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Based on observation, interview with staff , the facility failed to provide corridors that are separated from use areas by walls constructed with at least ? hour fire resistance rating. Findings include:

a)The Gym located on the second floor for the last 8 months will not meet criteria in the exceptions located in 19-3.6.1

19.3.6 Corridors.
19.3.6.1 Corridors shall be separated from all other areas by
partitions complying with 19.3.6.2 through 19.3.6.5. (See also
19.2.5.9.)
Exception No. 1: Smoke compartments protected throughout by an approved,
supervised automatic sprinkler system in accordance with
19.3.5.3 shall be permitted to have spaces that are unlimited in size
open to the corridor, provided that the following criteria are met:
(a) The spaces are not used for patient sleeping rooms, treatment
rooms, or hazardous areas.
(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 19.3.4, or the smoke compartment
in which the space is located is protected throughout by
quick-response sprinklers.
(c) The open space is protected by an electrically supervised automatic
smoke detection system in accordance with 19.3.4, or the entire
space is arranged and located to allow direct supervision by the facility
staff from a nurses ' station or similar space.
(d) The space does not obstruct access to required exits.

Based on observation, interview with staff, the facility failed to protect corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas with substantial doors, such as those constructed of 1? inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. There is no impediment to the closing of the doors and the doors are provided with a means suitable for keeping the door closed. 19.3.6.3 Findings include:

a) Double Doors to Radiology area are provided with a device designed to coordinate door closing, however there is a sign on the door stating use other door. Coordinator is broken and door will not close tightly in its frame if door is opened from the broken side.

b) Aluminum Door to conference room is not provided with latching hardware.

Based on observation, interview with staff, and review of Fire Alarm Reports, the facility failed to provide A fire alarm system that is required for life safety is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. Findings include:

a) Smoke detector located on the north side of smoke door in ER Lobby was less than 3 feet from Air Conditioning diffuser.

Based on observation, interview with staff, and review of humidity logs, the facility failed to provide Heating, ventilating, and air conditioning systems that comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2 Findings include:

a) The Central supply room was not documented as having positive air flow, humidity levels and air exchanges were not in accordance with Hospital Standards Chapter 667 Appendix A

b) The Soiled Utility and Clean Linen storage did not have exhausted air in accordance with Appendix A Hospital Standards Chapter 667.

c) The Janitors Carts (Housekeeping Carts) were stored in the same room as the Clean Linen. Rooms for Dirty and clean require separation and require a negative flow of 10 air exchanges, exhausted directly out doors.

d) The soiled work room adjacent to Central Supply was not documented as negative; window and doors were open preventing air to be exhausted properly.

e) Fresh air intakes for Surgery were installed 2-1/2 feet above ground (minimum is 6 feet) also the fresh air intake was full of grass clipping from lawn mower.

f) Endoscope processing is conducted in one room. Processing of scopes shall be as follows: Cleaning rooms shall allow for flow of instrumentation from the contaminated area to the clean area and, finally, to storage. The clean equipment rooms, including storage, shall protect the equipment from contamination. Contaminated area shall be negative, clean equipment including storage shall be positive air flow room (see Hospital Standards Chapter 667- 49 - 35).

Based on observation, interview, and review of the Humidity logs, the facility failed to provide Anesthetizing locations that are protected in accordance with Standard for Health Care Facilities NFPA 99 1999 edition chapter 5.4.1.1, and NFPA 101 2000 edition chapter 19.3.2.3. Findings include:

a) The humidity logs did not go back in time past May; the logs depicted humidity that exceeded 60% range. The chronically high Humidity levels exceeded maximum range with no corrective action.

b) The valve controlling humidifiers was turned off.

c) The Operating room did not have automatic smoke evacuation system installed in accordance with 5-4.1.2

d) Staff member C was asked by surveyor for the purpose of said equipment on the north wall in OR 2 (said equipment was Line Isolation Monitor Remote Alarm). Staff C did not know purpose of equipment, staff thought it was a Medical Gas Alarm. Provide documentation that all Staff is in-serviced in accordance with text outlined C-12.4.6.1
C-12.4.6 Indoctrination of Personnel
C-12.4.6.1 It is highly desirable that personnel involved in the care of patients, including nurses, aides, ward secretaries and physicians, irrespective of whether they are involved in anesthesia practices, be thoroughly indoctrinated in all aspects of fire safety, including the following
(a) The location of zone valves of nonflammable medical gas systems and the station outlets controlled by each valve
(b) The location of electrical service boxes and the areas served thereby
(c) The location and proper use of fire extinguishers (see C-12.4.4)
(d) The recommended methods and routes for evacuating patients (see Chapter 11, Health Care Emergency Preparedness)
(e) The steps involved in carrying out the fire plan of the hospital
(f) The location of fire alarm boxes, or knowledge of other methods for summoning the fire department

f) Facility failed to document periodic reviews of surgical operations and procedures conducted with special attention given to any change in materials, operations, or personnel. Also Staff member C indicated that the nurse anesthetist was not comfortable using a blended 99% oxygen mix for anesthesia. Staff was in the process of providing 21% medical air (Medical Air Tank) without the approval of the Medical Staff in accordance with NFPA 12-4.1.1.4.

