HospitalInspections.org

Based on review of facility documents, staff interviews, and observations, it was determined that the Governing Body failed to demonstrate it is effective in carrying out the responsibilities for the operation and management of the hospital.
The Governing Body failed to provide necessary oversight and leadership as evidenced by the lack of compliance with the following Conditions of Participation:

CFR 482.41 Physical Environment
CFR 482.41(b) Life Safety Code Standard

Based on observation, document review, and staff interview conducted on 9/20 and 9/21/17, it was determined that the facility failed to ensure the hospital is maintained for the safety of patients.

Findings include:

1. The facility failed to ensure the overall hospital environment is maintained for the safety and well-being of patients (Cross refer to Tag 701).

2. The facility failed to comply with the 2012 edition of the National Fire Protection Association's Life Safety Code (Cross refer to Tag 709).

Based on observation, it was determined that the facility failed to ensure the overall hospital environment is maintained for the safety and well-being of patients.

Findings include:

1. On 9/20/17 at 1:25 PM, in the presence of Staff #3, the edges of the counter at the Nurse's Station within the Surgical Intensive Care Unit (SICU), was chipped and peeling, exposing a porous surface that can not be cleaned.

2. On 9/20/17 at 1:45 PM, in the presence of Staff #3 in the SICU, the paint on the wall in Room #14 was peeling and chipped, exposing a porous surface that can not be cleaned.

3. On 9/20/17 at 2:00 PM, in the presence of Staff #3 in the Same Day Recovery Unit, the wall paper was peeling in the following rooms:

a. E 312

b. E 309

c. E 314

d. E 315

e. E 319

4. On 9/20/17 at 2:10 PM, in the presence of Staff #3 in the Same Day Recovery Unit, the strut for the flip down computer terminal was broken loose from the cover.


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5. On 9/21/17 at 10:30 AM, in the presence of Staff #5 and Staff #6 in Utility Room #F 335, dust accumulations was observed on the ceiling mounted heating and air conditioning diffuser.

6. On 9/21/17 at 10:30 AM, in the presence of Staff #5 and Staff #6 in the "F" Blue Pediatric Unit, painted wood-like trim material located at the Nurse's Station was worn, exposing a porous surface that could not be properly cleaned.

Based on observation, document review, and staff interviews, it was determined that the facility failed to ensure compliance with the 2012 edition of the National Fire Protection Association's Life Safety Code.

Findings include:

Reference #1: 2012 edition of the National Fire Protection Association's Life Safety Code, "101:7.2.1.6.2(1) ... A sensor shall be provided on the egress side, arranged to unlock the door leaf in the direction of egress upon detection of an approaching occupant."

Reference #2: 2012 edition of the National Fire Protection Association's Life Safety Code, "101:19.2.5.7.2.2 ... Sleeping Suites of more than 1,000 square feet shall have not less than two exits access doors remotely located from each other."

Reference #3: 2012 edition of the National Fire Protection Association's Life Safety Code, "101:7.5.1.3.2 ... Where two exits, exit accesses, or exit discharges are required, they shall be located at a distance from one another not less than one-half the length of the maximum overall diagonal dimension of the building or area to be served, measured in a straight line between the nearest edge of the exits, exit accesses, exit discharges, unless otherwise provided in 7.5.1.3.3 through 7.5.1.3.5."

Reference #4: 2012 edition of the National Fire Protection Association's Life Safety Code, "101:19.2.5.7.2.3(B) ... Sleeping suites shall not exceed 7,500 square feet where the smoke is protected throughout by one of the following: (1) Approved electrically supervised sprinkler system in accordance with 19.3.5.7 and total coverage (complete) automatic smoke detection in accordance with 9.6.2.9 and 19.3.4 (2) Approved electronically supervised sprinkler system protection complying with 19.3.5.8."

Reference #5: 2012 edition of the National Fire Protection Association's Life Safety Code, "101:9.6.1.3 ... A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electric Code and NFPA 72, National Fire Alarm and Signaling Code."

