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Based on observation and interview the facility failed to ensure egress corridors were continuously maintained free of all obstructions to full use in case of emergency as required in NFPA 101, 2012 Edition, Chapter 18.2.1.

Findings:

On 10/03/17 at 12:04 pm five wheelchairs were observed to be stored within the egress corridor near the emergency room entrance.

On 10/03/17 at 12:08 pm the plant operations manager was asked why the five wheelchairs were stored in the egress corridor and he said the wheelchairs should not be stored in the corridor.

Based on observation and interview the facility failed to ensure doors in exit passageways, and hazardous area enclosures had self-closing hardware as required.

Findings:

On 10/03/17 at 11:09 am a housekeeping closet located on the egress corridor was observed to not have self-closing hardware as required. The housekeeping closet was not negatively ventilated.

On 10/03/17 at 11:09 am the surveyor asked the plant operations manager if the test and balance report indicated the minimum number of air exchanges per hour and he said no.

On 10/03/17 at 11:15 am the housekeeping closet in the kitchen was observed to have the positively latching hardware taped so it would not positively latch when the door was placed in the closed position.

On 10/03/17 at 11:15 am the kitchen manager said the tape will be taken off so it can latch properly.

On 10/03/17 at 11:10 am the plant operations manger was asked if the housekeeping closets throughout the facility were on the initial test and balance inspection. He stated he did not know but would check. The plant operations manager failed to provide the test and balance inspection report. The plant operations manager was asked why the housekeeping closet did not have self-closing hardware and he said he was not aware of the requirement.

Based on observation, record review and interview the facility failed to ensure the beginning range of their relative humidity policy was 30% and failed to ensure proper ventilation pressures/exchanges were maintained in accordance with ASHRAE 170.

Findings:

On 10/03/17 at 11:08 am the surveyor observed the surgical central supply storage near administrative offices which could not be determined to be positively ventilated in accordance with ASHRAE 170. Multiple rooms throughout the facility, housekeeping closets, soiled linen, clean linen, were observed to be placed in repurposed areas from what the areas were originally built for. These areas did not meet ASHRAE 170 for negative or positive pressure in addition to meeting the minimum air exchanges per hour. The surgical suite housekeeping closet was not negatively ventilated as required and the minimum number of air exchanges per hour could not be verified.

On 10/04/17 at 11:22 am the surveyor asked the surgical manager how they confirmed if the surgical suite housekeeping closet was negatively ventilated and she stated she did not know.

On 10/04/17 at 11:22 am the surveyor asked the plant operations manager for the test and balance initial inspection report which includes housekeeping, soiled linen, clean linen, surgical central supply areas for confirmation of being positively or negatively ventilated in addition to having the minimum number of air exchanges per hour. The plant operations manager failed to provide the documentation.

Based on observation and interview the facility failed to ensure smoke detection devices were installed at the highest point of a vertical opening as required.

Findings:

On 10/04/17 at 11:42 am a vertical opening was observed to be at the main entrance and did not have smoke detectors installed at the highest point.

On 10/04/17 at 11:55 am the surveyor asked the plant operations manager why the vertical opening at the entrance to the facility was not smoke detector protected. He stated he did not know why as construction was completed before he worked at the facility.

NFPA 101, 2012 Edition
Chapter 18 New Health Care Occupancies
18.3.4.5.2
Detection in Spaces Open to Corridors, See 19.3.6.1
18.3.6.1 Corridor Separation
Corridors shall be separated from all other
areas by partitions complying with 18.3.6.2 through 18.3.6.5 (see also 18.2.5.4),
unless otherwise permitted by one of the following:
(b) The corridors onto which the spaces open in the
same smoke compartment are protected by an electrically
supervised automatic smoke detection system
in accordance with 18.3.4,

Based on observation and interview the facility failed to ensure ceiling tiles, escutcheons and gaps around piping going through ceiling tiles were sealed and in place to provide a smoke resistant smoke barrier as required.

Findings:

On 10/04/17 at 11:21 am the surveyor observed six ceiling tiles missing, two missing escutcheons, and three gaps around piping which would allow the spread of smoke and fire into the attic space of the facility.

