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Based on observation the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On August 22, 2012 the surveyor, accompanied by the Risk Management Coordinator, and staff, observed that the following corridor doors would not tightly close when tested.

1. Dietitian rated door, hole approximately 1/8 th inch
2. Med/Surgery housekeeping rated door, tested three of three times will not positively latch
3. Med/Surgery Deputy Director office, one hour rated door, closing device disconnected
4. ICU, staff door, closing device removed


During the exit conference on August 22, 2012, the above findings were again acknowledged by the CEO, Director of Quality/Medical staff Credentialing, Risk Management Coordinator, Plant Service Supervisor, Director of Plant Services, and the Chief Nursing Officer

In time of a fire failing to protect patients from heat and smoke could cause harm to the patients.

Based on observation the facility failed to fill penetrations in the smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of at least ? hour." (1 Hour New) Chapter 8, Section 8.3.6. "Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:"
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
(a) It shall be made on either side of the smoke barrier.
(b) It shall be made by an approved device that is designed for the specific purpose.

Findings include:

On August 22, 2012 the surveyor, accompanied by the Risk Management Coordinator, and staff, observed, unsealed penetrations in the smoke barrier/s, located at:

1. Smoke Barrier at ED Nurses station, conduits are not smoke tight

During the exit conference on August 22, 2012, the above findings were again acknowledged by the CEO, Director of Quality/Medical staff Credentialing, Risk Management Coordinator, Plant Service Supervisor, Director of Plant Services, and the Chief Nursing Officer.


Failing to fill holes in smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility, which will cause harm to patients.

Based on observation the facility failed to maintain the self closing/automatic-closing doors in the smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 19, Sections, 19.3.7.6 "Doors in smoke barriers shall comply with 8.3.4.1*" Doors in smoke barriers shall close the opening leaving only minimum clearance necessary for proper operation and shall be without undercuts, lovers, or grills."

Findings include:

On August 22, 2012 the surveyor, accompanied by the Risk Management Coordinator, and staff, observed, the smoke barrier doors, located at:

1. Med Surgery and OB. The doors will not close tight.
2. In patient Radiology. The doors will not close tight


During the exit conference on August 22, 2012, the above findings were again acknowledged by the CEO, Director of Quality/Medical staff Credentialing, Risk Management Coordinator, Plant Service Supervisor, Director of Plant Services, and the Chief Nursing Officer.

Failure to properly adjust or repair the smoke doors could cause harm to residents.
Non closing smoke doors could allow smoke to enter smoke zones not directly effected by the fire, which could cause harm to the patients.

Based on observation the facility did not maintain the integrity, smoke resistance, of doors in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.2.1 requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls and doors must be able to resist the passage of smoke. NFPA 80 "Fire Doors and Fire Windows" Chapter 2, Section 2-3.1.7 "The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. +/- 1/16 in for steel doors and shall not exceed 1/8 in. for wood doors.

Findings include:

On August 22, 2012 the surveyor, accompanied by the Risk Management Coordinator, and staff, observed, the following doors:

1. Bio Medical shop, rated door no self closing device
2. Kitchen door to the tray line, no self closing device
3. Dry food storage, rated door with a closing device would not positively latch when tested three of three times
4. Room 12, change of occupancy to storage, rated door no self closing device
5. ICU storage, rated door, self closing device removed
6. OR frozen section door with a closing device would not positively latch when tested three of three times

During the exit conference on August 22, 2012, the above findings were again acknowledged by the CEO, Director of Quality/Medical staff Credentialing, Risk Management Coordinator, Plant Service Supervisor, Director of Plant Services, and the Chief Nursing Officer.

Failing to prevent heat and smoke from spreading into the exit corridor will cause harm to patients.

Based on observation the facility did not keep exits readily accessible at all times.

