HospitalInspections.org

Based on observation and interview with staff, the facility failed to provide a common wall with a nonconforming building that is a fire barrier having at least a two-hour fire resistance rating. Findings,

The new Medical Office Building is a non-conforming building, the common wall at the connecting corridor was not constructed to provide at least a 2-hour fire resistance rating. Penetrations are not sealed and fire caulking was not used where required.

Based on observation and interview with staff, the facility failed to provide doors with latching hardware that complies with CMS regulations prohibiting the use of roller latches in all health care facilities. 19.3.6.3 Findings,

Doors to rooms 212, 213 & 214 have roller latches.

Based on observation and interview with staff, the facility failed to provide smoke barriers that are constructed to provide at least a one half hour fire resistance rating in accordance with 8.3. 19.3.7.3 Findings,

The smoke barrier walls have multiple voids and penetrations that were not sealed with material capable of maintaining a one half hour fire resistance rating. Penetrations were found where communication wiring passes through the smoke barriers, this condition was found throughout the hospital above the ceilings.

Based on observation and interview with staff, the facility failed to show that staff is familiar with procedures and is aware that drills are part of established routine. 19.7.1.2 Findings, include:

1 In all drills, the hospital's check list form was not fully completed, signed or a time logged in for each drill and the facility could not show records of full participation of staff at least quarterly on each shift.

2 The drill conducted on shift 2300 - 0700 hours at 0600. On 2 west, there was not a date, indicating that 2 west did not participate in the drill. The facility could not provide records that staff were in-serviced on policy and procedures for a fire/fire drill.

Based on observation and interview with staff, the facility failed to provide a fire alarm system in accordance with NFPA 72 National Fire Alarm Code. Findings:

1) There is no reacceptance test for the completed work orders for the fire alarm system, as required by 7-1.6.2 Reacceptance Testing. Reacceptance testing is required when there is modification, repair, or adjustment to system hardware or wiring.

2) The annual inspection of the fire alarm system does not include the combination fire and smoke dampers because there are no access panels to these combination fire and smoke dampers.

Based on observation and interview with staff the facility failed to provide complete coverage for all portions of the building. The facility failed to properly maintain the system in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 19.3.5. Findings,

1. The covered area of the receiving dock located on the south end of the building was not provided with automatic sprinkler system coverage.

2. The Facilities Automatic Suppression System has an outstanding yellow tag dated January 28, 2011.

Based on observation and interview with staff, the facility failed to provide a means of egress continuously maintained free of all obstructions or impediments. Findings:

Beds, carts, supplies, trash cans and charting stations are located in egress corridors in all areas in the hospital and parked on one side of the corridor.

Based on observation and interview with staff, the facility failed to provide piped in medical gas systems that comply with NFPA 99, Chapter 4. Findings,

The Oxygen Bottle Reserve system located in the bulk oxygen liquid supply enclosure was not provided with a covered roof to protect from inclement weather.

(1) Laboratory rooms with mechanical ventilation throughout or employing fume hoods as part of the exhaust system are required to have air supply and exhaust balanced to provide a negative pressure with respect to surrounding hospital occupancies NFPA 99, 1999 edition 5-4.2.1

Based on observation and interview with staff, the facility failed to provide the microbiology rooms with air supply and exhaust balanced to provide a negative pressure with respect to surrounding hospital occupancies. Finding:

The facility could not demonstrate or provide documentation that a room used as a microbiology laboratory and an additional room containing a fume hood used for microbiology procedures had air supply balanced to provide negative pressure with respect to surrounding hospital occupancies.


2. Receptacles in patient care areas must have impedance ground testing in accordance with NFPA 99 1999 edition 3-3.3.2.

Based on observation and interview with staff, the facility failed to perform impedance ground testing of receptacles in patient care areas. Finding: The facility could not provide documentation of performance of impedance ground testing.

Based on observation and interview with staff, the facility failed to provide records of maintenance and testing of the emergency eye bath and shower in accordance with NFPA 99 10-6, 10-8.1.4 Findings,

The facility could not provide records that the emergency eye bath and shower were maintained and tested on a periodic basis. 10-8.1.4

Based on observation and interview with staff, the facility failed to provide records that generators are inspected weekly and exercised under load for 30 minutes per month in accordance with NFPA 99. 3.4.4.1. Findings,

Generator logs failed to document transition time from January to June and failed to show documentation of routine maintenance and operational testing on the Generator Log Report Form. NFPA 110-6

Based on observation and interview with staff, the facility failed to provide a common wall with a nonconforming building that is a fire barrier having at least a two-hour fire resistance rating. Findings,

The new Medical Office Building is a non-conforming building, the common wall at the connecting corridor was not constructed to provide at least a 2-hour fire resistance rating. Penetrations are not sealed and fire caulking was not used where required.

