HospitalInspections.org

Based on observation and interview, the facility failed to maintain the two-hour fire barrier separating an area that is fire sprinkler protected from one that is not sprinkled. This deficient practice would allow fire and smoke to migrate throughout the facility. The facility has the capacity for 70 beds with a census of 30 on the day of survey.

Findings are:
Observations on 10-23-18 between 2:13 pm and 3:35 pm revealed:
1. Unsealed penetrations around pipes in the two-hour fire rated wall between the Boiler Rooms and Carpenter Shop.
2. Two 30-minute fire rated doors in a two-hour fire rated wall between the Boiler Rooms and Carpenter Shop.
3. Unsealed penetration around electrical pipe in the two-hour fire rated wall between Grounds Shop and Receiving.

During an interview on 10-23-18 between 2:13 pm and 3:35 pm, Maintenance Staff C confirmed the penetrations in the two-hour firewall.

Based on observation and interview, the facility failed to maintain means of egress free of obstructions. This deficient practice could delay evacuation during an emergency.
The facility has the capacity for 70 beds with a census of 30 on the day of survey.

Findings are:
Observations on 10-23-18 at 3:52 pm revealed, seven 32 gallon wheeled soiled linen containers stored in the corridor outside of Laundry.

During an interview on 10-23-18 at 3:52 pm, Maintenance Staff C confirmed the wheeled soiled linen containers stored in the corridor and stated laundry personnel were gone for the day.

NFPA Standard:
2012 NFPA 101, 19.2.1
Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11.

2012 NFPA 101, 7.1.10.1*
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.




38543

Based on observation and interview, the facility failed to maintain means of egress free and clear of all obstructions in the Clinic/Urgent Care and the 3rd floor main entry corridor. This deficient practice could delay evacuation of all occupants in the event of an emergency. The facility has the capacity of 70 beds with a census of 30 on the day of survey.

Findings are:

Observation on 10-23-2018 between 11:27 am and 3:42 pm, revealed the following:
1. Facility allowed an empty equipment cart and scale to remain in the exit corridor outside of exam rooms unattended.
2. Facility allowed the Physical therapy movable stairs to be stored in the corridor outside of the Stair tower S3 across from the elevators.

During an interview on 10-23-2018 between 11:27 and 3:42 pm, Maintenance Staff A confirmed the finding.


38544

Based on observation and interview, the facility failed to maintain means of egress free and clear of all obstructions in the first floor main entry corridor. This deficient practice could delay evacuation of all occupants in the event of an emergency. The facility has the capacity of 70 beds with a census of 30 on the day of survey.

Findings are:
Observation on 10-23-2018 at 3:28 AM revealed, the facility allowed the Bean Buggy coffee/food cart to remain in the main entry exit corridor near the gift shop unattended for multiple hours at a time.

During an interview on 10-23-2018 at 3:28 AM, Maintenance Staff B confirmed the finding.



Based on observation and interview, the facility failed to provide a single-action latching device on egress doors in Procedure Room #2 at Methodist Fremont Health Surgery Center located at 840 East 29th Street. This deficient practice would delay or prevent evacuation in the event of an emergency.

Findings are:

Observation on 10-22-2018 at 11:28 AM revealed the following:

1) All three exit doors from Procedure Room #2 were equipped with a slide-bolt locking device, requiring more than a single action to open the door.

During an interview on 10-22-2018 at 11:28 AM, Maintenance Staff B confirmed the finding.

Based on observation and interview, the facility failed to assure that all staff carried keys in the fifth floor locked unit. This deficient practice would delay egress during an emergency. The facility has the capacity for 70 beds with a census of 30 on the day of survey.

Findings are:
Observations on 10-23-18 between 11:00 am and 11:48 am revealed:
1. Housekeeping Staff A failed to be aware that a key could be used instead of a card to unlock all exit doors on the 5th floor Behavioral Unit.
2. Operations Coordinator A failed to be aware that a key could be used instead of a card to unlock all exit doors on the 5th floor Behavioral Unit.
3. Nursing Staff A failed to have the key to unlock the locked exit doors on the 5th floor Behavioral Unit.
4. Case Management Tech Staff A failed to have the key to unlock the locked exit doors on the 5th floor Behavioral Unit.

