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Based on observation, testing, and interview, the provider failed to maintain the smoke tight rating of corridor wall assemblies for the south wing. One randomly observed door (0110) to the corridor would not close and latch. Findings include:

1. Observation and testing at 8:57 a.m. on 11/29/11 revealed the door to the third floor room 355 (door number 0110) would not close and latch into the door frame under power of the automatic door closer. Interview with the director of safety services at the time of the observation confirmed that condition.

Based on observation and interview, the provider failed to maintain the 30 minute fire resistive rating of smoke barrier walls in two randomly observed locations. (south and west walls of the softener room in the central utility plant) had unsealed sprinkler pipe penetrations. Findings include:

1. Observation at 3:45 p.m. on 11/29/11 revealed the west wall of the softener room in the central utility plant had an unsealed pipe penetration for the six inch pipe marked return air. The wall that pipe penetrated was labeled as a smoke barrier wall. That same condition was also found for a six inch supply air pipe in the south wall of that same room. Interview at the time of the observation with the both director and assistant director of safety services confirmed those conditions.

A. Based on observation, testing, and interview, the provider failed to maintain the one hour separation between a soiled linen/trash holding room and the corridor. The corridor door to the soiled linen trash holding room for central sterilization (CS) was held open with a large rubber wedge. Findings include:

1. Observation at 3:00 p.m. on 11/29/11 revealed a soiled linen/trash holding room for CS. The one hour rated self-closing corridor door for that room was held open with a large rubber wedge. Interview with the CS supervisor at the time of the observation confirmed that finding. She stated she was not aware that door could not be propped open. She stated staff would prop the door open to move the large soiled linen and trash bins through the door.



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B. Based on observation and interview, the provider failed to maintain proper separation of a hazardous area. The storage room in the ultrasound suite had a non-fire rated door. Findings include:

1. Observation at 2:30 p.m. on 11/29/11 revealed a room labeled storage in the ultrasound department on the second floor. The door to that room was not a fire rated door. That room contained items that were combustible materials. Interview with the plant operations supervisor at the time of the observation confirmed that finding. Further observation revealed a near by office had a one-hour fire rated door. Discussion with the plant operations supervisor and plant operations director revealed those two rooms had switched functions.

C. Based upon observation, interview, and testing, improper door hardware was installed on two hazardous rooms. The Pre-Op and the PACU had doors closers mounted on hazardous areas doors which held the door in the open position. Hazardous room doors are to kept in the closed position at all times. Findings include:

1. Observation, testing, and interview at 1:25 p.m. on 11/29/11 of the door to the Pre-Op storage room revealed the door closer held the door (2778) in the open position. Testing of that door revealed the door stayed in the open position when opened to its maximum door swing. Upon pulling the door the closer would close the door. Interview with the plant operations supervisor revealed he believed the wrong closer arm had been installed on that door closer.


2. Observation, testing, and interview at 1:35 p.m. on 11/29/11 revealed the door to the clean supply room in PACU was being held open. Further observation revealed the door closer was holding the door (2759) in the open position. That room contained some clean bed linens, blankets, and several shelves of plastic wrapped items. Those items are considered combustible items and therefore make the room a hazardous area. Upon pulling the door the door closer closed the door. Interview with the plant operations supervisor revealed he believed the wrong closer arm had been installed on that door closer.




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D. Based on observation, record review, and interview, the provider failed to maintain proper separation of hazardous areas for the generator room in the central utility plant. One randomly observed set of 90 minute doors did not close and latch under the power of the door closer. Findings include:

1. Observation at 3:25 p.m. on 11/29/11 revealed the north leaf of the double-doors in the east two-hour fire wall of the generator room would not close and latch under the power of the automatic door closure while the generators were both running. That generator room was also used to store diesel fuel in two separate one-day supply tanks, one for each generator. Due to the amount of flammable liquid storage and the possible ignition source that area would be considered a high hazard area. Record review of the previous surveys results dated 11/18/09 revealed that condition had existed during the last survey. Interview with the director of safety services at the time of the observation confirmed that finding.

Based on observation and interview, the provider failed to ensure one randomly observed exit (information systems [IS] office suite) was readily accessible at all times in accordance with section 7.1 of the Life Safety Code. Findings include:

1. Observation at 11:02 a.m. on 11/29/11 revealed the door leading from the IS office suite to the exterior of the building had been blocked by chairs and carts. That door was a marked exit for egress from that area in the case of an emergency. Interview with the director of safety services at the time of the observation confirmed that condition.

Based on observation and record review, the provider failed to maintain the integrity of two hour horizontal exits. Randomly observed sets of horizontal exit doors located throughout the building were not labeled as 90 minute fire doors. Findings include:

1. Random observation on 11/29/11 revealed eight foot tall by four feet wide metal cross-corridor horizontal exit doors randomly located throughout the building excluding the ninth and tenth floors as well as the basement. Those doors did not have a manufacturer's label on them indicating a fire resistive rating of at least 90 minutes. Record review of previous FSES worksheets revealed that condition.

The building meets the FSES dated 12/1/11. Please mark an "F" in the completion date column to indicate the provider's intent to correct the deficiencies identified in K000.

Based on observation and interview, the provider failed to ensure staff were familiar with the fire drill procedures. Findings include:

1. Observation at 10:00 a.m. on 11/29/11 during a planned fire drill revealed the staff failed to properly clear items from the corridor. Two housekeeping carts and a clean linen cart were left in the corridor of the south wing of the second floor. During the drill staff did properly close the doors to the rooms, but those carts were not moved during the drill. Interview with the director of safety services at the time of the observation confirmed that finding. He stated he believed the staff had not heard a page though the buildings public addressing system. He thought that might have caused some confusion leading to the carts being left in the corridor.