NFPA 101 Life Safety Code, 2000, Chapter 19 Section 19.2.1, and Section 19.2.3.3. "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 19.2.3.3 "Aisles, corridors and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft (Existing built to 8 feet must be maintained 8 feet clear) in clear and unobstructed width". Chapter 7 Section 7.5.1.1" Exits shall be so located and exit access shall be arranged so that exits are readily accessible at all times." Section 7.5.1.2 "Where exits are not immediately accessible from an open floor area, continuous passageways, aisles, or corridors leading directly to every exit and shall be maintained and shall be arranged to provide access for each occupant to not less than two exits by separate ways of travel."

Findings include:

On August 22, 2012 the surveyor, accompanied by the Risk Management Coordinator, and staff, observed storage of equipment within the exit corridor. The storage was blocking the exit access in the following locations:

1 ED, two exit access reduced from eight feet to six feet when measured by, a couch, toy box, garbage can, phlebotomy cart, and three wheel chairs
2. Maternity, Labor side, exit access reduced from eight feet to approximately seven feet when measured by a scale, copy machine, storage cabinet, anesthesia cart, all equipment adjacent to room LDC

During the exit conference on August 22, 2012, the above findings were again acknowledged by the CEO, Director of Quality/Medical staff Credentialing, Risk Management Coordinator, Plant Service Supervisor, Director of Plant Services, and the Chief Nursing Officer.

Failure to keep the exit corridors and exit access clear could hinder the evacuation during an emergency and will cause harm to patients.

Based on Record Review and observation the facility failed to conduct the required fire drills.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.7.1.2 Fire exit drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions."

Findings include:

On August 22, 2012 the surveyor, accompanied by the Risk Management Coordinator, and staff, reviewed the facility's fire drill records. The surveyor noted there were no reports for the First quarter of 2012, first and second shift, Second quarter of 2012 first and second shift.

During the exit conference on August 22, 2012, the above findings were again acknowledged by the CEO, Director of Quality/Medical staff Credentialing, Risk Management Coordinator, Plant Service Supervisor, Director of Plant Services, and the Chief Nursing Officer.


Failure to train and drill the staff on fire procedures could result in harm to the patients.

Based on observation the facility failed to maintain the sprinkler heads and assure that all parts of the sprinkler system were in accordance with the UL Listing.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.5.1 "Buildings containing health care facilities shall be protected throughout by and approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection,
Testing, and Maintenance of Water-Based Fire Protection systems. NFPA 25, Section 2-2.1.1 "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign material , paint, and physical damage and shall be installed in the proper orientation..." NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, Chapter 3, Section 3-2.7.2, "Escutcheon Plates used with a recessed or flushed sprinkler shall be part of a listed sprinkler assembly."

Findings Include:

On August 22, 2012 the surveyor, accompanied by the Risk Management Coordinator, and staff, observations include the following findings:

1. Kitchen, five sprinklers, lint and grease
2. Kitchen refrigerator two of two sprinklers lint
3. Kitchen short order line, three of three sprinklers lint

During the exit conference on August 22, 2012, the above findings were again acknowledged by the CEO, Director of Quality/Medical staff Credentialing, Risk Management Coordinator, Plant Service Supervisor, Director of Plant Services, and the Chief Nursing Officer.


Failing to maintain sprinkler heads and keep the fusible link clean could allow a fire to burn longer before the sprinkler head will activate. Failing to maintain sprinkler heads, missing escutcheon plates, which are part of the UL Listing of the sprinkler assembly, could allow heat and smoke to effect other areas of the building. This could cause harm to the patients.

Based on Observations the facility failed to separate empty and full medical gas cylinders.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.2.4. "Medical gas storage and administration areas shall be protected in Accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99, Chapter 4, Section 4-3.5.2.2 (a) (2) "If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

Findings include:

On August 22, 2012 the surveyor, accompanied by the Risk Management Coordinator, and staff, observed medical gas storage rack in ER. The empty and full cylinders were not marked or segregated from each other. There were ten E-O2 cylinders mixed with two empty E-O2 cylinders.

