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Based on observation, interview with staff, the facility failed to provide doors in corridors that were provided with latching hardware in accordance with NFPA 101 2000 edition chapter 19.3.6.3. Doors are required to be installed with a means suitable for keeping the door closed tightly in its frame. Findings include:

1) The nurse server doors to each patent room is not provided with Latching Hardware.

Based on observation, interview with staff, the facility failed to provide Soiled linen or trash collection receptacles that exceed 32 gal (121 L) in capacity and the average density of container capacity in a room or space does not exceed .5 gal/sq ft (20.4 L/sq m) and the capacity of 32 gal (121 L) does not exceeded within any 64 sq ft (5.9-sq m) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) shall be located in a room protected as a hazardous area when not attended Findings include:

1) Five soiled linen receptacles were stage and stored together at the west end of ICU Suite.

Based on observation and interview with staff, the facility failed to provide and maintain Piped in medical gas systems that comply with NFPA 99, Chapter 4. Findings include:

1)The medical gas area alarm for ICU has tape over the audio buzzer. Staff indicated that the tape was to silence the alarm because it was broken.

2)Visual lights were burnt out on the Medical Gas Area Alarm located in Surgery Sterile Corridor

3) Medical Gas Zone Valve for Nitrous Oxide was valved off at 1 PM on Wednesday 12, 2014 at or around 1 PM. Operating Room Staff indicated that there was a leak in the system.

4) The zone valve for Radiology/ Nuclear Scan, formally Pre-Op for surgery, located in the restrictive corridor of the Operating Room Suite failed to have a intervening wall between the Oxygen valve and the outlet in accordance with NFPA 99 1999 edition chapter 4-3.1.2.3 (d). Zone valves Station outlets shall not be supplied directly from a riser unless a manual shutoff valve is located in the same story and is installed between the riser and the outlet with a wall intervening between the valve and the outlet.

5)Bottled Oxygen Backup located at the Bulk Oxygen Site was not provided with a cover to protect from Inclement weather .

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

1) The Relative humidity was not maintained equal to or greater than 35% in the cold months. Logs provided (Operating Room Temperature & Humidity) indicate that the humidity fell below 35%, with no corrective action taken in accordance with humidity logs provided and was substantiated by statements from Operating Room and Maintenance Staff. In the hot months of the year, humidity was logged above 60%, with no corrective action taken in accordance with humidity logs provided and this was also substantiated by statements from Operating Room and Maintenance Staff.

2) The Operating Rooms (Anesthesia Locations) were not provided with Supply and exhaust systems for windowless anesthetizing location, arranged to automatically vent smoke and products of combustion out in accordance with NFPA 99 5-4 .1.2. Submit Plans to Plan Review in accordance with Hospital Standards Chapter 667-47

3) Operating Room 3 is used for Bronchoscope Procedures. The Director of Engineering indicated that the room was not designed with negative air flow. Room 3 has a positive air flow (air movement out). Bronchoscope Procedure rooms at a minimum requires an air flow into the room, with 2 outside air exchanges an hour, 12 room air exchanges an hour , rooms may have air re-circulated in accordance with appendix note 7. Submit Plans to Plan Review in accordance with Hospital Standards Chapter 667-47

4) Based on interview with Operating Room Staff, the facility has not adopted Rules and Regulations or Posted Rules and Regulations that are in accordance with NFPA 99 1999 edition Chapter 12- 4.1.1.4 for the control of personal in Anesthetizing Locations. Operating Room Staff had not been throughly in-serviced for Specific Area Requirements for Anesthetizing Locations in accordance with 12-4.1.1 through 12-4.1.2.10. Operating Room Staff member #RR was asked to explain function of Line Isolation Monitor, staff was unable to explain the function of the equipment. Line Isolation Monitor circuits were not labeled. Physicians, and Support Staff has not had periodic review of manufactures ' safety guidelines and usage requirements for electrosurgcal units and similar appliances. Physicians, nurses nurse aids,engineers, technicians, and orderlies shall be cognizant of the risks associated with their use and to achieve this end, the hospital shall provide appropriate programs of continuing education for its personnel in accordance with NFPA 99 1999 edition chapter 7-6.5. Facility did not provide such program for all its personal or could provide documentation.