Based on observation and interview the provider failed to furnish an automatic fire sprinkler system with complete coverage for all portions of the building in accordance with NFPA 13 (Standard for the Installation of Sprinkler Systems) in two randomly observed locations (fourth floor west communications room and catheter lab number two). Findings include:

1. Observation at 1:28 p.m. on 11/29/11 revealed the communications rack area of communications room (0498) on fourth floor west was not offered proper sprinkler system coverage. That room was provided with two heads for sprinkler system coverage. However due to the arrangement of cable tray, lowered portions of the ceiling, and a wall column neither of the two heads could provide the correct pattern development to afford sprinkler protection to the communication rack in that corner of the room. Interview with the director of safety services at the time of the observation confirmed that finding

2. Observation at 1:15 p.m. 11/29/11 revealed a closet outside of Cath Lab two. That closet had two cabinet style doors. The closet contained several lead aprons used in cath lab procedures. The closet did not have a cabinet ceiling and was open all the way up to the structure above. A fire sprinkler head was not present in that space above the cabinet shelves. Interview with the plant operation supervisor at that time revealed he agreed with that finding.

I. A recertification survey for compliance with the Life Safety Code (LSC) (2000 existing business occupancy) was conducted from 11/28/11 through 11/30/11. The Rapid City Regional Hospital laundry (building 01) was found in compliance with LSC requirements for hospitals.

II. A recertification survey for compliance with the Life Safety Code (LSC) (2000 existing business occupancy) was conducted from 11/28/11 through 11/30/11. The Rapid City Regional Hospital sleep laboratory (building 02-Dakota Regional at 2929 5th Street, Rapid City) was found not in compliance with 42 CFR Part 482.41(b)(1), requirements for hospitals.

Based on observation and interview, the provider failed to maintain a one-hour fire resistive path of egress from the upper floor south stair enclosure to the exterior of the building for the Dakota Regional Building (sleep lab). Findings include:

1. Observation at 4:15 p.m. on 11/28/11 revealed the south stair enclosure had unprotected openings in both sides of the 5/8 inch Type X gypsum board in the one-hour fire-rated separation wall between the stair enclosure and the storage area below/beside it located on the lower level in the following areas:
*The east stair landing did not have gypsum board on the storage room side of the stair enclosure.
*The east enclosure wall below the stair landing had an unsealed penetration opening around a fire sprinkler line.
*The south wall of the storage room had numerous openings up to ten inches by twenty inches in size cut into the gypsum board at the stair enclosure separation.
*The west side of the stair enclosure above the lay-in ceiling was not extended above to maintain the required one-hour fire separation.

III. A recertification survey for compliance with the Life Safety Code (LSC) (2000 existing business occupancy) was conducted from 11/28/11 through 11/30/11. The Rapid City Regional Hospital outpatient dialysis building was found in compliance with LSC requirements for hospitals.

IV. A recertification survey for compliance with the Life Safety Code (LSC) (2000 existing business occupancy) was conducted from 11/28/11 through 11/30/11. The Rapid City Regional Hospital Heart Doctors' building (4150 5th Street, Rapid City, SD) was found in compliance with LSC requirements for hospitals.

A. Based on observation and interview, the provider failed to ensure the following in one of one areas (Virology Lab):
- A plug mold was ground fault circuit interrupter (GFCI) protected.
- Permanent wiring was used.
Findings include:

1. Observation at 1:50 p.m. on 11/30/11 revealed a plug mold had been installed over the two outlets located within six feet of the sink in the Virology Lab. That plug mold had three different types of medical testing devices plugged into it. There was no identifying label or test switch to ensure that plug mold had a GFCI. Interview with the DSS at the time of the observation confirmed that finding. He stated he was not aware if that line was GFCI protected. A multiple tap adapter was in-use for the plug mold on the other wall of the lab versus permanent wiring. Interview with the DSS at the time of observation confirmed that condition. He stated he was aware those devices were not acceptable in healthcare facilities. The DSS removed the multi-tap adapter at that time.

Interview at 9:00 a.m. on 12/1/11 with the DSS revealed he had the plug mold line tested in the Virology lab, and it was not GFCI protected. He stated maintenance was to install GFCI protection on the line that morning.



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The provider must comply with National Fire Protection Association (NFPA) 70 article 517-18 General Care Areas and article 305 Temporary wiring.

Based on observation and interview, the provider failed to install hospital grade electrical outlets in the cardiac treatment room and did not provide permanent wiring for equipment located in the tech center control room. Findings include:

1. Observation at 11:30 a.m. on 11/29/11 revealed non-hospital grade electrical outlets in the cardiac treatment room of the west addition. The room was equipped with an exam table, treadmill, and several other medical devices which are to be used in direct contact with patients. Those devices were all plugged into electrical outlets that did not have any designation indicating they were hospital grade or indication of which circuits they were connected to. Interview with the plant operations supervisor at that time revealed he agreed with that finding. He was unaware that non-hospital grade electrical outlets had been installed in the building.

2. Observation at 11:00 a.m. on 11/29/11 revealed computers and audiovisual equipment were plugged into power strips in the tech center control room. Interview with the plant operations supervisor at that time revealed this equipment was recently relocated to that room and permanent wiring should have been located in that room.