HospitalInspections.org

K 018

Based upon observation and interview, it was determined the facility failed to provide doors to protect corridor openings, in other than hazardous areas, to be substantial, or smoke resistant, as per regulations on one of eight building levels.

Findings include:

Observation on August 15, 2012 at 10:10 am revealed second floor patient room 223 has a wheeled charting station placed in a way that obstructs the corridor door closure.

Interview with Maintenance Employee (ME) on August 15, 2012 at 10:10 am confirmed the door closure is obstructed by equipment, and the subsequent correction of this item during the time of the survey.

K 033

Based upon observation and interview, the facility failed to provide exit egress components to have a fire resistive rating of at least one hour, or to provide a continuous path of egress as per regulations on one of eight building levels.

Findings include:

Observation on August 16, 2012 at 9:30 am revealed basement stair tower door BFD #12 lacks positive latching with the door closure.

Interview with ME on August 16, 2012 at 9:30 am confirmed the stair tower door lacks positive latching in the frame.

K 046

Based upon documentation review and interview, the facility failed to inspect/test emergency lighting for at least 1-1/2 hour duration annually and 30 seconds monthly in accordance with regulations in one of one generator location.

Findings include:

Document review on August 14, 2012 at 9:20 am revealed facility lacks documentation that the emergency battery pack lighting in the emergency generator location is tested 30 seconds per month and 1-1/2 hour annually.

Interview with ME on August 14, 2012 at 9:20 am confirmed the lack of battery testing documentation.

K 051

Based on observation and interview, the facility failed to provide a fire alarm system with approved components, devices or equipment to be installed and maintained in accordance with regulations on one of eight building levels.

Findings include:

Observation on August 15, 2012 at 10:35 am revealed second floor behavioral health unit staff could not readily open the manual fire alarm pull-station cover with a key (across from environmental services closet) due to a broken lock-set.

Interview with ME on August 15, 2012 at 10:35 am confirmed the manual fire alarm pull-station is inaccessible, and the subsequent correction of this item during the time of the survey.

K 064

Based on observation and interview, the facility failed to ensure that the portable fire extinguishers are installed, inspected and maintained in accordance with regulations on one of eight building levels.

Findings include:

1. Observation on August 15, 2012 at 10:17 am revealed second floor speech therapy has a table wedged against the fire extinguisher.

Interview with ME on August 15, 2012 at 10:17 am confirmed the fire extinguisher access is blocked, and the subsequent correction of this item during the time of the survey.

2. Observation on August 15, 2012 at 10:35 am revealed second floor behavioral health unit staff had a difficult time quickly finding the location of the fire extinguisher cabinet key, as well as finding the correct individual key on the key ring for the fire extinguisher cabinet.

Interview with ME on August 15, 2012 at 10:35 am confirmed behavioral health staff shall be inserviced as to the instant access of the fire extinguisher cabinet key.

K 069

Based on observation and interview, it was determined the cooking equipment/facilities failed to comply with regulations on two of two dietary hood suppression systems.

Findings include:

Observation on August 15, 2012 between 9:15 am and 11:20 am revealed the following hood suppression filters have openings and are not tight-fitting. This would allow dust and grease to enter the above duct work:
A. First floor kitchen (9:15 am).
B. First floor cafeteria serving line (11:20 am).

Interview with ME on August 15, 2012 at 11:20 am confirmed the hood suppression filters shall be replaced with tight-fitting filters.

K 076

Based upon observation and interview, it was determined that facility personnel failed to store medical gas in accordance with regulations on two of eight building levels.

Findings include:

1. Observation on August 14, 2012 at 11:45 am revealed third floor P. A. C. U. clean utility room has an E-size oxygen cylinder laying on the floor.

Interview with ME on August 14, 2012 at 11:45 am confirmed the oxygen cylinder is unsecured and the subsequent correction of this item during the time of the survey.

2. Observation on August 15, 2012 at 9:20 am revealed basement respiratory oxygen storage room has 21 E-size oxygen cylinders that are within 20 feet of combustible items (this area lacks sprinkler coverage).

3. Interview with ME on August 15, 2012 at 9:20 am confirmed the oxygen is not separated at least 20 feet away from combustibles, and the subsequent correction of this item during the time of the survey.

K 077

Based on document review, observation and interview, it was determined the facility failed to provide piped in medical gas components that comply with NFPA 99, 1999 edition on four of eight building levels.

