medical services performed under contract are provided in a safe and effective manner