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Based on observation and interview with staff the facility failed to ensure surgical suite air quality was being monitored and documented. Findings:

On 06/15/16 at 10:41 a.m., the operating rooms airfilter quality logs were not available when requested. Airflow manometer readings were not being recorded or documented. The airflow quality of the life of the final filters serving the surgical suite were not being documented or maintained.

At 10:42 a.m., the director of facility management was interviewed. He was asked for the documentation of airflow quality for the operating rooms. He said that they do not have documentation on when air filters are changed. He was asked how he determines the condition of the air filters that serve the operating rooms. He said they are changed at least every 6 months and visual checks are also done so if any filters look dirty they are changed. He was asked if they check manometer readings in determining when to change filters, and he said no.

AIA Health Care Guidelines & ANI/ASHE Standard 170-208 Ventilation of Health Care Facilities requires the manometers to be used to determine the life of filters. A 1.1 of ANI/ASHE Annex A outlines that filters shall be replaced based on air pressure drop in accordance with the manometer readings.

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

On 6/14/16 at 11:35 a.m., the emergency egress corridor within the surgical suite was observed to be used for storeage. There were multiple surgical beds, 6 wired framed wheeled storage carts storing indiviudal surgery patient sterile sugery supplies, 2 multiple shelve racks stored in the corridor had sterile surgical suturing supplies stored in the corridor egress pathway.

At 11:41 a.m., the director of surgery and director of facility management acknowledged the stored items in the egress pathway within the surgical suite.


NFPA 101, 2000 Edition, Chapter 19:
19.2 MEANS OF EGRESS REQUIREMENTS
19.2.1 General.
Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
Exception: As modified by 19.2.2 through 19.2.11.

Chapter 7:
7.1.10 Means of Egress Reliability.
7.1.10.1*
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on observation, and record review the facility failed to ensure protection of the facilities anesthetizing locations. Findings:

On 06/14/16 at 14:17, on review of the provided facility humidity logs the facility humidity levels for January 2016 were recorded less than the 30% RH as allowed by state law levels in accordance with S&C Letter S&C: 13-25-LSC & ASC - This Waiver Does Not Apply: When more stringent RH control levels are required by State or local laws and regulations.

Facility relative humidity (RH) documentation dated January 2016:
Operating room #2-
1-4-16 25RH
1-7-16 25RH
1-15-16 25RH
1-18-16 25RH
1-19-16 25RH
1-20-16 25RH

Operating room #6-
1-5-16 25RH
1-11-16 25RH
1-12-16 25RH
1-27-16 25RH

Operating room #8-
1-5-16 25RH
1-11-16 25RH
1-12-16 25RH
1-19-16 25RH

The facility temperature and humidity logs reviewed indicated a normal range for humidity RH levels by visual indication of it being a grayed out section on the facility form. The grayed out section for humidity range revealed 20 to 60 for relative humidity.

Based on observation it was determined the facility failed to ensure transfilling hazardous area was protected. Findings:

On 06/15/16 at 14:01, the transfilling oxygen hazardous area closet had an electrical outlet less than 5 feet from the floor. There were 3 tanks of liquid oxygen stored in this closet.

The director of facility maintenance acknowledged the electrical outlet less than 5 feet from the floor of the trans filling oxygen room.


NFPA 99, 1999 Edition:
8-6.2.5 Gases in Cylinders and Liquefied Gases in Containers.
8-6.2.5.1 Transfilling Cylinders.
(a) Mixing of compressed gases in cylinders shall be prohibited.
(b) Transfer of gaseous oxygen from one cylinder to another shall be in accordance with CGA Pamphlet P-2.5, Transfilling of High Pressure Gaseous Oxygen to Be Used for Respiration. Transfer of any gases from one cylinder to another in patient care areas of health care facilities shall be prohibited.
8-6.2.5.2 Transferring Liquid Oxygen.
Transferring of liquid oxygen from one container to another shall be accomplished at a location specifically designated for the transferring that is as follows:
(a) Separated from any portion of a facility wherein patients are housed, examined, or treated by a separation of a fire barrier of 1-hour fire-resistive construction; and
(b) The area is mechanically ventilated, is sprinklered, and has ceramic or concrete flooring; and
(c) The area is posted with signs indicating that transferring is occurring, and that smoking in the immediate area is not permitted.
Transferring shall be accomplished utilizing equipment designed to comply with the performance requirements and producers of CGA Pamphlet P-2.6, Transfilling of Low-Pressure Liquid Oxygen to be Used for Respiration, and adhering to those procedures.
The use and operation of small portable liquid oxygen systems shall comply with the requirements of CGA Pamphlet P-2.7, Guide for the Safe Storage, Handling and Use of Portable Liquid Oxygen Systems in Health Care Facilities.

Based on observation it was determined the facility failed to ensure protecting the facility from use of temporary wiring. Findings:

On 03/23/16 at 12:35 p.m., hosptial grade surge supressors/power strips were observed to be in use within the operating rooms within the surgical suite of the facility. Each of the surge supressors/power strips were mounted on a metal wheeled post.

The director of facility management was asked for the minutes of the board of directors for their approval of the use of the acceptance/use of the CMS categorical waiver for the use of surge supressors/power strips in their operating rooms. The board minutes indicating their approval for the use of CMS categorical wavier for the use of surge supressors/power strips was not provided.
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Based on observation it was determined the facility failed to ensure eletrical wiring was protected. Findings:

On 6/15/2016 at 10:41 a.m., an open electrical junction box in the air handeling unit room was observed to have no cover.
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Based on observation, record review and staff interview it was determined the facility failed to ensure proection of critical care areas were protected. Findings:

On 6/16/2016 at 10:30 a.m., a review of facility documentation revealed there were no line isolation monitors in operating rooms 1 through 7.

At 10:31 a.m., the director of facility management was asked if each of the facility's operating rooms contained line isolation monitors. He said no, that operating rooms 1-7 do not have line isolation. He was then asked what surgeries take place in operating rooms 1 through 7. He said operating rooms 1, 2, 3 they do heart and ortho, 4, 5, 6 they do general surgery, and operating room 7 they do urology cases.