Based on observation and interview with staff, the facility failed to provide doors with latching hardware that complies with CMS regulations prohibiting the use of roller latches in all health care facilities. 19.3.6.3 Findings,

Doors to rooms 212, 213 & 214 have roller latches.

Based on observation and interview with staff, the facility failed to provide smoke barriers that are constructed to provide at least a one half hour fire resistance rating in accordance with 8.3. 19.3.7.3 Findings,

The smoke barrier walls have multiple voids and penetrations that were not sealed with material capable of maintaining a one half hour fire resistance rating. Penetrations were found where communication wiring passes through the smoke barriers, this condition was found throughout the hospital above the ceilings.

Based on observation and interview with staff, the facility failed to show that staff is familiar with procedures and is aware that drills are part of established routine. 19.7.1.2 Findings, include:

1 In all drills, the hospital's check list form was not fully completed, signed or a time logged in for each drill and the facility could not show records of full participation of staff at least quarterly on each shift.

2 The drill conducted on shift 2300 - 0700 hours at 0600. On 2 west, there was not a date, indicating that 2 west did not participate in the drill. The facility could not provide records that staff were in-serviced on policy and procedures for a fire/fire drill.

Based on observation and interview with staff, the facility failed to provide a fire alarm system in accordance with NFPA 72 National Fire Alarm Code. Findings:

1) There is no reacceptance test for the completed work orders for the fire alarm system, as required by 7-1.6.2 Reacceptance Testing. Reacceptance testing is required when there is modification, repair, or adjustment to system hardware or wiring.

2) The annual inspection of the fire alarm system does not include the combination fire and smoke dampers because there are no access panels to these combination fire and smoke dampers.

Based on observation and interview with staff the facility failed to provide complete coverage for all portions of the building. The facility failed to properly maintain the system in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 19.3.5. Findings,

1. The covered area of the receiving dock located on the south end of the building was not provided with automatic sprinkler system coverage.

2. The Facilities Automatic Suppression System has an outstanding yellow tag dated January 28, 2011.

Based on observation and interview with staff, the facility failed to provide a means of egress continuously maintained free of all obstructions or impediments. Findings:

Beds, carts, supplies, trash cans and charting stations are located in egress corridors in all areas in the hospital and parked on one side of the corridor.

Based on observation and interview with staff, the facility failed to provide piped in medical gas systems that comply with NFPA 99, Chapter 4. Findings,

The Oxygen Bottle Reserve system located in the bulk oxygen liquid supply enclosure was not provided with a covered roof to protect from inclement weather.

(1) Laboratory rooms with mechanical ventilation throughout or employing fume hoods as part of the exhaust system are required to have air supply and exhaust balanced to provide a negative pressure with respect to surrounding hospital occupancies NFPA 99, 1999 edition 5-4.2.1

Based on observation and interview with staff, the facility failed to provide the microbiology rooms with air supply and exhaust balanced to provide a negative pressure with respect to surrounding hospital occupancies. Finding:

The facility could not demonstrate or provide documentation that a room used as a microbiology laboratory and an additional room containing a fume hood used for microbiology procedures had air supply balanced to provide negative pressure with respect to surrounding hospital occupancies.


2. Receptacles in patient care areas must have impedance ground testing in accordance with NFPA 99 1999 edition 3-3.3.2.

Based on observation and interview with staff, the facility failed to perform impedance ground testing of receptacles in patient care areas. Finding: The facility could not provide documentation of performance of impedance ground testing.

Based on observation and interview with staff, the facility failed to provide records of maintenance and testing of the emergency eye bath and shower in accordance with NFPA 99 10-6, 10-8.1.4 Findings,

The facility could not provide records that the emergency eye bath and shower were maintained and tested on a periodic basis. 10-8.1.4

Based on observation and interview with staff, the facility failed to provide records that generators are inspected weekly and exercised under load for 30 minutes per month in accordance with NFPA 99. 3.4.4.1. Findings,

Generator logs failed to document transition time from January to June and failed to show documentation of routine maintenance and operational testing on the Generator Log Report Form. NFPA 110-6