During an interview on 10-23-18 at 10:00 am and 11:28 am, Maintenance Staff B confirmed that staff on the sixth floor failed to have keys or have knowledge of the use of keys to unlock the exit doors.

Based on observation and interview, the facility failed to assure fire rated stair doors latched within the doorframe. This deficient practice would allow the stair enclosure to be filled with smoke, fire and gasses. The facility has the capacity of 70 beds with a census of 30 on the day of survey.

Findings are:
Observation on 10-23-18 at 12:03 pm and 3:37 pm revealed:
1. The second floor stair door to stair tower S3 failed to latch within the doorframe.
2. The stair door leading into the Carpenters basement failed to close and latch within the doorframe.

During an interview on 10-23-18 at 12:03 pm and 3:37 pm, Maintenance Staff B confirmed the stair doors failed to latch within the frame.

Based on observation and interview, the facility failed to assure that hazard room doors would close and latch within the doorframe. This deficient practice would delay closing of the door and allow the spread of fire and smoke within exit corridors. The facility has the capacity of 70 beds with a census of 30 on the day of survey.

Findings are:
Observation on 10-23-18 between 2:27 pm and 3:52 pm revealed:
1. The first floor electrical room 1336 door equipped with a closure, failed to latch within the doorframe.
2. A metal kick-down installed on the lower corner of the Carpenter's Shop door which lead to Receiving.
3. Kitchen food storage room located in Receiving was over 100 square feet and failed to provide a self-closing device.
4. The Furnace Room in Receiving failed to be smoke tight, three walls failed to extend to the roof deck and no ceiling was provided, which created open areas above the ceiling tiles of the rooms adjacent.
5. Double doors to Receiving into the corridor, equipped with closures failed to latch within the doorframe.
6. The east door of the double doors into the Laundry equipped with a closure, failed to latch within the doorframe.

During an interview on 10-23-18 between 2:27 pm and 3:52 pm, Maintenance Staff C confirmed the doors failed to latch to the hazard areas.


38543

Based on observation and interview, the facility failed to assure the door to a hazardous area would close and latch within the doorframe, and failed to separate hazardous areas by smoke resistive partitions. These deficient practices would allow fire, smoke and gasses to migrate into the exit corridor. The facility has the capacity for 70 beds with a census of 30 on the day of survey.

Findings are:

Observations on 10-22-18 between 11:23 am and 12:36 pm revealed the following:
1. Old OR room 2 used for storage, the door failed to provide latching device.
2. OR room 7 used for storage, the door failed to provide latching device.
3. Room housing steam sterilizers equipped with self-closing device and latching hardware was obstructed by floor mat from closing.
4. Door to Janitors closet in OB surgery area failed to provide a self-closing device.
Observations on 10-23-2018 between 2:26 pm and 4:19 pm revealed the following:
5. Room 0093, MRI HVAC room in basement, 1 ½ hour rated door failed to be provided with self-closing device.
6. Room 1342 door, housekeeping in Imaging/MRI, failed to be provided with self-closing device.

During interviews on 10-22-18 between 11:23 am and 12:26 pm, and on 10-23-2018 between 2:26 pm and 4:19 pm, Maintenance Staff A confirmed the findings.


38544

Based on observation and interview, the facility failed to assure the door to a hazardous area would close and latch within the doorframe, and failed to separate hazardous areas by smoke resistive partitions. These deficient practices would allow fire, smoke and gasses to migrate into the exit corridor. The facility has the capacity for 70 beds with a census of 30 on the day of survey.