On 10/04/17 at 11:21 am the surveyor asked the plant operations manager to observe each of the areas missing ceiling tiles, two missing escutcheons, and three gaps around piping. The plant operations manager stated they would correct each of the areas.

Based on observation and interview the facility failed to ensure electrical wiring complied with NFPA 70, National Electric Code and in-service biomed equipment had current inspections as required.

Findings:

On 10/03/17 at 2:37 pm the sysmex hemacult XS-1000 in the laboratory had an expired inspection dated 03/2013.

On 10/03/17 at 2:38 pm the centrifuge located across from the expired sysmex hemacult XS-1000 device had an expired inspection sticker dated 7/2016.

On 10/03/17 at 2:38 pm the laboratory manager was asked what the inspection policy was for the medical devices in the facility laboratory. She stated all equipment should be inspected yearly.

On 10/03/17 at 3:02 pm the sterilizer located in the semi-restricted area of the surgical suite was observed to not have a current pressure vessel inspection certificate.

On 10/03/17 at 3:03 pm the surveyor asked the plant operations manager for the current documentation or the certificate of inspection for the pressure vessel in the surgical sterilizer. The plant operations manager failed to provide the documentation to confirm the pressure vessel in the facility sterilizer was currently inspected.

On 10/04/17 at 11:58 am a three receptacle multiplug and an extension cord was observed to be in use at the staff break area near the radiology managers desk.

Based on record review and interview the facility failed to ensure fire drills included the verification of the transmission of a fire alarm signal as required.

Findings:

On 10/04/17 during record review of facility fire drills the fire drill documentation did not contain verification of the transmission of a fire alarm signal.

On 10/04/17 at 11:48 am the plant operations manager was asked to show where the verification of the transmission of a fire alarm signal was completed for each of the facility fire drills. The plant operations manager stated their fire drills did not document they verified the transmission of a fire alarm signal.

Based on record review and interview the facility failed to maintain the medical gas systems as required in NFPA 99, 2012 Edition, Chapter 5.1.4.3.

Findings:

On 10/04/17 during record review the APEX Medical Gas System Inspection Report dated 06/15/17 indicated areas of non-compliance. The APEX report indicated the source valve was not a 3-piece ball valve with indicating handle with brazed extensions.

On 10/04/17 at 11:32 am the plant operations manager was asked for the repair invoices to confirm the APEX medical gas system inspection report findings had been repaired and completed. The plant operations manager failed to provide documentation which confirmed the out of complaince findings from the APEX inspection report dated 06/17/17 had been completed and corrected.

Based on record review and interview the facility failed to ensure completing building systems risk assessments for their medical gas system as required.

Findings:

On 10/04/17 at 11:00 am during record review the plant operations manager was asked for their building systems risk assessment for their medical gas systems. The plant operations manager failed to provide the building systems risk assessment for their medical gas system.

Based on record review and interview the facility failed to ensure electrical receptacles in patient care areas had initial impedance/physical integrity/continuity/correct polarity/retention force testing as required in NFPA 99, 2012 Edition, Chapter 3.3.2.1 through 3.4.3.1.

Findings:

On 10/03/17 during record review the facility's annual patient care area electrical receptacle testing was missing.

On 10/03/17 at 3:33 pm the plant operations manager was asked for the initial patient care area electrical receptacle testing. The plant operations manager failed to provide the initial impedance testing for the facility.

Based on observation, and interview the facility failed to ensure the wet location operating room was protected by either isolated power or ground-fault circuit interrupters (GFCI) as required.

Findings:

On 10/04/17 at 3:27 pm the operating room electrical receptacles were observed to not have GFCI receptacles installed.

On 10/04/17 at 3:27 pm the plant operations manager was asked for documentation that the electrical receptacles located in the one operating room wet location had GFCI receptacles. The plant operations manager failed to provide the documentation to verify the operating room receptacles were GFCI.

Based on record review and interview the facility failed to ensure the facility's building system risk assessments for their essential electric system (EES) as required.

Findings:

On 10/04/17 at 4:17 pm during record review the plant operations manager was asked for the building systems risk assessment for their essential electrical systems. The plant operations manager failed to provide the building systems EES risk assessment.