Based on observation, review of Building Plans and interview with staff, the internal governing structure, responsible for elements of hospital operation, building design, purchasing specifications, inspection procedures, and maintenance schedules, failed to delegate to staff for hiring of consultants, architects, engineers, to submit remodeling, modification, renovation plans or to change room use to Authority Having Jurisdiction in accordance with Hospital Standards Chapter 667-47. The design of the building was altered in the following areas that impacted the Performance Design in accordance with NFPA 101 2000 Life Safety Code 5.8.14. Findings include:

1)The Soiled Utility Room located in sterile corridor was not being used to store waste. The waste was transferred out into the Emergency Room Suite creating traffic in and out of a non-restrictive to restrictive corridor, over burdening the design of the suite .

2)The Emergency Room Suite Egress Corridor was cluttered with equipment. The clean storage room located on the south side of the Emergency Department corridor was being used as a Doctors sleep room, destabilizing the amount of storage space intended for equipment.

3)Pre-Op Holding area is now occupied with Radiology Equipment (Nuclear Scan Machine). Currently there is no space for pre-op patients, the egress corridor or in front of Nurses Station can not be used for Pre-Op holding. Egress corridors shall be free and clean of obstacles / patient beds at all times, NFPA 101 chapter 7.1.10.1, also the corridor was designed as unrestricted space for Contaminated Equipment ,Sterile Equipment, and Pathology Specimens to be transferred through and from other ancillaries's spaces of the Surgery Suite.


Based on observation and interview with Director of Engineering/Safety Officer, the internal governing structure, responsible for elements of hospital operation, failed to have a Health Care Emergency Preparedness Plan that has the framework to assess, mitigate, prepare for, respond to, and recover from, disasters NFPA 99 1999 edition chapter 11.5.3.2. Findings include:

1) The Boiler does not have two sources of fuel piped. The Diesel Equipment is located on the boiler, however piping was not completed. The Boiler severs components that are essential to maintaining the Operating Room Environment (humidity, sterilizers, etc.)

Based on observation, interview with staff, the facility failed to maintain and test Fume hoods in accordance with NFPA 99. 1999 edition chapter 5.4.3, 5.6.2 Findings include:

1) Micro-Biology room, located in the Laboratory, is provided with a Fume Hood . The hood has not been tested since September of 2012. Sticker located on the Fume hood indicated that the annual test was required on September of 2013. Test shall include balancing the room to provide a negative pressure in relation ship to adjacent spaces and the vent that extended through roof shall be provided with warning signs in accordance with 5-6.2.

Based on observation and interview with staff, the facility failed to provide Electrical wiring and equipment that is Maintained, Tested, and Inserviced in accordance with NFPA 70, National Electrical Code. 9.1.2, and NFPA 99. Findings include:

1)The Operating Room Electrical Supply was not served from two sources of power in accordance with NFPA 99 1999 edition chapter 3-3.2.1.2. (a) 1. Critical Care areas (Operating Rooms), shall be served by a single automatic branch panel (s) served from automatic transfer switch's and from one normal power circuit.

2)Operating Rooms 2 and 3 were not provided with Battery Back Up Lighting in accordance with NFPA 99 1999 edition chapter 3-6.3.1.1. The emergency system shall have an alternate source of power, separate from and independent from the normal source of power and will be effective for 1 1/2 hour after loss of normal/emergency power. The battery back up power shall provide lighting for operating rooms in the event of complete loss of power and for the time that the generator is starting and coming on line.

3)The Emergency Generator, located adjacent to the Boiler Room was not provided with a 1 1/2 hour battery back up light.