Findings are:
Observations on 10-23-2018 between 11:22 AM and 2:43 PM revealed:
1) Fourth floor storage room #4013 door was not equipped with a self-closing device.
2) Respiratory procedure area storage room #1247-S door was equipped with a kickstand/hold-open device.
3) 1st floor mechanical room #1242 had a 5-inch hole in the ceiling in the northeast corner of the room.
4) 1st floor mechanical room #1242 had a 2-inch hole in the wall in the northeast corner of the room.
5) 1st floor mechanical room #1255 had six 1-inch holes in the wall around pipe and conduit penetrations.
6) 1st floor communications room #1251 had five 1.5-inch holes in the wall and ceiling around pipe and conduit penetrations.

During interviews on 10-23-2018 between 11:22 AM and 2:43 PM, Maintenance Staff B and Maintenance Staff D confirmed the findings.


Based on observation and interview, the facility failed to assure the door to a hazardous area would close and latch within the doorframe, and failed to separate hazardous areas by smoke resistive partitions at Methodist Fremont Health Surgery Center located at 840 East 29th Street. These deficient practices would allow fire, smoke and gasses to migrate into the exit corridor.

Findings are:

Observation on 10-22-2018 at 11:45 AM revealed the following:

1) Boiler room door rubbed on the floor rug, preventing it from closing.

During an interview on 10-22-2018 at 11:45 AM, Maintenance Staff B confirmed the findings.

Based on observation and interview, the facility failed to maintain cooking appliances in the correct position so they were covered by the kitchen exhaust hood fire-extinguishing system. This deficient practice would cause failure of the suppression system to adequately cover all appliances in the event of a grease fire. The facility has the capacity of 70 beds with a census of 30 on the day of survey.

Findings are:
Observation on 10-23-2018 at 3:45 PM revealed, the Kitchen serving area had two deep fat fryers that were not properly aligned with the fire-extinguishing system nozzles.

During an interview on 10-23-2018, Maintenance Staff B confirmed the finding.

Based on observation and interview, the facility failed to assure an audible/visual fire alarm device was provided in the exterior patio on the 5th floor. This deficient practice would prohibit immediate notification of the staff of a fire situation. The facility has the capacity of 70 beds with a census of 30 on the day of survey.

Findings are:
Observations on 10-23-18 at 11:25 am revealed, the exterior patio on the fifth floor failed to provide an audible visual fire alarm device.

During an interview on 10-23-18 at 11:25 am, Maintenance Staff B confirmed the lack of the audible visual device.


38543

Based on observations and interview, the facility failed to provide audible/visual fire alarm notification devices in two consultation rooms. The lack of fire alarm notification devices could cause a fire emergency to go undetected in the area of facility because of the inability to see or hear an alarm device. The facility has the capacity for 70 beds with a census of 30 on the day of survey.

Findings are:

Observation on 10-22-18 between 12:07 pm and 12:08 pm revealed the following:
1. OR Consultation room #1 had no audible/visual notification device.
2. OR Consultation room #2 had no audible/visual notification device.

During interviews on 10-22-18 between 12:07 pm and 12:08 pm, Maintenance Staff A confirmed the findings.

Based on observation and interview, the facility failed to assure that the above ground fire sprinkler pipes in the non-sprinkled areas of the building were protected by a fire sprinkler system. This deficient practice would have the potential for the sprinkler pipe to be damaged and the fire to spread throughout the facility. The facility has the capacity for 70 beds with a census of 30 on the day of survey.

Findings are:
Observations on 10-23-18 at 3:17 pm revealed, the sprinkler main installed in the non- sprinkled Boiler Rooms was not sprinkler protected.

During an interview on 10-23-18 at 3:17 pm, Maintenance Staff C confirmed the lack of sprinkler protection to the sprinkler main in the Boiler Rooms.

NFPA Standard:
NFPA 13 2002, 8.15.3.3
Private service main aboveground piping shall not pass through hazardous areas and shall be located so that it is protected from mechanical and fire damage. 8.15.3.3.1

Private service main aboveground piping shall be permitted to be located in hazardous areas protected by an automatic sprinkler system. 8.15.3.3.2

Based on observation and staff interview, the facility failed to maintain the required minimum clearance around a fire sprinkler deflector, provide an escutcheon ring, and maintain ceiling tile. The deficient practice could prevent the fire sprinkler from activation in the case of fire and could obstruct the spray pattern of the sprinkler resulting in inefficient coverage and failure to extinguish a fire. The facility has the capacity for 70 beds with a census of 30 on the day of survey.

