HospitalInspections.org

Based upon observations made during the Survey conducted on 10/09/12 between the hours of 0900 to 1515 while accompanied by facility staff we observed a gap between the double doors leading to the soiled linen rooms which could allow for the possible movement of smoke.

1. Soiled Linen/Clean Linen Rooms in the TCU Wing
2. Soiled Linen/Clean Linen Rooms in the Hospital Wing

Doors are to be constructed to resist the possible movement of smoke, a large gap could allow for the possible movement of smoke which could place patients, staff or visitors at risk.

Based upon observations made during the Survey conducted on 10/09/12 between the hours of 0900 to 1515 while accompanied by facility staff we observed doors in the following locations that were equipped with sliding bolt locks in addition to the regular passage lock:

1. X-Ray Room Suite Doors were equipped with sliding bolt lock in addition to passage lock hardware
2. Administrative Office Area and Copy Room were equipped with sliding bolt lock in addition to passage lock hardware.

Facility has installed these additional sliding bolt locks for security, however NFPA 101 7.2.1.5.4 requires doors to be opened with not more than one releasing operation, a two step release, such as a passage knob and an independent slide bolt is not acceptable. Possibility exists for undue delay in exiting the area in the event of an emergency due to more than one operation to open the door or unfamiliarity with the operation which could place those individuals at risk to possible harm.

Based upon observations made during the Survey conducted on 10/09/12 between the hours of 0900 to 1515 while accompanied by facility staff we observed that the Fire Alarm Panel is located on the Critical Branch of the Type 1 Essential Electrical System. Per NFPA 99, 3-4.2.2.2 Alarm and Alerting Systems including the Fire Alarm Panel are to be located on the Life Safety Branch of the Essential Electrical System. Facility will need to confirm that their Essential Electrical System is in compliance with NFPA 99. Failure of the Essential Electrical System to function as required in the event of an Emergency would place patients, staff and visitors at risk of possible harm.

Based upon observations made during the Survey conducted on 10/09/12 between the hours of 0900 to 1515 while accompanied by facility staff we observed the improper use of multi-plug power strips and unapproved cube style adaptors in the following locations:

1. Power strip being used in Clean Utility Room (#90) for battery charger and portable flashlight
2. Power strips being used at TCU Nurses Station for portable radio and pencil sharpener
3. Power strip being used in Billing Office
4. Power strip being used in Social Services Office, appliance plugged into power strip need to be plugged directly into an approved electrical outlet
5. Power strip being used in Utility Room by room #121 (Old Assisted Living Wing) battery chargers
6. Power strip being used in Administrative Assistant Office, Appliances
7. Power strips being used in Sunrise Cafe for stereo equipment
8. Power strips being used in Physical Therapy, equipment
9. Power strips being used in Administrative Office Area
10. Power strips being used in Cafeteria (Lunch Box) for kitchen equipment
11. Power strip being used in room #85, appliance
12. Power strip being used in Dietary Office
13. Power strip being used in Doctors Lounge and Nurse Lounge
14. Power strips being used in Respitory Office (#36)
15. Unapproved Cube Style Adaptor being used in Housekeeping/Linen Storage (#177) no built in circuit breaker

C.M.S. has made an interpretation regarding the approved use of multi-plug power strips with flexible cords and consider therm to be the same as an extension cord and thus can not be used in lieu of permanent wiring. However C.M.S. also has allowed for a Waiver Request to allow the continued use of these devices if certain safety parameters are met. The failure to ensure that electrical devices are plugged directly into approved electrical outlets increases the risk of possible fire due to overheating of electrical wiring and thus placing patients, staff and visitors at risk of possible harm.

Based upon observations made during the Survey conducted on 10/09/12 between the hours of 0900 to 1515 while accompanied by facility staff we observed a gap between the double doors leading to the soiled linen rooms which could allow for the possible movement of smoke.

1. Soiled Linen/Clean Linen Rooms in the TCU Wing
2. Soiled Linen/Clean Linen Rooms in the Hospital Wing

Doors are to be constructed to resist the possible movement of smoke, a large gap could allow for the possible movement of smoke which could place patients, staff or visitors at risk.

Based upon observations made during the Survey conducted on 10/09/12 between the hours of 0900 to 1515 while accompanied by facility staff we observed doors in the following locations that were equipped with sliding bolt locks in addition to the regular passage lock:

1. X-Ray Room Suite Doors were equipped with sliding bolt lock in addition to passage lock hardware
2. Administrative Office Area and Copy Room were equipped with sliding bolt lock in addition to passage lock hardware.

Facility has installed these additional sliding bolt locks for security, however NFPA 101 7.2.1.5.4 requires doors to be opened with not more than one releasing operation, a two step release, such as a passage knob and an independent slide bolt is not acceptable. Possibility exists for undue delay in exiting the area in the event of an emergency due to more than one operation to open the door or unfamiliarity with the operation which could place those individuals at risk to possible harm.

Based upon observations made during the Survey conducted on 10/09/12 between the hours of 0900 to 1515 while accompanied by facility staff we observed that the Fire Alarm Panel is located on the Critical Branch of the Type 1 Essential Electrical System. Per NFPA 99, 3-4.2.2.2 Alarm and Alerting Systems including the Fire Alarm Panel are to be located on the Life Safety Branch of the Essential Electrical System. Facility will need to confirm that their Essential Electrical System is in compliance with NFPA 99. Failure of the Essential Electrical System to function as required in the event of an Emergency would place patients, staff and visitors at risk of possible harm.

Based upon observations made during the Survey conducted on 10/09/12 between the hours of 0900 to 1515 while accompanied by facility staff we observed the improper use of multi-plug power strips and unapproved cube style adaptors in the following locations:

1. Power strip being used in Clean Utility Room (#90) for battery charger and portable flashlight
2. Power strips being used at TCU Nurses Station for portable radio and pencil sharpener
3. Power strip being used in Billing Office
4. Power strip being used in Social Services Office, appliance plugged into power strip need to be plugged directly into an approved electrical outlet
5. Power strip being used in Utility Room by room #121 (Old Assisted Living Wing) battery chargers
6. Power strip being used in Administrative Assistant Office, Appliances
7. Power strips being used in Sunrise Cafe for stereo equipment
8. Power strips being used in Physical Therapy, equipment
9. Power strips being used in Administrative Office Area
10. Power strips being used in Cafeteria (Lunch Box) for kitchen equipment
11. Power strip being used in room #85, appliance
12. Power strip being used in Dietary Office
13. Power strip being used in Doctors Lounge and Nurse Lounge
14. Power strips being used in Respitory Office (#36)
15. Unapproved Cube Style Adaptor being used in Housekeeping/Linen Storage (#177) no built in circuit breaker

C.M.S. has made an interpretation regarding the approved use of multi-plug power strips with flexible cords and consider therm to be the same as an extension cord and thus can not be used in lieu of permanent wiring. However C.M.S. also has allowed for a Waiver Request to allow the continued use of these devices if certain safety parameters are met. The failure to ensure that electrical devices are plugged directly into approved electrical outlets increases the risk of possible fire due to overheating of electrical wiring and thus placing patients, staff and visitors at risk of possible harm.