HospitalInspections.org

On 03/02/16 at 15:29, it was observed a magnetic locked open fire rated door leading from the EMS entrance did not have positive latching hardware.
At 15:30, it was observed the double mag locked doors leading into the emergency department did not have positive latching hardware.
At 15:36, the ER patient room #3 was observed to not have positive latching hardware.
On 03/02/16 at 15:40, the soiled utility room next to ER patient room #101 was observed to not have positive latching hardware.
At 16:12, the nurse's locker room was observed to not have positive latching hardware.
On 03/03/2016 at 11:50, the nurse's lockers next to the operating/endo room were observed to not have positive latching hardware.

The maintenance supervisor acknowledged each of the doors without positive latching hardware.

Based on observation, and staff interview it was determined the facility failed to ensure hazardous areas were protected. Findings:
On 03/02/16 at 14:28, the two fire doors to the mechanical equipment electrical room located in the basement were observed to be held open. One of the doors was observed to be held open by wire around the door knob and anchored to an electrical panel. The second door to the electrical room was held open due to damage to the frame assembly.
At 14:28, the two fire doors to the boiler room were observed to be held open.
At 14:29, the maintenance supervisor stated the door frame assembly to the electrical room was damaged when the old generator was taken out of that area. He acknowledged each of the doors held open.

Based on observation it was determined the facility failed to maintain fire wall barriers in the facility. Findings:

On 03/03/16 at 14:20, the east and west hall was observed to have multiple penetrations in the fire wall barriers.

On 03/02/16 the maintenance supervisor acknowledged the penetrations to the fire wall barriers.

Based on observation and staff interview it was determined the facility failed to ensure hazardous areas within the facility were protected. Findings:
On 03/02/16 at 14:28, a artificial Christmas tree, and wooden 6ft ladder were observed to be stored within the electrical room.
At 14:29, an anesthesia machine, wooden 4 shelve cabinet was observed stored in the boiler room.
At 14:30, a firewall in the boiler room was observed to have a 4 foot crack open to the next room.
On 03/02/16 at 14:39, a 4x7 sheet of untreated plywood was observed to be part of the firewall covering in the boiler room.
On 03/03/16 at 16:04, the housekeeping closet across from the inpatient office had no self closing hardware.

At 16:06, the clean utility closet next to patient room #116 had no self-closing hardware.

Based on observation it was determined the facility failed to ensure egress doors had a releasing mechanism that could be opened with not more than one releasing operation. Findings:

On 03/02/16 at 15:41, deadbolt locks were observed to be on patient room's: #103, #105, #107, #108, #109 in the emergency department.

At 15:41, the maintenance supervisor advised patient room #103 was repurposed into a staff break room, and patient room #105 was turned into a sleep room for doctors. He said that patient room #108 was the staff sleep room for radiology.

At 15:41, the surveyor asked the maintenance supervisor if the facility plans for repurposing the facility's originally approved floor plan was submitted to OSDH Plan Review. He said he did not know.

NFPA 101, 2000 Edition
Chapter 7
7.2.1.5.10
A latch or other fastening device on a door leaf shall be provided with a releasing device that has an "obvious method of operation" and that is "readily operated" under all lighting conditions.
7.2.1.5.10.2
The releasing mechanism "shall open the door leaf with not more than one releasing operation."

Based on observation and staff interview it was determined the facility failed to ensure emergency lighting is so arranged that failure of any single lighting fixture will not leave the area in darkness. Findings:

On 03/02/16, after walking throughout the facility it was observed there were no existing secondary lighting arrangements to ensure that the failure of any single lighting fixture would not leave any area of the facility in darkness.

Based on observation it was determined the facility failed to ensure emergency lighting within the egress corridor, exit access and exit discharge. Findings:

On 03/03/16 at 10:00 a.m., each of the egress corridors, exit access, and exit discharge was observed to not have emergency lighting.

At 10:01 a.m., the maintenance supervisor was asked what lights throughout the facility were on emergency generator power. He said he did not know what all lights were on emergency generator power.