Findings are:

Observation on 10-22-18 between 12:07 pm and 12:36 pm revealed the following:
1. OR Consultation room #1 was missing a ceiling tile.
2. Janitor's closet in the OB Surgery area on 4th floor was missing an escutcheon ring.

Observation on 10-23-18 between 11:12 am and 11:22 am revealed:
3. A Blanket warmer encroached into the required minimum 18 inch clearance from obstruction to the sprinkler deflector in Room 3087
4. Items stored in Room 3100, Dialysis storage, encroached into the required 18 inch clearance from obstruction to the sprinkler deflector.

During an interviews on 10-22-18 between 12:07 pm and 12:36 pm, and on 10-23-18 between 11:12 am and 11:22 am, Maintenance Staff A confirmed the obstructions to the sprinkler defectors, missing escutcheon ring, and missing ceiling tile.


38544

Based on observation and interview, the facility failed to maintain the Fire Sprinkler System by allowing foreign materials to accumulate on the fire sprinkler deflector and bulb. This deficient practice would cause failure of fire sprinklers to operate as designed. The facility has the capacity of 70 beds with a census of 30 on the day of survey.

Findings are:
Observations on 10-23-2018 between 2:18 PM and 3:50 PM revealed:
1) First floor medical records room #1257 fire sprinkler had dust and lint on the bulb and deflector.
2) First floor housekeeping room #1280 fire sprinkler had dust and lint on the bulb and deflector.
3) First floor gift shop fire sprinklers had dust and lint on the bulb and deflector.
4) Kitchen coordinator office sprinkler had dust and lint on the bulb and deflector of the fire sprinkler.

During interviews on 10-23-2018 between 2:18 PM and 3:50 PM, Maintenance Staff B confirmed the findings.



Based on observation and interview, the facility failed to maintain the Fire Sprinkler System at Methodist Fremont Health Surgery Center located at 840 East 29th Street by allowing foreign materials to accumulate on the fire sprinkler deflector and bulb. This deficient practice would cause failure of fire sprinklers to operate as designed.

Findings are:

Observation on 10-22-2018 at 11:20 AM revealed the following:

1) Women's locker room fire sprinkler had dust and lint on the bulb and deflector.

During an interview on 10-23-2018 at 11:20 AM, Maintenance Staff B confirmed the findings.

Based on record review and interview, the facility failed to assure that a complete policy was in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than ten hours in any twenty-four hour period. The lack of a complete written policy and procedure would result in staff failing to implement interim safety measures in the event of an emergency. This deficient practice affected all occupants. The facility has the capacity for 70 beds with a census of 30 on the day of survey.

Findings are:
Record review on 10-22-18 at 1:32 pm, of the fire watch procedures revealed the facility did not have a complete policy regarding the procedures to be taken in the event that the sprinkler system was out of service for more than ten hours in a twenty-four hour period.
1. The policy failed to list emergency impairments would include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping and equipment failure.
2. The facility failed to have a list of contact information including property owner or designee, insurance company, fire alarm company and sprinkler company.

During an interview on 10-22-18 at 2:32 pm, Administration Staff B confirmed the lack of specific items in the fire watch policy.

NFPA Standard:
NFPA 25, 2011,15.5 Preplanned Impairment Programs.
15.5.1 All preplanned impairments shall be authorized by the impairment coordinator.
15.5.2 Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented:
(1) The extent and expected duration of the impairment have been determined.
(2) The areas or buildings involved have been inspected and the increased risks determined.
(3) Recommendations have been submitted to management or the property owner or designated representative.
(4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following:
(a) Evacuation of the building or portion of the building affected by the system out of service
(b)*An approved fire watch
(c)*Establishment of a temporary water supply
(d)*Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire
(5) The fire department has been notified.
(6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified.
(7) The supervisors in the areas to be affected have been notified.
(8) A tag impairment system has been implemented. (See Section 15.3.)
(9) All necessary tools and materials have been assembled on the impairment site.