During the exit conference on August 22, 2012, the above findings were again acknowledged by the CEO, Director of Quality/Medical staff Credentialing, Risk Management Coordinator, Plant Service Supervisor, Director of Plant Services, and the Chief Nursing Officer.

In an emergency, patients would be harmed if an empty medical gas cylinder was mistakenly taken from the storage area.

K144 IS A CONDITION OF PARTICIPATION

Based on record review and Staff interview the facility failed to document the required testing of the emergency generator.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.7.6 " Maintenance and Testing (See 4.6.12) Section 4.6.12.2 " Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 99 "HEALTH CARE FACILITIES". Chapter 3, Section 3-5.4.1.1 (a) and Section 3-4.4.1.1 (b) "Generator sets shall be tested twelve (12) times a year... Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Chapter 6, Section 6-4.1 "Level 1 and Level 2 EPSSs, including all appurtenant components shall be inspected weekly and shall be exercised under load at least monthly. NFPA 110, Chapter 6, Section 6-4.2 "Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes...
Chapter 3, Section 3-4.1.1.8. (Level/Type 1) "The generator sets shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power.
or Section 3-5.3.1 (Level/Type 2) "The emergency system shall be installed and connected to the alternate source of power specified in 3-4.1.1.2 and 3-4.1.1.3 so that all functions specified herein for the emergency system will be automatically restored to operation within 10 seconds after interruption of the normal source."

Findings Include:

On August 22, 2012 the surveyor, accompanied by the Risk Management Coordinator, and staff, reviewed the generator test records. No documentation of thirty minute monthly generator run time tests and and transfer times of less than ten seconds were seen for the years of 2011 and 2012. During an interview of the Maintenance Staff, the Staff members stated that they were not aware of the emergency generator testing requirements.

During the exit conference on August 22, 2012, the above findings were again acknowledged by the CEO, Director of Quality/Medical staff Credentialing, Risk Management Coordinator, Plant Service Supervisor, Director of Plant Services, and the Chief Nursing Officer.


Failure to test the emergency generator under load, inspect weekly, and document time from normal power to emergency power could result in harm to patients during emergency system failures.

Based on observation the facility failed to provide protection from electrical shock.
Based on Observation the facility allowed the use of a multiple outlet adapter, power strips and did not use the wall outlet receptacles for appliances.


NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19-5.1 "Utilities shall comply with the provisions of Section 9.1. Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70 "National Electrical Code. NEC, 1999, ARTICLE 110, SECTION 110-12 (a) Unused Openings. "Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment.", Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 1999 Edition. NFPA 99, Chapter 3, Section 3-3.2.1.2, "All Patient Care Areas," Section 3-3.2.1.2 (d) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.


Findings include:

On August 22, 2012 the surveyor, accompanied by the Risk Management Coordinator, and staff,
observed that the electrical panels located in the following areas had unused unprotected openings. And the following areas have refrigerators or microwaves plugged into power strips:

1. Boiler room above water softener, J-box cover missing exposed energized electrical wiring
2. Boiler room, panel TF-panel -XR, exposed energized electrical wires and board
3. To the right of the Fire sprinkler riser, two J-boxes covers open , exposed energized electrical
4. Security office, microwave plugged into power strip
5. On Call Dr's room, refrigerator plugged into extension cord and daisy chained into power strip
6. ED Nurse Manager office, refrigerator plugged into power strip
7. ED electrical room, L2A electrical panel missing two of thirty six blanks, exposed energized electrical wiring

During the exit conference on August 22, 2012, the above findings were again acknowledged by the CEO, Director of Quality/Medical staff Credentialing, Risk Management Coordinator, Plant Service Supervisor, Director of Plant Services, and the Chief Nursing Officer.


The use of multiple outlet adapters could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.
Failing to protect energized electrical equipment or wiring can cause a shock or fire. A fire could cause harm to the patient.