Based on record review and staff interview it was determined the facility failed to ensure there was a written plan for the protection of all patients for their evacuation in the event of an emergency. Findings:

On 03/02/16 at 11:08 a.m., the maintenance supervisor was asked for the facility's emergency plan. The surveyor was not provided the facility's emergency plan during the time the surveyor was on survey from 03/02/16 to 03/04/16.

Based on record review and staff interview it was determined the facility failed to ensure fire drills were completed each quarter on each shift. Findings:

On 03/02/16 at 11:15 a.m., the facility was asked for fire drill documentation for the last 24 months. The fire drill records provided indicated only two fire drills. The facility records provided indicated fire drills were completed on 2-11-15 and Jan 2016.

Based on record review and staff interview it was determined the facility failed to ensure the inspection records for their facility fire alarm system required maintenance and testing was kept readily available. Findings:

On 03/02/16 at 11:10 a.m., the maintenance supervisor was asked for the smoke alarm sensitivity testing report. He said he did not have the report.
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Based on observation and record review it was determined the facility failed to inspect, test and maintain fire dampers. Findings:

On 03/02/16 the east hall and west hall was observed to have fire dampers that penetrate through the fire wall. Upon record review of fire inspection report revealed the fire dampers were not inspected.

On 03/02/16 the maintenance supervisor acknowledged the inspection report not containing fire dampers were inspected.

Based on record review and staff interview it was determined the facility failed to ensure smoke detection devices were installed. Findings:

On 03/03/16 at 11:41 a.m., no smoke detection was observed in the critical care operating/endo room in the surgical suite. There was no smoke detection observed in the ante-room leading into the operating/endo room within the surgical suite.

At 11:41 a.m., the maintenance supervisor acknowledged there were no smoke detection devices.

Based on observation it was determined the facility failed to ensure and maintain in operational condition their sprinkler system was maintained in reliable operating condition. Findings:

On 03/02/16 at 14:34 the high temperature sprinkler system heads located in the basement maintenance work area were observed to be installed where the spray pattern is obstructed.

At 14:35, multiple sprinkler heads throughout the facility were observed to have corrosion and lint debris.

At 14:36 the maintenance supervisor acknowledged the obstructed sprinkler heads in the basement, and sprinkler heads with corrosion/lint.

Based on observation and staff interview it was determined the facility failed to ensure the HVAC system was installed and complies with NFPA, and manufacturer's specifications. Findings:

On 03/02/16 at 11:15 a.m., test and balance report(s) for the facility were not provided on request from the surveyor.

On 03/04/16 at 09:30 a.m., the HVAC system servicing the operating/endo room within the surgical suite was observed to not have manometers installed.

At 09:31 a.m., the maintenance supervisor was interviewed. He was asked how it was determined to change the air filters servicing the surgical suite. He said the filters are changed every couple of months.

On 03/04/16 at 15:35, the exhaust vent in the soiled utility room next to patient room #101 was not operating to provide a negative airflow area.

On 03/04/16, the mechanical vent exhausts for in the facility's soiled linen/biohazard storage areas were observed to not be working to provide negative airflow.

On 03/04/16 the maintenance supervisor acknowledged the non-working mechanical vents in soiled linen, and biohazard storage areas.

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Based on observation, staff interview and record review it was determined that the facility failed to ensure that each of their operating rooms were provided with automatic smoke evacuation. Findings:

On 3/04/16 at 10:56 a.m., it was determined on record review of the facility's floor plans and observation in the surgical suite that automatic smoke evacuation was not included or installed in their operating rooms.

At 10:57 a.m., the maintenance supervisor was interviewed. He was asked if the operating rooms were equipped with smoke evacuation and he said he did not know.

NFPA 99, 1999 edition,
Chapter 5-4.1.2
Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.
Chapter 5-4.1.3
Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.
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Based on observation and staff interview it was determined the facility failed to ensure portable heating device(s) element(s) used in non-sleeping staff/employee areas did not exceed 212 degrees Fahrenheit. Findings:
On 03/04/16 at 1:30 p.m., a space heater was observed in the human resource office under a desk.

At 1:31 p.m., the maintenance supervisor was interviewed. He was asked if the manufacturer's documentation was available for the surveyor's review that indicated the heating element did not exceed 212 degrees Fahrenheit. He said the documentation was not available and he did not know.

