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Based on record review and interview, the facility failed to ensure the humidity in 2 of 3 anesthetizing locations were maintained between 20% and 60% and within the relative humidity range established in surgical services policy documentation. NFPA 99 9.3.1.1 requires heating, cooling, ventilating, and process systems serving spaces or providing health care functions covered by this code or listed within ASHRAE 170, Ventilation of Health Care Facilities. ASHRAE 170, requires mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 20 percent or greater. CMS requires Operating Rooms not to exceed 60% humidity per S&C 13-25-LSC. This deficient practice could affect staff and up to 2 patients.

Findings include:

Based on review of relative humidity documentation for January 2020 through August 2020 with the Vice President of Operations and the Facilities Director from 10:15 a.m. to 12:30 p.m. on 09/29/20, documentation of the relative humidity in Operating Room 1 was greater than 60% for 06/08/20 through 06/12/20. Relative humidity in Operating Room 2 was at 16% on 01/17/20 and was greater than 60% for 05/26/20 through 05/29/20. Based on review of "Standards for Patient Care in Anesthesiology Policy" dated February 2020, Policy 3.3.5 states "relative humidity shall be kept at not less than 50%". Based on interview at the time of record review, the Vice President of Operations stated Operating Rooms 1 and 2 can be used for general anesthesia, the Anesthesiology Policy contains reporting to maintenance as the corrective action when relative humidity is not maintained, she was unaware of why 50% was established as a relative humidity minimum for the rooms and agreed relative humidity documentation showed relative humidity had been exceeded for both 50% and 60% and was below 20% on 01/17/20.

This finding was reviewed with the Vice President of Operations at the exit conference.

Based on record review and interview, the facility failed to ensure all fire dampers in the facility were inspected and provided necessary maintenance at least every four years in accordance with NFPA 90A. LSC 9.2.1 requires heating, ventilating and air conditioning (HVAC) ductwork and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. NFPA 90A, 2012 Edition, Section 5.4.8.1 states fire dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. NFPA 80, 2010 Edition, Section 19.4.1 states each damper shall be tested and inspected 1 year after installation. Section 19.4.1.1 states the test and inspection frequency shall then be every 4 years except for hospitals where the frequency is every 6 years. If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in-place if so equipped. The damper shall not be blocked from closure in any way. All inspections and testing shall be documented, indicating the location of the fire damper, date of inspection, name of inspector and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on record review of with the Vice President of Operations and the Facilities Director from 10:15 a.m. to 12:30 p.m. on 09/29/20, fire damper inspection and maintenance documentation within the most recent six year period stated was not available for review. The review of facility blueprint documentation for the original building built in 1949 stated fire dampers were located in the building. In addition, review of an inspection contractor's "Fire/Smoke Damper Maintenance Record" dated 04/28/10 indicated the fusible link for 7 fire dampers was inspected and replaced on 04/28/10. Based on interview at the time of record review, the Facilities Director stated the location of the 7 fire dampers could not be determined, the facility does not have fire dampers but agreed fire damper inspection and testing documentation within the most recent six year period was not available for review.

This finding was reviewed with the Vice President of Operations at the exit conference.

This deficiency was cited on 08/21/19. The facility failed to implement a systemic plan of correction to prevent recurrence.

Based on record review and interview, the facility failed to ensure documentation of electrical outlet receptacle testing at 25 of 25 patient bed locations within the most recent twelve month period was available for review in accordance with NFPA 99. NFPA 99, Health Care Facilities Code, 2012 Edition, Section 6.3.4.1.1 states hospital-grade receptacle testing shall be performed after initial installation, replacement or servicing of the device. Section 6.3.3.2, Receptacle Testing in Patient Care Rooms requires the physical integrity of each receptacle shall be confirmed by visual inspection. The continuity of the grounding circuit in each electrical receptacle shall be verified. Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed; and retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 grams (4 ounces). Section 6.3.4.2.1.2 states, at a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter. This could affect all patients.

Findings include:

Based on record review of with the Vice President of Operations and the Facilities Director from 10:15 a.m. to 12:30 p.m. on 09/29/20, documentation of an itemized listing of hospital-grade receptacle testing at patient bed locations and in locations where deep sedation or general anesthesia is used within the most recent twelve month period was not available for review. Based on interview at the time of record review, the Facilities Director stated the facility tested hospital grade receptacles but documentation of an itemized listing of hospital-grade receptacle testing at patient bed locations within the most recent twelve month period was not available for review. In addition, the Facilities Director stated the four red receptacles in a wall mounted outlet box with a red cover plate near the head of the bed in patient Room 202 were replaced with hospital grade receptacles on or after 08/21/19, the facility tested them but agreed testing documentation on or after 08/21/19 was also not available for review.

This finding was reviewed with the Vice President of Operations at the exit conference.

This deficiency was cited on 08/21/19. The facility failed to implement a systemic plan of correction to prevent recurrence.