15.6 Emergency Impairments.
15.6.1 Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure.
15.6.2 When emergency impairments occur, emergency action shall be taken to minimize potential injury and damage.
15.6.3 The coordinator shall implement the steps outlined in Section 15.5.

Based on observation and staff interview, the facility failed to install portable fire extinguishers so the top of the extinguisher was no more than five feet above the finished floor. This condition could prevent staff from accessing a fire extinguisher during a fire, which would allow a fire to increase in size. The facility has the capacity for 70 beds with a census of 30 on the day of survey.

Findings are:

Observation on 10-23-18 at 2:16 pm revealed, the fire extinguisher installed in Equipment Room 0016 measured 61 ½ inches to the top of the handle.

During an interview on 10-23-18 at 2:16 pm, Maintenance Staff A confirmed the measurement.

Based on observation and staff interview, the facility failed to maintain corridor doors to resist the passage of smoke. This deficient practice would allow smoke and fire gases to migrate throughout the smoke compartment. The facility has the capacity for 70 beds with a census of 30 on the day of survey.

Findings are:

Observations on 10-23-18 between 11:00 am and 11:20 am revealed the following:
1. Room 3009 door failed to latch and seal within the door frame.
2. Room 3096 door failed to latch and seal within the door frame.

During interviews on 10-23-18 between 11:00 am and 11:20 am, Maintenance Staff A confirmed the findings.

Based on observation and interview, the facility failed to maintain the smoke barrier to resist the passage of smoke and gases at Methodist Fremont Health Surgery Center located at 840 East 29th Street. This deficient practice would allow smoke and gases to migrate into the exit corridor, causing delay or preventing evacuation in the event of an emergency.

Findings are:

Observation on 10-22-2018 at 11:40 AM revealed the following:

1) Multiple 1-inch holes around pipe and conduit penetrations in the smoke barrier wall above the recovery area beds.

During an interview on 10-22-2018 at 11:40 AM, Maintenance Staff B confirmed the findings.

Based on observation and interview, the facility failed to maintain fire rated doors in a smoke barrier so they fully closed within the doorframe. This deficient practice would allow smoke to spread between smoke compartments. The facility has a capacity of 70 and a census of 30 residents at the time of the survey.

Findings are:
Observation on 10-23-18 between 11:01 am and 11:47 am revealed:
1. The gap between the 5th floor east smoke separation doors next to the Directors' Office was excessive and failed to be smoke-tight.
2. The gap between the 5th floor south cross corridor smoke doors was excessive and failed to be smoke-tight.
3. The gap between the 5th floor north end smoke separation doors was excessive and failed to be smoke-tight.

During an interview on 10-23-18 between 11:01 am and 11:47 am, Maintenance Staff B confirmed the excessive gap between the smoke doors.



38543

Based on observation and interview, the facility failed to ensure smoke separation doors were capable of resisting the passage of smoke. The deficient practice would allow smoke and gasses to spread between these smoke compartments. The facility has the capacity for 70 beds with a census of 30 on the day of survey.

Findings are:

Observation on 10-22-18 at 11:39 am revealed, the double smoke doors, BNC 1119083 & BNC 1119082, at the south end of the hallway outside of OR 8 which were equipped with self-closing devices and latching hardware failed to seal to resist the passage of smoke.

During interview on 10-23-18 at 11:39 am, Maintenance Staff A confirmed the findings.


38544

Based on observation and interview, the facility failed to assure smoke barrier doors sealed to prevent the passage of smoke and gases. This deficient practice would allow smoke and gases to migrate into the exit corridor and migrate to another smoke compartment. The facility has the capacity of 70 beds with a census of 30 on the day of survey.

Findings are:
Observations on 10-23-2018 at 2:48 PM revealed, the first floor smoke barrier doors #1250 by room #1340 did not seal to prevent the passage of smoke.