1) Any change in protocol shall be approved by the Governing Body.
2) Facility failed to provide documentation that Medical Staff jointly considered and agreed upon rules and regulations for personal in Anesthetizing Locations 12-4.1.1.4

1 Based on observation and interview with staff, the facility failed to maintain design features initially approved for construction. The building must be maintained in accordance with approved design specifications. Any variations shall require the approval of the authority having jurisdiction prior to the actual change NFPA 101 2000 Life Safety Code 5.1.7.
(5.1.7* Maintenance of Design Features. The design features
required for the building to continue to meet the performance
goals and objectives of this Code shall be maintained for
the life of the building. Such performance goals and objectives
shall include complying with all documented assumptions and
design specifications. Any variations shall require the approval
of the authority having jurisdiction prior to the actual change.)
(See also 4.6.9.2)

a) The Laundry, Clean Linen, and Housekeeping Cart storage area is being used as an all-purpose area. Dirty equipment, Janitor Carts and Clean Linen Supply are in a shared space with crossed traffic to Laundry room (equipment and Linens are stored in the same rooms and the clean linen room is a go between for the laundry). The dirty to clean process for any application requires a flow from dirty to clean, the process does not allow for those parameters to have cross traffic without separation. (The area requires a separation with added HVAC requirements and a Flow.)
This all purpose area's lack of negative air flow resulted in the dust balls and lent allover the fans, equipment and clean linen. Room requires a terminal clean.

b) The Sterile Supply room is not accessible except through the Soiled Work Room adjacent to Central Supply. The door to Sterile Supply Room Door is blocked shut from the Corridor.
The Sterile Supply shall have access with the use of an area to put on proper attire (Head cover, shoe cover, costume/scrubs) before entering from a public way.


2. Based on observation and interview with staff, the facility failed to conduct training concerned with the application and maintenance of electric appliances, including physicians, nurses nurse aids, engineers, technicians, and orderlies, staff shall be cognizant of the risks associated with their use. To achieve this end the hospital shall provide appropriate programs of continuing education for its personnel.

This program shall include periodic review of manufacturers ' safety guidelines and usage requirements for electrosurgical units and similar appliances 7-6.5.1. Personnel involved in the use of energy-delivering devices, including, but not limited to, electrosurgical units
surgical lasers, electrocauterizers, and fiberoptics, shall receive periodic training in fire suppression 7-6.5.2 Findings include:

a) No documentation for risks associated with the one time use Battery Powered Cauterizing Tool located in the Emergency Room (tool creates a spark). The Tool poses a fire risk in-conjunction with combustible Alcohol and 99% oxygen.

b) No Comprehensive program documentation or hazard evaluation of equipment used in the hospital could be provided that included physicians, nurses nurse aids, engineers, technicians, etc. Text above in item (a) can be used as an example of the cognizant risks associated with that piece of equipment.

Based on observation, interview with staff, the facility failed to provide Eye wash suitable for quick drenching or flushing of the eyes and body, 10-6. Periodic safety inspection shall include the testing of all emergency showers, eye baths, and other emergency equipment. Laboratory safety officer shall prepare and supervise the proper completion of a safety checklist that can be preserved for record. 10-8.1.4 Findings include:

No documentation for Eye wash preventive maintenance/ Monthly flushing was available. Safety Program Officer was not sending reports to governing body that depicted compliance with all Maintenance Procedures spelled out in NFPA 99 10-8.1

Based on observation and interview with staff, the facility failed to provide Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2 Findings include:

a) Receptacles in patient rooms are not hospital grade.

b) Receptacles changed out have not had a Impedance Ground Test NFPA 99 1999 edition chapter 3-3.3.2.1

c) Facility could not provide Impedance Test for Patient Care areas through out the hospital 3-3.4.3.1

d) Recovery was not provided with Nurse Call System.

e) No Ground Fault for receptacle located above the hand washing sink in Recovery.

f) Operating Rooms Suites are not provided with two sources of power one normal, one from emergency power. (Facility is only provided with one source, emergency power)

g) There is no battery back up lighting for operating rooms.