Reference #6: 2012 edition of the National Fire Protection Association's Life Safety Code, "101:2.1 ... General. The Documents referred in this chapter, or portions of such documents, are referenced within this code, shall be considered part of the requirements of this code, and the following shall also apply: ... 2.2 NFPA Publications ... NFPA 70, National Electric Code, 2011 edition ... NFPA 72, National Fire Alarm and Signaling Code, 2010 edition ..."

Reference #7: 2010 edition of the National Fire Protection Association's National Fire Alarm and Signaling Code, "72:3.3.81 ... Emergency Communication System - Combination. Various emergency communication systems such as fire alarm, mass notification, ..., or others and which may be served through a single control system or through an interconnection of several control systems."

Reference #8: 2010 edition of the National Fire Protection Association's National Fire Alarm and Signaling Code, "72:3.3.79.1.1 ... Distributed Recipient Mass Notification System. A distributed recipient mass notification system is a system meant to communicate directly to the targeted individuals and groups that might not be in the contiguous area."

Reference #9: 2010 edition of the National Fire Protection Association's National Fire Alarm and Signaling Code, "72:24.4.2.20.5 ... In situations where existing notification appliances previously used exclusively for fire alarm applications, and are marked with the word "FIRE," and are to be used for other emergency notification purposes, field modifications to the markings shall be permitted, provided that it is accomplished by one of the following methods: (1) Replacement of the manufacturer's approved escutcheon or trim plate, (2) Covering of, or removal of, the word "FIRE" using a manufacturer's approved method, (3) Installation of a permanent sign directly adjacent or below the notification appliance indicating that it is multi-purpose and will operate for fire or other emergency conditions."

Reference #10: 2010 edition of the National Fire Protection Association's National Fire Alarm and Signaling Code, "72:24.4.2.7.3 ... Required Documentation. Every system shall include the following documentation, which shall be delivered to the owner or owners representative upon final acceptance of the system: (1) An owner's manual including a complete set of operating instructions and maintenance manuals, manufacturer's published instructions, and product data sheets covering all system equipment. (2) Record and as-built drawings. (3) One current copy of the record of completion form, updated to reflect all additions or modifications. (4) For soft-ware based systems, a record copy of the system specific software. (5) Emergency response plan, with operational management procedures defined for management and activation of the system."

Reference #11: 2011 edition of the National Fire Protection Association's National Electric Code, "70:110.26 Spaces About Electrical Equipment ... Access and working space shall be provided and maintained about all electrical equipment... (A) Working Space ... Working space for equipment operating at 600 volts, nominal or less...shall comply with the dimension of 110.26(A)(1)... Table 110.26(A)(1) Working Spaces Nominal Voltage to Ground 0-150 3 Minimum Clear Distance 914 mm (3 ft)..."

Reference #12: 42 CFR 482.14(b)(9) " ... Every patient sleeping room has an outside window or outside door."

1. On 9/20/17 at 1:00 PM, in the presence of Staff #3, the Critical Care Unit (CCU) Patient Sleeping Suite on Level "I," nine (9) of fifteen (15) patient sleeping rooms lacked a window or door to the outside. The rooms identified were #I 302, #I 303, #I 304, #I 305, #I 306, #I 313, #I 314, #I 315, and #I 316.

2. On 9/20/17 at 1:30 PM, in the presence of Staff #3, the Medical Intensive Care Unit (MICU) Patient Sleeping Suite on Level "I," two (2) of seventeen (17) patient sleeping rooms lacked a window or door to the outside. The two (2) rooms identified were #I 333 and #I 334.

3. On 9/20/17 at 2:00 PM, in the presence of Staff #3, the Surgical Intensive Care Unit (SICU) Patient Sleeping Suite on Level "E,", two (2) of seventeen (17) patient sleeping rooms lacked a window or door to the outside. The two (2) rooms identified were #13 and #14.