During an interview on 10-23-2018 at 2:48 PM, Maintenance Staff B confirmed the finding.

Based on observation and interview, the facility failed to provide dead fronts for all circuits in electrical panel boxes and failed to provide a correct panel directory. These deficient practices could cause a delay and injury when turning off the power during an electrical issue emergency. The facility has the capacity for 70 beds with a census of 30 on the day of survey.

Findings are:
Observations on 10-23-18 at 2:33 pm and 3:07 pm revealed:
1. The electrical panel box B71E located in the basement 0081 Room had an open breaker in circuit 15.
2. The electrical panel box 24 located in Room 2214 failed to provide an updated directory, circuit 32 labeled for elevator lighting, which had been removed.

During an interview on 10-23-18 at 3:07 pm, Maintenance Staff C confirmed the missing dead front and stated that the elevator had been removed in 2017 and the directory failed to be updated.

NFPA Standard:
2011 NFPA 70, 408.38
Panelboards shall be mounted in cabinets, cutout boxes, or enclosures designed for the purpose and shall be dead front.


38543

Based on observation and interview, the facility allowed storage to obstruct access to electrical panels. This deficient practice could cause a delay and injury when turning off the power during an electrical issue. The facility has the capacity for 70 beds with a census of 30 on the day of survey.

Findings are:

Observations on 10-22-18 at 11:33 am revealed, items stored in front of electrical panel boxes in the mechanical closet between OR 3 and OR 4.

During an interview on 10-22-18 at 11:33 am, Maintenance Staff A confirmed the items stored in front of the electrical panel boxes.

NFPA Standard:
2011 NFPA 70, 110.26
Sufficient access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment.

Based on documentation review and interview, the facility failed to hold fire drills under varied conditions for 1 of 3 shifts reviewed by not conducting the fire drills at least one hour apart from all other drills on the shift. This condition did not provide simulated training for staff to respond to a fire emergency during various activities and staffing levels, which would affect fire procedure response. The facility has the capacity for 70 beds with a census of 30 on the day of survey.

Findings are:

Fire drill documentation review on 10-25-18 at 11:02 am revealed, Second shift fire drills were conducted at 4:03 pm on 3-27-18, and 3:08 pm on 8-20-18.

During an interview on 10-25-18 at 11:02 am, Maintenance Staff E confirmed the drills failed to be conducted during varied conditions.

Based on observation and interview, the facility failed to provide identification for three remote manual stop switches for the emergency generators. This deficient practice could delay shutdown of the generator during a malfunction, which could cause damage to the generator resulting in loss of emergency power that would affect all patients. The facility has the capacity for 70 beds with a census of 30 on the day of survey.

Findings are:
Observation on 10-23-18 at 3:15 pm revealed, the facility failed to provide identification for the remote manual shutdown switches.

During an interview on 10-23-18 at 3:15 pm, Maintenance Staff C confirmed the lack of identification remote stops for the generator.

NFPA Standard:
2010 NFPA 110, 5.6.5.6*
All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building.

2010 NFPA 110, 5.6.5.6.1
The remote manual stop station shall be labeled.

Based on observation and interview, the facility failed to provide tamper-resistant electrical outlets in the Pediatric Care area. This deficient practice increased the potential for injury from an electrical shock. The facility has the capacity of 70 beds with a census of 30 on the day of survey.

Findings are:
Observations on 10-23-2018 between 11:06 AM and 11:09 AM revealed:
1) Fourth floor pediatric rooms #4023 and #4024 were not equipped with tamper-resistant electrical outlets.
2) Fourth floor hallway near pediatric rooms #4023 and #4024 was not equipped with tamper-resistant electrical outlets.

During interviews on 10-23-2018 between 11:06 AM and 11:09 AM, Maintenance Staff D confirmed the findings.

