Volume 2025 | No. 2
SURVEYOR
PHYSICAL ENVIRONMENT AND LIFE SAFETY
■ Throughout the hospital, environmental services closets contained eyewash bottles described as immediate first aid for an injured worker to reach an approved eyewash station. If a risk assessment determines that chemicals in use require access to an eyewash station then a compliant eyewash station is required, however no risk assessment was provided. ■ The boiler/chiller room containing corrosive chemicals was not equipped with an eyewash station. ■ Based on documentation review, seven of 22 eyewash stations in the most recent annual report failed some component of the annual inspection.
Examples of ACHC Surveyor findings: ■ "Pull cords" in patient bathrooms were wrapped around grab bars, hindering access and operation by a fallen patient. ■ In the emergency department bathroom near patient triage the emergency pull cord was too long to dangle, resting on the floor when unwound, so it had been wrapped around the coat hook, making it inaccessible except when standing.
Compliance tips for:
Compliance tips for:
The intent of the standard is to maintain patient safety by providing a means for patients to access help using a call system.
Nerd Newbies (understand the requirement)
While an ANSI-compliant eyewash station in every location where corrosive chemicals are stored or used would be best practice, that is not the requirement. Rather, a documented risk assessment is expected to drive the decision for those locations. When an eyewash station is present, it must be plumbed to achieve tepid water temperature with a single-action valve that fully activates flow within one second. Weekly station activation must be logged, along with annual inspection and testing. ■ Inventory all locations where corrosive materials are present. ■ Cross reference these locations with the inventory of eyewash stations/ emergency showers. ■ Audit for a documented risk assessment in locations without eyewash/ emergency shower. ■ Audit weekly activation logs. ■ Audit annual inspection and testing. ■ Educate staff to alert facilities anytime corrosive material storage is added to a new location. ■ Educate staff to alert facilities whenever a station activation fails (no flushing fluid, temperature out of 60-100⁰F range , etc.)
Nerd Newbies (understand the requirement)
■ Conduct random system tests to ensure operability. ■ Resize pull cords to eliminate the need to tie them up.
Nerd Apprentices (audit for excellence)
■ Evaluate backup and downtime communication methods (e.g., radios, overhead paging) through drills simulating nurse call failure. ■ Add nurse call accessibility verification to mock surveys or patient safety tracers to identify barriers before surveyors do.
Nerd Trailblazers (prepare the path for others)
Nerd Apprentices (audit for excellence)
03.07.03 (CAH) 11.06.05* *For surveys that took place between June 1, 2024, and April 6, 2025, this standard was numbered 11.07.03. Ventilation, light, and temperature controls
Nerd Trailblazers (prepare the path for others)
Frequency of the citation: 03.07.03 89%, 11.06.05 55%
Overview of the requirement: The hospital must meet guidelines for temperature, humidity, ventilation, and air pressure relationships. Ventilated spaces are categorized as critical or non-critical based on the function of the space. Comment on deficiencies: Compliance is evaluated through observation, interview, and document review. Surveyors noted: ■ Improper room pressurization. ■ Lack of environmental monitoring. ■ Incomplete humidity policy implementation. ■ Inadequate airflow containment during construction.
03.05.03 (CAH) Patient call system Frequency of the citation: 56%
Overview of the requirement: The system that allows patients to call for assistance is accessible and operational at all times. Comment on deficiencies: Compliance is evaluated through observation. Surveyors noted emergency pull cords that were wrapped around fixtures to avoid creating a tripping hazard. The effort at mitigation made the cord inaccessible in the case of a patient fall.
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