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Based on observation and staff interview it was determined the facility failed to ensure protection of their hazardous areas as required.

Findings:

On 03/06/17 at 11:15 am, biohazard waste closet on the 28th floor was observed to have no self-closing hardware and it could not be determined if the area was negatively ventilated as required. There was a noticeable odor emanating from the room when the door was opened.

The administrator acknowledged the no self-closing hardware and odor.

On 03/07/17 at 11:55 am, patient room 2931 was oberved to be repurposed into hazardous area housekeeping closet. The shelves were observed to be stocked with multiple containers of hazardous housekeeping chemical cleaning supplies. The door to this area did not have self-closing hardware.

At 12:02 pm, patient room 2932 was observed to be repurposed into clean linen storage. There was no self-closing hardware on the door.

The administrator acknowledged the missing self-closing hardware.

Based on observation and staff interview it was determined the facility failed to ensure their sprinkler system was tested and maintained in accordance with NFPA 25.

Findings:

On 03/06/17 at 12:05 pm, a yellow tag was observed to be on the fire alarm system dated 12/29/16. On review the sprinkler annual from 2016 did not contain information regarding the facility having completed a main drain test.

The administrator acknowledged the existing yellow tagged fire alarm system and no main drain record.

Based on observation and staff interview it was determined the facility failed to ensure electrical wiring and equipment was compliant with NFPA 70 of the National Electric Code.

Findings:

On 03/06/17 at 12:04 pm, a power tap was observed to be in room 29M nursing supervisors office, rooms 2910 and 29F1 had a microwave and refrigerator plugged into power taps, the doctor's dictation room had a power tap daisy chained into a surge suppression device.

On review of documentation the last impedance inspection and testing was completed on 03/31/14 when the facility was first opened. No annual impedance inspection and testing for 2015, 2016 was provided.

The administrator acknowledged the impedance inspection/testing, power taps, and electrical issues.

Based on staff interview it was determined the facility failed to ensure elevator(s) were inspected, tested and maintained conforming to ASME/AMSI A17.3 Safety Code for Existing Elevators and Escalators.

Findings:

On 03/06/17 the 2015, 2016 annual elevator cylinder inspection and hydrostatic tests were requested for the facility's elevators and were not provided.

The administrator acknowledged the missing requested inspection reports for the facility elevators.

Based on staff interview it was determined the facility failed to ensure risk assessments for their building systems were conducted and completed as required.

Findings:

On 03/06/17 at 9:20 am, the administrator was asked for the facility's building systems risk assessments and they were not provided.

The administrator acknowledged the missing building systems risk assessments.

Based on staff interview it was determined the facility failed to ensure the building risk assessment for their medical gas systems were conducted and completed as required.

Findings:

On 03/06/17 at 9:20 am, the administrator was asked for their building systems risk - medical gas risk assessment(s) and it was not provided.

The administrator acknowledged the missing building systems medical gas system risk assessment.

Based on observation, record review and staff interview it was determined the facility failed to ensure the facility medical gas systems were inspected and maintained as required.

Findings:

On 03/06/17 at 10:45 am, the medical gas system inspection reports were requested for 2016, and 2015. The annual medical gas inspection reports for 2015, and 2016 were not provided. Record review indicated the last medical gas inspection was completed on 04/04/14 when the facility was first opened.

At 12:47 pm, medical gas system valves connections and outlets were observed to be in each of the patient rooms on floors 28, and 29.

On 03/07/17 the facility provided four Airgas inspection reports. Record review indicated no medical gas system valves, connections or outlets were inspected or tested for patient rooms on floor 28 and 29 of the facility.

