Inspection Detail
Inspection: 111866034 - St Mary Desert Hospital
Inspection Information - Office: San Bernardino District Office
Site Address:
St Mary Desert Hospital
18300 Hwy 18
Apple Valley, CA 92307
Mailing Address:
, , 00000
Union Status: NonUnion
SIC:8069
NAICS: 0
Inspection Type: Accident
Scope: Partial
Advanced Notice: N
Ownership: Private
Safety/Health: Health
Close Conference: 03/25/1991
Emphasis: L:Carcreg
Case Closed: 11/20/1991
Type | Activity Nr | Safety | Health |
---|---|---|---|
Accident | 361055593 |
Violations/Penalties | Serious | Willful | Repeat | Other | Unclass | Total |
---|---|---|---|---|---|---|
Initial Violations | 3 | 3 | 14 | 20 | ||
Current Violations | 3 | 3 | 14 | 20 | ||
Initial Penalty | $2,900 | $54,000 | $0 | $1,270 | $0 | $58,170 |
Current Penalty | $2,900 | $54,000 | $0 | $1,270 | $0 | $58,170 |
FTA Penalty | $0 | $0 | $0 | $0 | $0 | $0 |
# | Citation ID | Citaton Type | Standard Cited | Issuance Date | Abatement Due Date | Current Penalty | Initial Penalty | FTA Penalty | Contest | Latest Event | Note |
---|---|---|---|---|---|---|---|---|---|---|---|
1. | 01001 | Other | 3203 A02 | 03/25/1991 | 03/25/1991 | $0 | $0 | $0 | - | ||
2. | 01002 | Other | 5143 A05 | 03/25/1991 | 03/25/1991 | $85 | $85 | $0 | - | ||
3. | 01003 | Other | 5194 E01 | 03/25/1991 | 04/24/1991 | $0 | $0 | $0 | - | ||
4. | 01004 | Other | 5194 G08 | 03/25/1991 | 04/24/1991 | $0 | $0 | $0 | - | ||
5. | 01005 | Other | 5220 L03 A02 | 03/25/1991 | 03/25/1991 | $0 | $0 | $0 | - | ||
6. | 01006 | Other | 5220 L03 A03 | 03/25/1991 | 04/18/1991 | $85 | $85 | $0 | - | ||
7. | 01007 | Other | 5220 I04 | 03/25/1991 | 03/25/1991 | $0 | $0 | $0 | - | ||
8. | 01008 | Other | 5220 I05 A01 | 03/25/1991 | 03/25/1991 | $55 | $55 | $0 | - | ||
9. | 01009 | Other | 5220 I05 A02 | 03/25/1991 | 03/25/1991 | $55 | $55 | $0 | - | ||
10. | 01010 | Other | 5220 K02A | 03/25/1991 | 03/25/1991 | $0 | $0 | $0 | I - Informal Settlement | ||
11. | 01011 | Other | 5220 M02 A | 03/25/1991 | 04/24/1991 | $450 | $450 | $0 | - | ||
12. | 01012 | Other | 5220 M02 B | 03/25/1991 | 04/24/1991 | $450 | $450 | $0 | - | ||
13. | 01013 | Other | 14301 A | 03/25/1991 | 03/25/1991 | $45 | $45 | $0 | - | ||
14. | 01014 | Other | 14301 B | 03/25/1991 | 03/25/1991 | $45 | $45 | $0 | - | ||
15. | 02001 | Serious | 5162 A | 03/25/1991 | 03/25/1991 | $450 | $450 | $0 | - | ||
16. | 03001 | Serious | 5220 F01 A | 03/25/1991 | 03/25/1991 | $2,000 | $2,000 | $0 | - | ||
17. | 04001 | Serious | 5220 F02 B | 03/25/1991 | 03/25/1991 | $450 | $450 | $0 | - | ||
18. | 05001 | Willful | 5220 G02 B | 03/25/1991 | 03/25/1991 | $18,000 | $18,000 | $0 | - | ||
19. | 06001 | Willful | 5220 G03 | 03/25/1991 | 03/25/1991 | $18,000 | $18,000 | $0 | - | ||
20. | 07001 | Willful | 5220 H02 | 03/25/1991 | 03/25/1991 | $18,000 | $18,000 | $0 | - |
Investigation Summary
At approximately 3:30 p.m. on June 14, 1990, Employees #3 and #4 were operating an Ansco Cryotherm ethylene oxide (EtO) medical instrument sterilizer in the surgical central supply area adjacent to, but separate from, the surgical suites at a full service hospital. Employees #1 through #5 suffered skin and respiratory exposure to ethylene oxide. Employee #2 responded to the audible alarm and donned an unapproved respirator to shut down the system. All of the employees were treated by a physician on site; none were hospitalized. The ethylene oxide sterilizer mechanical room and the mechanical ventilation system did not meet ANSI design and operational standards because of an inefficient and ineffective gas exhaust and extraction system. The inefficacy of the system was compounded by the temporary malfunction of the general HVAC in the surgical suites, which was down for repair, and the lack of a dedicated make-up air ventilation system. By depending on the general HVAC to make up for the poor system in the sterilizer room, an excessive concentration of off-gassed EtO collected and was dispersed into the ambient atmosphere.
Keywords: RESPIRATORY, VENTILATION, ETHYLENE OXIDE, WORK RULES, INHALATION, GAS, SKIN, CHEMICAL VAPOR, OVEREXPOSURE, MECH MALFUNCTION
# | Inspection | Age | Sex | Degree of Injury | Nature of Injury | Occupation |
---|---|---|---|---|---|---|
1 | 111866034 | Non Hospitalized injury | Poisoning(Systemic) | Health aides, except nursing | ||
2 | 111866034 | Non Hospitalized injury | Poisoning(Systemic) | Machinery maintenance occupations | ||
3 | 111866034 | Non Hospitalized injury | Poisoning(Systemic) | Health aides, except nursing | ||
4 | 111866034 | Non Hospitalized injury | Poisoning(Systemic) | Health aides, except nursing | ||
5 | 111866034 | Non Hospitalized injury | Poisoning(Systemic) | Health aides, except nursing |