Ventilation, Temperature and Humidity
Findings
EC.02.01.01, EP5
There was no warning sign on a roof vent that serves the patient isolation rooms below. Biohazard signs should be used to advise maintenance staff of the potential hazards of working in the vicinity of the expelled hazardous gases and vapors.
EC.02.02.01, EP5
Liquid nitrogen was used in the Dermatology clinic as a treatment modality and decanted by the nurse into a styrofoam cup from a Dewar. The nurse indicated that latex gloves were worn during this process and no other protective items although the MSDS information for handling liquid nitrogen requires that a protective gown, eye shield and thermo gloves are to be worn whenever handling the product.
EC.02.02.01, EP10
The May 2013 trace gas report indicated that both OR 7 and the C-section room had levels of Nitrous
Oxide greater than the allowable 25ppm. There was no documentation that the deficiencies had been corrected and the rooms retested.
EC.02.05.01, EP6
It was discovered the decontamination room in the OR had positive pressure relative to the OR central core corridor.
The surveyor observed in tour of Endo Decontamination and Scope Processing Room that the area was positive relative to the surrounding exterior corridor. The space should be negative relative to the surrounding area to prevent spread of airborne contaminants.
OR 5, 7, 9 and C-Section room do not meet the required 15 air exchanges per hour as documented on the
June 2013 testing documentation. One room was as low as 7.5 air exchanges.
The Central Sterile clean processing room was negative to the adjacent space as documented in the April
13 testing documentation.
The OR sterile storage room had negative air flow in relation to the adjacent corridor.
The hospital’s procedures did not address shutting off the malfunctioning system and notifying staff in affected areas for internal disruptions.
Surgical operating space; it was identified that the surgical case carts were being stored within a space labeled on the facilities Life safety plans as sterile supple room number 2342. After reviewing the facilities balancing report that was supplied by Northstar Environmental, LTD dated 4-18-12, page 92 noted that the design supply air of 180 CFM and final CFM air of 180 indicated that the space does not have the required positive air flow.
McKenna Consulting
PO Box 3187
Charleston, WV 25332
Phone: 304-988-1047
Fax: 304-988-1281 www.mckennaconsulting.com
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Ventilation, Temperature and Humidity
Findings
EC.02.05.01, EP6 continued
During the life safety building tour and validated in a discussion with the engineering manager, the surveyor noted that in the Pavilion Tower in the basement the air directional flow was measured with a tissue for the Central Processing area. The air flow for the decontamination room was negative to the outside corridors. The air flow between the sterile area and the sterile storage area was negative to the outside corridors. The air flow should have been positive between the sterile area and the sterile storage area and the outside corridors.
Airborne Infection Isolation Room; on the day of survey the pressure monitor outside the room was indicating that the room was at (Negative .0040). The Guidelines for Design and
Construction of Health Care Facilities, (2010 edition) 7.2.1 (f) requires a minimum of (Negative
.01).
Airborne Infection Isolation Room; on the day of survey the pressure monitor outside the room was indicating that the room was at (Negative .0075). The Guidelines for Design and Construction of
Health Care Facilities, (2010 edition) 7.2.1 (f) requires a minimum of (Negative .01).
Airborne Infection Isolation Room; on the day of survey the pressure monitor outside the room was indicating that the room was at (Negative .0076). The Guidelines for Design and Construction of
Health Care Facilities, (2010 edition) 7.2.1 (f) requires a minimum of (Negative .01).
There was no documentation to support that the hospital was monitoring and recording relative humidity values within the sterile supply room on the second floor. The ASHRAE Standard 62,
Ventilation for Acceptable Indoor Air Quality, recommends a maximum RH of 70 percent for sterile storage areas. The maintenance staff has since installed a temperature/humidity meter and added the requirement for daily monitoring/recording by the OR staff.
Operating suite had a negative air flow in relation to the corridor and to the sterile supply room.
Clean areas should have a positive air flow in relation to less clean areas. The facilities maintenance staff worked on rebalancing the air flow to the entire operating room suite.
At the beginning of the first day of the survey the sterile dispensing room on the basement level had a negative air flow in relation to the corridor. Clean areas should have a positive air flow in relation to less clean areas. The facilities maintenance staff worked on rebalancing the air flow to the entire operating room suite.
There was no documentation to support that the hospital was monitoring and recording relative humidity values within the sterile supply room on the basement level. The ASHRAE Standard 62,
Ventilation for Acceptable Indoor Air Quality, recommends a maximum RH of 70 percent for sterile storage areas.
McKenna Consulting
PO Box 3187
Charleston, WV 25332
Phone: 304-988-1047
Fax: 304-988-1281 www.mckennaconsulting.com
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Ventilation, Temperature and Humidity
Findings
EC.02.05.01, EP6 continued
The air pressure relationship for cath lab room #3 was negative to neutral when tested. The requirement is for the airflow to be positive from the room to the corridor. UPDATE: follow-up inspection on day 2 showed the room was now positive after the engineering department made some adjustments.
