HospitalInspections.org

K017

A) Based on observation on October 23, 2012, the surveyor found that the nurse's station in the old Emergency Room area is not longer staffed and it is open to an exit access corridor via sliding glass windows. The vacant nurse's station does not comply with the requirements under exception # 1 of 19.3.6.1.

K021

A) Based on random observation, the surveyor finds that fire doors are held open by means that do not comply with 7.2.1.8: Findings include fire doors that are held open with magnetic hold open devices and that do not have smoke detectors installed within five feet of the doors in accordance with 7.2.1.8 and on one or both sides of the doors in accordance with NFPA 72: Locations include:

1) Food Storage Room in the Kitchen Building

2) Fire Door to the Lab

3) Two fire doors between the Kitchen Building and the assisted living building

K029

A) A new designated office space in the "new construction" area has been converted to storage room for Omni Cells. The surveyor finds that the room lacks a one hour fire rated enclosure and a 3/4 hour self closing/positive latching door in accordance with 18.3.2.1.

K038

A) The surveyor finds that one building entrance has a pair of doors that are part of a means of egress and that have locks that would require a key to exit (if locked). The exit path would not always be available without the use of a key or special knowledge in accordance with 7.2.1.5.1

Findings include:

The building entrance near the old Gift Shop has two pairs of doors that are also identified as an exit. The outer pair of doors has a double cylinder dead-bolt that when locked would require a key to exit.

B) Based on random observation the surveyor finds that means of egress is not always provided and maintained as a safe path to a public way.

Findings include:

The facility has two outpatient, mobile units that visit weekly and park on the east side of the building. The temporary communication and power cables for these mobile units run across the ground, up a set of exterior steps and connect to the building on the east wall. The cables cross a required exit path from the Boiler Room and the cords cross a required exit path from the Mobile Units. The facility uses a ramp over rubber transition device to cover the cables; however the device is roughly 8" high and constitutes a tripping hazard.

K 046

A) The surveyor finds that the facility has two new recently constructed operating rooms. From direct observation on 10/24/12, these the surveyed finds that the operating rooms lack emergency lighting with battery back-up in accordance with 3-3.2.1.2 (5. e) on page 24 of NFPA 99 - 1999.

K062

A) The documentation for four sprinkler systems for all of 2012 was reviewed by the surveyor on 10/23/12. While the documentation is extensive, the documentation is incomplete for four of four sprinkler systems and the documentation of testing, maintenance and service does not comply with NPH 12/NFPA 25- 1999:

1) The building has a dry-pipe pre-action sprinkler system in a computer area. This system is identified in sprinkler documentation; however the documentation includes no annual testing (one year/three years testing) in accordance with NFPA 25 and it includes not documentation for internal inspection of the dry pipe valve (annually).

2) The building has multiple sprinkler drains that are identified and at least one test and drain valve. However, a main drain is not identified.

3) The inspector's test valve do not identify which building or sprinkler system is served and the quarterly documentation of sprinkler testing or flow switches and tamper switches does not identify which building or sprinkler system is tested.

a) The testing of tamper switch supervision lacks specific identification by system and location.

b) Quarterly testing includes static and residual pressure documentation; however it is not clear what is being documented: (a main drain test which is only required annually or quarterly flow testing using an inspector's test valve that is designed to simulate the flow of one sprinkler head, which requires no documentation of static and residual pressures).

4) The Kitchen Building is fully sprinkler except for a set of steps at the far end of the Kitchen. The space under the steps is used for storage but lacks sprinkler protection in accordance with NFPA 13.

A) The provider has a laundry room that lacks an in line lint trap in the dryer exhaust duct in accordance with CMS Guidelines.

Findings include:

There is an existing Soiled Utility Room at the far west end of the Hospital. This room has a washer and dryer that is used by the provider. The dryer has a long horizontal extension but does not have any type of in line lint trap. On the afternoon of 10/23/12, the surveyor observed that there is a small build up of lint on everything behind the dryer.

A) From random observation, the surveyor finds that oxygen tanks are not stored in accordance with NFPA 99.

Findings inlcude:

1) There is a storage room opposite Room 203. The oxygen tanks stored in this room are stored too close to combustibles (less than 5'-0").