Further record review revealed each of the four inspection reports had impairments outlined that needed repair/installation:

1. Nitrogen Manifold, Airgas inspection dated 02/07/17,
with the following impairments:
a) Manifold relief valve discharge connection on top of the manifold cabinet is not turned down and screened
b) The source piping is not labeled for gas served with standard designation colored labels
c) The one (1) inch source valve is not labeled
d) the source valve is not a three-piece ball valve with indicating handle and brazed extensions (it is a threaded ball valve)
e) The 1.5 inch main valve is not labeled

2. Nitrous Oxide manifold, Airgas inspection dated 02/07/17,
with the following impairments:
a) The manifold is outside and not protected from temperatures lower than 20 degrees Fahrenheit
b) The manifold relief valve discharge connection on top of the manifold cabinet is not turned down and screened
c) The source piping is not labeled for gas served with standard designation colored labels
d) The one (1) inch source valve is not labeled
e) The source valve is not a three-piece ball valve with indicating handle and brazed extensions. (it is a threaded ball valve)
f) The 1.5 inch main valve is not labeled

3. Medical Vacuum, Airgas inspection dated 02/07/17,
with the following impairments:
a) Pumps 1 & 2 run almost continuously. Pumps 3 & 4 alternately start "On" when the vacuum drops to 15 inHg and "Off" when the vacuum reaches 19 inHg. With the current setup installing and monitoring a "Lag Vacuum" signal at the master alarm panels.
b) The receiver is "not valved to allow draining or servicing without interrupting the vacuum system".
c) The vacuum pipe labels are not white w/black lettering (standard designation colors in NFPA 99, 2012; Table 5.1.11
d) There's not a 4 inch source valve installed in the vacuum piping that allows isolation of the system from the piping

4. Amico Master Alarm Panel, Airgas inspection dated 02/08/17,
with the following impairments:
a) Medical air compressor system lag compressor - activated locally, but not at the two (2) master alarm panel's
b) Vacuum pump lag vacuum pump running - required signal not present

The administrator acknowledged not having the medical gas system annual inspection reports for 2015/2016 and the outlined impairments detailed on the Airgas inspection reports dated 02/07/17 and 02/08/17.

Based on record review and staff interview it was determined the facility failed to ensure annual inspection and testing of electrical receptacles at patient bed locations in accordance to NFPA 99, 2012 Edition, Chapter 6.3.4.

Findings:

On 03/06/17 the 2015, 2016 annual inspection/testing documentation for electrical receptacles at patient bed locations was requested and not provided. The only documentation provided by the facility was the initial acceptance inspection from Meek's Electrical on 04/03/14.

The administrator acknowledged the missing annual inspection and testing for electrical receptacles at patient bed locations.

Based on staff interview it was determined the facility failed to ensure the building risk assessment for their essential electrical systems were conducted and completed as required.

Findings:

On 03/06/17 at 9:20 am, the administrator was asked to provide their building systems risk - essential electric system risk assessments and it was not provided.

The administrator acknowledged the missing building systems essential electric system risk assessment.

Based on record review and staff interview it was determined the facility failed to ensure annual testing and periodic maintenance of the generator's automatic transfer switch(s) as required.

Findings:

On 03/06/14 annual transfer switch inspection and maintenance reports for 2015 and 2016 were requested and not provided. On review of generator documentation provided by the facility revealed inspection and maintenance of the facility's automatic transfer switch was not completed.

The administrator acknowledged the missing automatic transfer switch documentation.

Based on observation and staff interview it was determined the facility failed to ensure current inspections on laboratory equipment in current service.

Findings:

On 03/06/17 a laboratory located on the 29th floor room 2913 the following equipment was observed to not have current inspection labels: centrifuge, and specimen refrigerator.

The administrator acknowledged the laboratory equipment is currently in service without current inspections in room 2913.

Based on observation and staff interview it was determined the facility failed to ensure oxygen was stored in locations designed, constructed and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.

Findings:

On 03/06/17 Twelve "E" sized oxygen cylinders were observed stored in room 2913. Room 2913 is a patient room which was repurposed into a laboratory. There was no precautionary signage observed that was readable from five feet indicating the storage of medical gases.

The administrator acknowledged the stored oxygen cylinders in room 2913, in addition to the room having no signage.