Surveyors focus on environment of care at one facility

Nurse Leader Insider, April 2, 2007

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When the time came for the University of Pittsburgh Medical Center's unannounced five-day Joint Commission survey, staff at the 1,500-bed facility were ready. The staff were interviewed by surveyors, who combed through all areas of the facility.

The life safety specialist who toured the building checked every smoke and fire door to ensure that they closed and latched properly. The specialist often paused to talk with people on the floors.

"I didn't know the life safety [specialist] was doing this, but interestingly, he spent a lot of time interviewing staff," says Bill Smith, director of environmental health and safety.

The specialist struck up a conversation with someone on every unit, and they talked about routine areas such as fire response procedures.

Citations hit common problematic standards
The hospital received two Environment of Care (EC) requirements for improvements (RFI).

Under EC. 1. 10 (managing safety risks), the surveyors found that some of the hospital's eyewash units were sink-mounted, allowing the use of all hot water during an eyewash.

"We've done an analysis of them all, and everything we can find says that scalding and damage to human tissue doesn't happen until about 118°-120° F, and we've measured all of the [eyewash units]," Smith says. None of the units' temperatures go above 117° F.

He could have argued after the fact and backed up his contention with research showing that the eyewash units were safe, but he says it was not worth the battle because it would not have voided the RFI. As it was, surveyors also tacked a couple of improperly stored oxygen tanks onto the citation, and these violations were unarguable.

It seems surveyors are lumping items under EC. 1. 10 as a catch-all standard, which Smith likens to OSHA's general duty clause. The general duty clause allows inspectors to cite a problem in workplace safety if isn't named under a specific OSHA regulation.

Staff felt comfortable with questions
In general, Smith felt the survey went well. He recommends that other hospitals not set up elaborate presentations for surveyors, as he got the sense they weren't really looking for it.

Source: Briefings on Hospital Safety, HCPro, Inc., April 2007


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