K077

A) The surveyor finds from random observation on the morning of 10/24/12, that the provider has pipe medical system in newly constructed areas that do not comply with NFPA 99 - 1999:

Findings include:

1) The new Anesthesia Workroom has a medical vacuum outlet. The provider was not able to demonstrate how this is part of a system that is not used for patient care or how it is piped to comply, as a non-patient use, in accordance with NFPA 99.

2) The new sterile processing room has a medical air outlet. The provider was not able to demonstrate how this outlet is part of an air system that is not used for patient care.

A) The surveyor finds that the old surgical unit and the old emergency room area are both mostly vacant and multiple plumbing fixtures have been removed. However, some of the fixtures have not been proper capped off and the plumbing wastes are open to the rooms. This is a plumbing code violation and an infection control problem.

B) The surveyor finds from documentation review and personnel interview that the facility lacks an emergency procedures plan for the loss of a fuel source in accordance with CFR 485.623 (c)(3). The provider has an engineering study dated 8/15/11 that indicates that the boilers are fed from natural gas and that an alternate source of fuel for the boilers is not available. The director of facilities indicates that the facility does not currently have an alternate source of fuel plan for the heating systems (which includes the boilers).

This item is cited under K130 to allow for a PoC and tracking under the Life Safety K-tags and by Life Safety Surveyors.

1) As an alternative to an alternate source of fuel plan for heating, the provider's evacuation plan was reviewed. The evacuation plan includes information regarding who and how but includes no information regarding why (such as severe damage due to a fire or loss or the heating system due to a loss of the fuel source). And the evaluation plan does not identify where patients would be evacuated to.

K147

A) The surveyor finds from random observation that some electrical systems or materials are not installed and maintained in accordance with NFPA 70-1999. Findings include:

1) The use of electrical outlet extension devices for permanent uses. Locations include

a) Medical Records area with a battery back up device on the floor and several plug strips that are piggy backed together.

b) Omni cell Server Room in Medical Records with plug strips hanging from cords and piggy backed together.

c) Old E R area - Dictation Room has an orange extension cord

K017

A) Based on observation on October 23, 2012, the surveyor found that the nurse's station in the old Emergency Room area is not longer staffed and it is open to an exit access corridor via sliding glass windows. The vacant nurse's station does not comply with the requirements under exception # 1 of 19.3.6.1.

K021

A) Based on random observation, the surveyor finds that fire doors are held open by means that do not comply with 7.2.1.8: Findings include fire doors that are held open with magnetic hold open devices and that do not have smoke detectors installed within five feet of the doors in accordance with 7.2.1.8 and on one or both sides of the doors in accordance with NFPA 72: Locations include:

1) Food Storage Room in the Kitchen Building

2) Fire Door to the Lab

3) Two fire doors between the Kitchen Building and the assisted living building

K029

A) A new designated office space in the "new construction" area has been converted to storage room for Omni Cells. The surveyor finds that the room lacks a one hour fire rated enclosure and a 3/4 hour self closing/positive latching door in accordance with 18.3.2.1.

K038

A) The surveyor finds that one building entrance has a pair of doors that are part of a means of egress and that have locks that would require a key to exit (if locked). The exit path would not always be available without the use of a key or special knowledge in accordance with 7.2.1.5.1

Findings include:

The building entrance near the old Gift Shop has two pairs of doors that are also identified as an exit. The outer pair of doors has a double cylinder dead-bolt that when locked would require a key to exit.

B) Based on random observation the surveyor finds that means of egress is not always provided and maintained as a safe path to a public way.

Findings include:

The facility has two outpatient, mobile units that visit weekly and park on the east side of the building. The temporary communication and power cables for these mobile units run across the ground, up a set of exterior steps and connect to the building on the east wall. The cables cross a required exit path from the Boiler Room and the cords cross a required exit path from the Mobile Units. The facility uses a ramp over rubber transition device to cover the cables; however the device is roughly 8" high and constitutes a tripping hazard.

K 046

A) The surveyor finds that the facility has two new recently constructed operating rooms. From direct observation on 10/24/12, these the surveyed finds that the operating rooms lack emergency lighting with battery back-up in accordance with 3-3.2.1.2 (5. e) on page 24 of NFPA 99 - 1999.