Findings include:

1. Document review on August 14, 2012 at 9:15 am revealed last medical gas report (April 10, 2012) noted the following urgent or high priority items:
A. Oxygen source: The source and main valves are required to be labeled with "Gas", "Area Served", and "Do not close except in emergency". The label must be color coded (high).
B. Alarms: Two (2) signals do not appear to work and require correction (high).
C. Alarms: The right bank empty signal for the Nitrous Oxide manifold is required to be wired to the master alarm panels (urgent).
D. Patient Terminals: One (1) wall vacuum inlet has flow below the minimum of 3.0 scfm and requires correction (high).
E. Patient Terminals: Two (2) hosed vacuum inlets have flow below the minimum of 3.0 scfm and require correction (high).

Interview with ME on August 14, 2012 at 9:15 am confirmed the medical gas urgent or high priority items.

2. Observation on August 14, 2012 between 10:40 am and 11:30 am revealed the following medical gas lines above the ceiling tile are not labeled with the correct color in accordance with the colors indicated in the standard color-marking of the Compressed Gas Association, intended for medical use:
A. Fourth floor vacuum lines outside of I. C. U. (10:40 am).
B. Fourth floor vacuum lines inside office across from Nursing Supervisor office (10:42 am).
C. Third floor vacuum lines in corridor near room 308 (11:30 am).

Interview with ME on August 14, 2012 at 11:30 am confirmed the piped-in medical gas labels are not labeled correctly.

3. Observation on August 15, 2012 between 1:00 pm and 1:35 pm revealed the following medical gas lines above the ceiling tile are not labeled with the correct color in accordance with the colors indicated in the standard color-marking of the Compressed Gas Association, intended for medical use:
A. First floor corridor near room 108 (1:00 pm).
B. Ground floor E. R. trauma room (1:30 pm).
C. Ground floor E. R. room #6 (1:35 pm).

Interview with ME on August 15, 2012 at 1:35 pm confirmed the piped-in medical gas labels are not labeled correctly.

K 078

Based upon review of documentation and interview, it was determined that the facility failed to comply with regulations for five of five anesthetizing locations.

Findings include:

Document review on August 16, 2012 at 11:20 am revealed facility did not maintain consistent relative humidity equal to or greater than 35% during the months of January, February, March and April, 2012 in four operating rooms and a C-section room.

Interview with ME on August 16, 2012 at 11:20 am confirmed lack of consistent relative humidity at or above 35% in anesthetizing locations.

K 130

28 Pa. Code ? 103.4(3). FUNCTIONS

The governing body, with technical assistance and advice from the hospital staff, shall do the following: (3) Take all reasonable steps to conform to all applicable Federal, State and local laws and regulations. This REGULATION has not been met.

35 P.S. ? 448.808. Issuance of license.

(a) STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:

(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered;

Based on observation and interview, it was determined the following item(s) did not conform to applicable Federal,State and local laws and regulations on one of eight building levels.

Findings include:

Observation on August 15, 2012 at 11:05 am revealed first floor old cath-lab is under construction. During this renovation, there is ceiling tile removed, unsealed floor penetrations, and the fire suppression system indicates a low charge. Director of Facility Management indicated plans for renovating this area are awaiting state-plan approval from the Department of Health. Facility shall verify there are fire safety measures in place during construction of this project.

Interview with ME on August 15, 2012 at 11:05 am confirmed fire safety measures shall be in place during construction.

K 147

Based upon observation and interview, it was determined the electrical wiring and/or equipment failed to comply with Life Safety Code requirements or electrical safety policies on one of eight building levels.

Findings include:

1. Observation on August 14, 2012 between 10:45 am and 1:00 pm revealed facility has items blocking electrical panel access at the following locations:
A. Fourth floor I. C. U. electrical alcove, television stand, monitor, and rocking chair (10:45 am).
B. Third floor O. R. Men's locker room, cabinet (1:00 pm).

Interview with ME on August 14, 2012 at 1:00 pm confirmed the electrical panels are blocked, and the subsequent correction of item B only during the time of the survey.

2. Observation on August 16, 2012 at 9:45 am revealed basement shipping/receiving office has an extension cord.

Interview with ME on August 16, 2012 at 9:45 am confirmed the use of an extension cord and the subsequent correction of this item during the time of the survey.