Based on observation and interview, the facility failed to assure that the remote annunciator panels for 3 of 3 generators that had been installed in 2002 and 2007 were equipped with the required notifications as listed in NFPA 99 code. This deficient practice would delay the response to maintain the generator in the event of a malfunction. The facility has the capacity for 70 beds with a census of 30 on the day of survey.

Findings are:
Observation on 10-23-18 between 3:00 pm and 3:53 pm revealed:
1. The remote annunciator panels for three of three generators only provided an online and trouble alarm conditions.

During an interview on 10-23-18 between 3:00 pm and 3:53 pm, Maintenance Staff A confirmed the annunciator panels failed to provide all alarm conditions as required by NFPA 99 and stated that the generators were installed in 2002 and 2007.


NFPA Standard:
NFPA 99 Standard for Health Care Facilities (2012), Chapter 6, Electrical Systems,
6.4.1.1.17 Alarm Annunciator. A remote annunciator that is storage battery powered shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see 700.12 of NFPA 70, National Electrical Code).
The annunciator shall be hard-wired to indicate alarm conditions of the emergency or auxiliary power source as follows:
1. Individual visual signals shall indicate the following:
(a) When the emergency or auxiliary power source is operating to supply power to load
(b) When the battery charger is malfunctioning
2. Individual visual signals plus a common audible signal to warn of an engine generator alarm condition shall indicate the following:
(a) Low lubricating oil pressure
(b) Low water temperature (below that required in 6.4.1.1.11)
(c) Excessive water temperature
(d) Low fuel when the main fuel storage tank contains less than a 4-hour operating supply
(e) Overcrank (failed to start)
(f) Overspeed

6.4.1.1.16.1 Internal Combustion Engines.
Internal combustion engines serving generator sets shall be equipped with the following:
1. Sensor device plus visual warning device to indicate a water-jacket temperature below that required in 6.4.1.1.11
2. Sensor devices plus visual pre-alarm warning device to indicate the following:
(a) High engine temperature (above manufacturer's recommended safe operating temperature range)
(b) Low lubricating oil pressure (below manufacturer's recommended safe operating range)
(c) Low water coolant level
3. Automatic engine shutdown device plus visual device to indicate that a shutdown took place due to the following:
(a) Overcrank (failed to start)
(b) Overspeed
(c) Low lubricating oil pressure
(d) Excessive engine temperature
4. Common audible alarm device to warn that one or more of the pre-alarm or alarm conditions exist

Based on documentation review and interview, the facility failed to ensure that the transfer time from normal power to emergency power was not more than 10 seconds. These deficient practices increased the potential that the generator would fail to run during loss of power. The facility has the capacity for 70 beds with a census of 30 on the day of survey.

Findings are:

Documentation review on 10-25-18 at 11:36 am revealed the facility failed to document emergency power transferred within 10 seconds during the monthly load test of the generator.

During an interview on 10-25-18 at 11:36 am, Maintenance Staff E confirmed the findings the lack of information of the generator to supply service within 10 seconds.

Based on observation and interview, the facility failed to provide cover plates for electrical junction boxes. This deficient practice increased the potential for electrical shock or an electrical fire. The facility has the capacity of 70 beds with a census of 30 on the day of survey.

Findings are:
Observations on 10-23-2018 between 2:42 PM and 2:43 PM revealed:
1) First floor mechanical room #1255 had two missing cover plates on electrical junction boxes.
2) First floor communications room #1251 had one missing cover plate on an electrical junction box.

During interviews on 10-23-2018 between 2:42 PM and 2:43 PM, Maintenance Staff B confirmed the findings.



Based on observation and interview, the facility failed to provide cover plates for electrical junction boxes at Methodist Fremont Health Surgery Center located at 840 East 29th Street. This deficient practice increased the potential for electrical shock or an electrical fire.

Findings are:

Observation on 10-22-2018 at 11:33 AM revealed the following:

1) East nurse station electrical panel had two blank spacers missing.

During an interview on 10-23-2018 at 11:33 AM, Maintenance Staff B confirmed the findings.