K062

A) The documentation for four sprinkler systems for all of 2012 was reviewed by the surveyor on 10/23/12. While the documentation is extensive, the documentation is incomplete for four of four sprinkler systems and the documentation of testing, maintenance and service does not comply with NPH 12/NFPA 25- 1999:

1) The building has a dry-pipe pre-action sprinkler system in a computer area. This system is identified in sprinkler documentation; however the documentation includes no annual testing (one year/three years testing) in accordance with NFPA 25 and it includes not documentation for internal inspection of the dry pipe valve (annually).

2) The building has multiple sprinkler drains that are identified and at least one test and drain valve. However, a main drain is not identified.

3) The inspector's test valve do not identify which building or sprinkler system is served and the quarterly documentation of sprinkler testing or flow switches and tamper switches does not identify which building or sprinkler system is tested.

a) The testing of tamper switch supervision lacks specific identification by system and location.

b) Quarterly testing includes static and residual pressure documentation; however it is not clear what is being documented: (a main drain test which is only required annually or quarterly flow testing using an inspector's test valve that is designed to simulate the flow of one sprinkler head, which requires no documentation of static and residual pressures).

4) The Kitchen Building is fully sprinkler except for a set of steps at the far end of the Kitchen. The space under the steps is used for storage but lacks sprinkler protection in accordance with NFPA 13.

A) The provider has a laundry room that lacks an in line lint trap in the dryer exhaust duct in accordance with CMS Guidelines.

Findings include:

There is an existing Soiled Utility Room at the far west end of the Hospital. This room has a washer and dryer that is used by the provider. The dryer has a long horizontal extension but does not have any type of in line lint trap. On the afternoon of 10/23/12, the surveyor observed that there is a small build up of lint on everything behind the dryer.

A) From random observation, the surveyor finds that oxygen tanks are not stored in accordance with NFPA 99.

Findings inlcude:

1) There is a storage room opposite Room 203. The oxygen tanks stored in this room are stored too close to combustibles (less than 5'-0").

K077

A) The surveyor finds from random observation on the morning of 10/24/12, that the provider has pipe medical system in newly constructed areas that do not comply with NFPA 99 - 1999:

Findings include:

1) The new Anesthesia Workroom has a medical vacuum outlet. The provider was not able to demonstrate how this is part of a system that is not used for patient care or how it is piped to comply, as a non-patient use, in accordance with NFPA 99.

2) The new sterile processing room has a medical air outlet. The provider was not able to demonstrate how this outlet is part of an air system that is not used for patient care.

A) The surveyor finds that the old surgical unit and the old emergency room area are both mostly vacant and multiple plumbing fixtures have been removed. However, some of the fixtures have not been proper capped off and the plumbing wastes are open to the rooms. This is a plumbing code violation and an infection control problem.

B) The surveyor finds from documentation review and personnel interview that the facility lacks an emergency procedures plan for the loss of a fuel source in accordance with CFR 485.623 (c)(3). The provider has an engineering study dated 8/15/11 that indicates that the boilers are fed from natural gas and that an alternate source of fuel for the boilers is not available. The director of facilities indicates that the facility does not currently have an alternate source of fuel plan for the heating systems (which includes the boilers).

This item is cited under K130 to allow for a PoC and tracking under the Life Safety K-tags and by Life Safety Surveyors.

1) As an alternative to an alternate source of fuel plan for heating, the provider's evacuation plan was reviewed. The evacuation plan includes information regarding who and how but includes no information regarding why (such as severe damage due to a fire or loss or the heating system due to a loss of the fuel source). And the evaluation plan does not identify where patients would be evacuated to.

K147

A) The surveyor finds from random observation that some electrical systems or materials are not installed and maintained in accordance with NFPA 70-1999. Findings include:

1) The use of electrical outlet extension devices for permanent uses. Locations include

a) Medical Records area with a battery back up device on the floor and several plug strips that are piggy backed together.

b) Omni cell Server Room in Medical Records with plug strips hanging from cords and piggy backed together.

c) Old E R area - Dictation Room has an orange extension cord