Volume 2024 | No. 2
SURVEYOR
ACUTE CARE HOSPITAL NOTES FOR THE FACILITIES DIRECTOR
CHAPTER 11: PHYSICAL ENVIRONMENT 11.01.10 Eyewash stations and emergency showers Overview of the requirement:
The physical environment is the hospital’s largest and most critical piece of medical equipment, playing a vital role in patient care. Comparing results from 2021 standards to 2024 shows a mixed bag. In 2021, two physical environment standards ( 11.00.01 and 11.07.03 ) were cited on 47% of acute care hospital surveys. In 2024, 11.00.01 dropped to a remarkable 8%, well below the threshold for inclusion in this year’s report, but 11.07.03 rose to a frequency of 61%. For life safety standards, five were reported in the 2021 Surveyor Quality Review , appearing on between 44 and 58% of surveys conducted. Those five are repeated this year, but in every case, the frequency of citation declined, establishing a new range from 37 to 45%. This is encouraging data, but there is still work to be done. Physical environment and life safety standards always produce a significant number of deficiencies. Combining regular environmental rounding in collaboration with department leaders on the clinical and
Approved eyewash stations must be provided in every area where a person may be exposed to hazardous corrosive materials. Compliance is assessed through observation and document review. Citations mentioned a wide range of hospital locations where bleach or other corrosive chemicals are stored and used that lack eyewash stations. Many noted missing inspection logs for weekly or annual inspections.
Comment on deficiencies:
administrative side of the hospital’s operations will be helpful in identifying problems early. Communicating how your team looks at each space and construction element can help you find champions among your clinical colleagues. One goal is to extend your team’s effectiveness by having keen-eyed partners in every department who will catch and report environmental issues as soon as they arise.
Frequency of citation:
47%
Examples of surveyor findings:
n There is no eyewash station in the generator room where specific gravity testing is being conducted for the generator battery. This condition requires a plumbed eyewash station within 55 feet or 10 seconds access. n The hospital’s policy requires weekly eyewash station inspections. In the eye center, there was no documentation that the station had been checked in the past seven weeks. n There is no eyewash station in the dialysis unit where bleach is used to clean machines. This requires a plumbed eyewash station. n Eyewash stations in the dialysis unit, kitchen, and equipment decontamination rooms did not have mixing valves and were fed from only cold water. n Hazardous corrosive chemicals were observed in use in the main kitchen and chiller rooms. Neither space has an eyewash station. n Risk assess each department or area to identify whether there are caustic or corrosive chemicals to determine where an eyewash station is required. n Eyewash stations often require a mixing valve to maintain tepid water temperature of 60-100⁰F. n Every eyewash station requires a documented weekly inspection and an annual test and inspection.
Richard L. Parker, MBA, CHFM Associate Director, Life Safety & Physical Environment
FREQUENT DEFICIENCIES IN PHYSICAL ENVIRONMENT AND LIFE SAFETY STANDARDS
Tips for complianc e:
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
Maintain inspection logs and document corrective actions. Audit logs to ensure consistent performance.
11.01.10
11.07.03
13.02.01
13.02.02
13.03.01
13.04.01
13.04.07
13.04.09
13.05.09
Physical Environment
Life Safety
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