Based on observation and interview, the facility failed to prohibit the use of extension cords and power strips as a substitute for adequate wiring. This deficient practice would create electrical injury and increase the probability of a fire in the PACU. The facility has the capacity for 70 beds with a census of 30 on the day of survey.

Findings are:

Observations on 10-22-18 between 11:53 am and 11:55 am revealed the following:
1. A Hospital grade power strip was not mounted on a cart with equipment plugged into it in PACU. Maintenance Staff A removed the power strip at the time of observation.
2. A non-Hospital grade power strip was plugged into the wall at the head of the bed across from the bathroom in PACU. Maintenance Staff A removed the power strip at the time of observation.

During an interview on 10-22-18 between 11:53 am and 11:55 am, Maintenance Staff A confirmed the use of power strips.


38544

Based on observation and interview, the facility failed to prohibit the use of electric extension cords and power-strips as a substitute for permanent wiring. This deficient practice increased the potential for the electrical system to fail and cause a fire. The facility has the capacity of 70 beds with a census of 30 on the day of survey.

Findings are:
Observations on 10-23-2018 between 3:00 PM and 3:28 PM revealed:
1) Human Resources office had a refrigerator and a microwave plugged into an electric extension cord.
2) Bean Buggy by the Gift Shop had three coffee pot warmers plugged into an electric power-strip.

During interviews on 10-23-2018 between 3:00 PM and 3:28 PM, Maintenance Staff B confirmed the findings.

Based on observation and interview, the facility failed to store a compressed flammable gas cylinder so it was restrained from tipping over and failed to assure that an exterior gas enclosure area was free from combustibles. These deficient practices had the potential for the cylinder to tip over, breaking the valve off and becoming a projectile, and to spread fire to bulk oxygen tanks in the event of an exterior fire. The facility has the capacity for 70 beds with a census of 30 on the day of survey.

Findings are:
Observation on 10-23-18 at 3:31 pm and 4:10 pm revealed:
1. A four-foot tall compressed flammable gas cylinder was freestanding in the Grounds Shop and failed to be restrained.
2. The bulk oxygen enclosure had dried weeds at least three feet tall along the fence.

In an interview on 10-23-18 at 3:31 pm and 4:10 pm, Maintenance Staff C confirmed that the oxygen cylinder was not restrained and that the weeds along the fence were overgrown.

NFPA Standard:
2010 NFPA 55, 9.3.2
Weeds and long dry grass shall not be within 15 ft (4.6 m) of any bulk oxygen storage container.



38543

Based on observation and interview, the facility allowed storage of combustibles within 5 feet of oxygen cylinders. This deficient practice increased the potential for a fire to occur. The facility has the capacity for 70 beds with a census of 30 on the day of survey.

Findings are:

Observations on 10-22-18 at 11:25 am revealed, combustibles storage within five feet of oxygen cylinders in the Surgical Suite prep room.

Observations on 10-23-18 between 3:12 pm and 3:58 pm, revealed:
1. Combustibles storage within five feet of oxygen cylinders in Room 1607, CP Store room.
2. Combustibles storage within five feet of oxygen cylinders in the ER Room 1066

During an interviews on 10-22-18 at 11:25 am and on 10-23-18 between 3:12 pm and 3:58 pm, Maintenance Staff A confirmed the storage of combustibles within five feet of the oxygen cylinders.

NFPA Standard:
NFPA 99, 2012, 11.3.2.3
Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following:
(1) Minimum distance of 6.1 m (20 ft)
(2) Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed
in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems
(3) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1/2 hour

Based on observation and interview, the facility failed to label oxygen cylinders as empty or full and failed to segregate full and empty cylinders. The deficient practice increased the potential for an empty cylinder to be taken when a full one was needed. The facility has the capacity of 70 beds with a census of 30 on the day of survey.

Findings are:
Observations on 10-23-2018 at 11:38 AM revealed, fourth floor oxygen storage room #4046 did not have signs identifying full and empty oxygen cylinders.

During an interview on 10-23-2018 at 11:38 AM, Maintenance Staff D confirmed the finding.