The air pressure relationship for cath lab room #2 was negative to neutral when tested. The requirement is for the airflow to be positive from the room to the corridor. UPDATE: follow-up inspection on day 2 showed the room was now positive after the engineering department made some adjustments.
EC.02.05.01, EP8
Natural Gas is used in the boiler room and there are no signs identifying the main shutoff valves that would help in the event of a full or partial shutdown.
EC.02.05.09, EP3
The main supply shutoff valves, located at the bulk oxygen tanks and the nitrous oxide manifold, were not labeled to what the valves controlled or that they should not be shutoff except in an emergency.
There were three area shutoff valves, located in the OR; they were blocked by stretchers or beds.
There was a shutoff valve, located in cardiac cath blocked by a stretcher.
It was observed that the Medical Gas zone valves were not clearly identified as required. Staff were asked on 5 west to identify which shut-off valve would control a patient room.
It was observed that the Medical Gas zone valves on 5 east were not clearly identified as required. They were listed by the original building architect identifier, rather then the existing room number. The nurses were not familiar with the architect identifier numbers.
EC.02.06.01, EP13
The surveyor observed that the GI decontamination area's airflow was positive to the hallway. The engineering staff was present at the time of the observation and tested the environment and noted the same.
The decontamination processing room located on the first floor (not within the sterile OR core) had a positive air flow in relation to the corridor. Dirty areas should have a negative air flow in relation to cleaner areas.
McKenna Consulting
PO Box 3187
Charleston, WV 25332
Phone: 304-988-1047
Fax: 304-988-1281 www.mckennaconsulting.com
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Ventilation, Temperature and Humidity
Findings
IC.02.02.01, EP2
At this site and at other sites that perform US with transvaginal probes, the process for checking the
Cidex OPA prior to each use is not being performed. The Infection Control Practitioner states that this process was derived from a discussion at the Infection Control Committee.
A surgical instrument was in a double pack plastic/paper peel pouch with the open end of the inner pouch folded over. Four additional double pack plastic/paper peel pouches with instruments were noted to have the open end of the inner pouch folded over. According to the AAMI standards, the inner peel pouch should never be folded over since this may entrap air and inhibit the sterilization process. The organization examined their supply of all of the instruments stored in double pack plastic/paper peel pouches, and identified additional units that were not prepared properly.
While touring the inner corridor, it was noted that a surgical instrument was in a double pack plastic/paper peel pouch with the open end of the inner pouch folded over. Four additional double pack plastic/paper peel pouches with instruments were noted to have the open end of the inner pouch folded over. According to the AAMI standards, the inner peel pouch should never be folded over since this may entrap air and inhibit the sterilization process. The organization examined their supply of all of the instruments stored in double pack plastic/paper peel pouches, and identified additional units that were not prepared properly. The individuals responsible were retrained immediately. All of the incorrectly prepared pouches were reprocessed. During the survey, the nurses in the Operating Room were trained to identify the units that were not prepared properly, remove them from use, and send the units to be reprocessed.
The soiled scopes were observed carried by a nurse into the decontamination area and placed into the sink. The technician explained the cleaning of the scopes and placement into the high-level disinfection process. Once the scopes had been cleaned, it was explained that the clean scopes were then carried through decontamination area to be hung in the designated cabinets for storage
The hospital had not implemented infection prevention and control activities when performing intermediate and high level disinfection and sterilization of medical equipment and devices.
McKenna Consulting
PO Box 3187
Charleston, WV 25332
Phone: 304-988-1047
Fax: 304-988-1281 www.mckennaconsulting.com
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Ventilation, Temperature and Humidity
Findings
IC.02.02.01, EP4
Unpackaged laryngoscope blades were stored on the endo cart. The laryngoscope blades were touching a laryngoscope handle and another item in a package.
A laryngoscope blade, a bullard laryngoscope and a stylet were stored unpackaged in a difficult airway cart.
During observation of the endoscopy storage cabinets, it was noted that an endoscope was touching a towel stored at the bottom of the cabinet. The endoscopes should be hung freely without touching any area of the cabinet.
In another cabinet, an endoscope was observed touching the side of the cabinet.
A nebulizer used by physicians at the site for treatment of acute asthmatic episodes was noted to be stored in a general utility room with no indication as to whether it was clean and ready for patient use or soiled.
A pulmo-aide nebulizer used by physicians at the site for treatment of acute asthmatic episodes was noted to be stored with orthopedic casting equipment with no indication as to whether it was clean and ready for patient use or soiled. In the treatment room a baby scale was noted to be stored with no indication as to whether it was clean or soiled.
McKenna Consulting
PO Box 3187
Charleston, WV 25332
Phone: 304-988-1047
Fax: 304-988-1281 www.mckennaconsulting.com
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