Based on observation and staff interview it was determined the facility failed to maintain and service the facility's existing incinerator. Findings:

On 03/04/16 at 13:10, the facility's incinerator was observed to be made of steel and to have a brown grainy covering. The top of the flue was tilted and was observed to have several linear cracks near the top of the chimney flue. There was no cap or grate on the top of the chimney flue. The top of the flue extends approximately a few feet over the top of the flat roof of the facility. The maintenance supervisor was asked for incinerator burn logs and he said they did not have burn logs.

At 13:11, the maintenance supervisor was asked if the incinerator is in service. He said that the facility burns all waste in addition to biohazard waste.

Based on observation the facility failed to ensure the means of egress were continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Findings:

On 03/03/16 at 10:00 a.m., two wire frame supply racks were stored within the corridor directly across from the emergency room nurse's station.

At 10:02 a.m., floor tiles, portable x-ray machine and housekeeping cart were observed to be stored in the egress corridor near the maintenance office.

Based on observation it was determined the facility failed to ensure trash collection receptacles greater than 32 gallons be protected as a hazardous area when not attended. Findings:

On 03/03/16 at 11:23 a.m., Four (4) unattended containers with shredded paper/paper products over 32 gallons each were observed stored open to the egress corridor.

At 11:23 a.m., the maintenance supervisor acknowledged the 4 waste containers stored open to the corridor and not in a protected hazardous area room.

Based on observation and record review it was determined the facility failed to ensure anesthetizing locations were protected. Findings:

On 03/02/16 at 11:12 a.m., the facility temperature and humidity policy was reviewed. The facility humidity and temperature policy indicated the low-end range number for humidity was equal to or greater than 20%.

At 11:12 a.m., the maintenance supervisor acknowledged the facility policy indicating relative humidity range in their policy was 20% to 60%.

Based on observation, and staff interview it was determined the facility failed to ensure their Type 1 EES system was properly installed. Findings:

On 03/03/16 at 11:28 a.m., the life safety code branch panel and critical branch panel components were observed to be mixed.

At 11:28 a.m., the maintenance supervisor acknowledged the life safety and critical panel components were mixed.

Based on observation and staff interview it was determined the facility failed to ensure temporary wiring was not used in the facility. Findings:

On 03/02/16 at 15:59, two APC surge protectors were observed to be daisy chained together under the nurse's station desk in the emergency department.

At 16:00, a multiplug was observed to be in use under the emergency rooms nurse's desk.

At 16:24, 2 power taps were observed to be in use in the business office.

At 16:28 the maintenance supervisor acknowledged the use of power taps, dasiy chained surge protectors and multiplug.

On 03/04/16 at 10:55 a.m., a extension cord was observed to be plugged into a power tap in the radiology office.

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Based on observation it was determined the facility failed to ensure electrical receptacles near a water source were GFCI. Findings:

On 03/02/16 at 16:58, 2 electrical plugs were observed to not be GFCI in the dictation room.

On 03/03/16 at 11:54 a.m., the surgical suite supply room with a counter top sink had a coffee pot plugged into a electrical outlet that was not GFCI.

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Based on observation it was determined the facility failed to ensure use of hospital grade electrical receptacles at critical care areas in the facility. Findings:

On 03/03/16 at 12:40 p.m., after touring through the critical care areas in the facility no hospital grade electrical receptacles were observed in each of the patient care areas. Also, on observation no emergency power red plugs could be verified at the critical care areas located in the facility.
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Based on observation it was determined the facility failed to ensure the maintenance and inspection for the surgical suites operating/endo room line isolation system. Findings:

On 03/04/16 at 15:20, the inspection label for the line isolation system for the surgical suite was dated July, 2011. It listed Command/Medical Electronics out of Tulsa, OK as the inspecting company.

At 15:21, the surveyor asked the maintenance supervisor if there was another inspection label or report indicating the line isolation system was current. He said no, and that he will get them out to inspect it.

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Based on observation it was determined the facility failed to maintain closed junction boxes in the plenum space of East and West Hall. Findings:

On 03/03/16 at 14:20, the east and west hall was observed to have 3 open junction boxes.

On 03/02/16 the maintenance supervisor acknowledged the open junction boxes.