HospitalInspections.org

Based upon observation during the hospital facility tour on May 1, 2012, the physical environment was not maintained in a safe condition as evidenced by:

1. Between 4:15 and 4:30 PM the line isolation monitor panels in Operating Rooms 2 and 3 were tested and it was found that the alarms were not audible with the steel door to the panel in the normal closed position. As such, this alarm would normally not be heard by operating room staff during a surgical case with any amount of background noise present. The risk of having excessive electrical leakage current go undetected could have serious consequences to any surgical patient in these rooms. The plant operations supervisor verified that the similar make/model and configuration of line isolation monitor panel was present in Operating Room 1.

2. On the facility tour between 10 AM - 5 PM, the water supply to the automated chemical dispensing units in most of the janitors' closets throughout the hospital were identified as plumbed with a shutoff valve downstream of atmospheric vacuum breaker. This situation can cause the atmospheric vacuum breaker to permanently fail resulting is risk for back siphonage through any hose attached to the mop sink faucet. The resulting failure could adversely affect the health of anyone drinking or using the potentially contaminated water in the hospital.

3. At approximately 4:45 PM, the operating room 2, which is sometimes used for cystoscopy, was identified to have a floor drain which had dried up, thus potentially permitting sewer gases to escape into the operatin g room. There was also a sewer fly hovering around the drain. This situation poses infection control risks for any of the surgical patients in OR 2.

4. At approximately 10:45 AM, this surveyor tours the Materials Management Room 179 and attached housekeeping storage room. There was an accumulation of dust and debris under the shelving units in these rooms. The bottom shelves for many of the storage units had less than 4 inches of clearance which made it difficult for housekeeping to clean under the shelves. This unsanitary condition can also promote pest problems which could facilitate the spread of infection and disease. Note: There were also fixed shelving units with low bottom shelves in the Clean Uitlity Room 237.

5. AT approximately 2:30 PM, it was noted that the Pharmacy IV room had two shelving units with dust on top of the shelves. These units were not provided with sloped tops. It is important that the IV room in particular be kept clean to help protect product being compounded in the IV hood.

Based upon direct observation during the facility tour on May 1, 2012, the hospital did not provide proper ventilation in the Central Sterile Supply Room as evidenced by:

1. At 4:35 PM, the air flow was tested by means of a flutter test and identified to be flowing out of the decontamination room in to the Central Sterile Supply Room. This condition can potentially contaminate sterile supplies & instruments being processed/stored in CSR which would adversely impact staff working in the room as well as any patients that would be coming in contact with these instruments.