4. During a tour of the Emergency Department on 9/20/17 at 1:30 PM, in the presence of Staff #5 and Staff #6, it was identified that access-controlled egress locks were installed and functioning on emergency exits without a sensor on the egress side in the following locations: (Refer to Reference #1)

a. Exit door near Acute Room #18.

b. Exit door near Room #2.

c. Exit door near Room #C 345.

d. During an interview, Staff #7 confirmed that access-controlled egress locks were active and required a card to release the doors in the direction of egress.

5. On 9/20/17 at 2:00 PM, in the presence of Staff #5 and Staff #6, it was identified that access-controlled egress locks were installed and functioning without a sensor on the egress side at Horizontal Exits between the hospital and the Medical School, located on Levels B, C, G, H, and I. Refer to Reference #1.

3. On 9/21/17 at 11:00 AM, in the presence of Staff #3 and Staff #4, the Cardiothoracic Intensive Care Unit (CTICU) Suite was found to be over one thousand square feet and was not equipped with two (2) remote exits. Refer to Reference #2 and Reference #3.

a. A review of the facility Life Safety Code Plan for Level "E", revised on March 31, 2017, indicated the CTICU Sleeping Suite was 2,655 square feet.

6. On 9/20/17 at 1:00 PM, in the presence of Staff #3, the Critical Care Unit (CCU) Suite on Level "I" was found to be larger than five thousand square feet, and lacked an approved electronically supervised sprinkler system. Refer to Reference #4.

a. A review of the facility Life Safety Code Plan for Level "I", revised on March 31, 2017, indicated the CCU Sleeping Suite was 5,271 square feet.

7. On 9/20/17 at 1:30 PM, in the presence of Staff #3, the Medical Intensive Care Unit (MICU) Suite on Level "I" was found to be larger than five thousand square feet, and lacked an approved electronically supervised sprinkler. Refer to Reference #4.

a. A review of the facility Life Safety Code Plan for Level "I", revised on March 31, 2017, indicated the MICU Sleeping Suite was 5,292 square feet.

8. On 9/20/17 at 2:00 PM, in the presence of Staff #3, the Surgical Intensive Care Unit (SICU) Suite on Level "E", was found to be larger than five thousand square feet, and lacked an approved electronically supervised sprinkler system. Refer to Reference #4.

a. A review of the facility Life Safety Code Plan for Level "E", revised on March 31, 2017, indicated the SICU Sleeping Suite was 5,050 square feet.

9. During an interview on 9/21/17 with Staff #4, it was determined that the fire alarm system was used for alerting occupants of non-fire related emergencies within the building. The use of the fire alarm system for non-fire related emergency notifications has created a "Distributed Recipient Mass Notification System", which does not comply with the requirements of the National Fire Protection Association's National Fire Alarm and Signaling Code. Refer to Reference #5, Reference #6, Reference #7, Reference #8, Reference #9, and Reference #11.

a. Staff #4 confirmed the following:

i. This modification to the fire alarm system is used to alert law enforcement throughout the building when a patient "in custody" has escaped. Refer to Reference #8.

ii. Modifications were made to the fire alarm system without getting acceptance testing results or an operator's manual. Refer to Reference #5 and Reference #10.

iii. Upon request, there were no shop drawings or approved plans available for review. Refer to Reference #10.

iv. Buttons to activate the "Code Orange" system were installed in the Main Emergency Room, Radiology Core, Trauma Department, Fast Track, and Dental Clinic. A "Code Orange" is the facility's system for notifying staff that a prisoner has escaped. These buttons are wired directly into the Fire Alarm Control Panel. Refer to Reference #7.

v. The strobe lights for the fire alarm system are labeled,"FIRE", and activate throughout the hospital and alert all occupants when "Code Orange" is activated. Refer to Reference #9.

vi. An audible message is announced throughout the hospital providing "Code Orange" information to all occupants within the hospital. Refer to Reference #9.

vii. Existing notification devices labeled, "FIRE", which were previously used for fire alarm notifications only, are now used for notifying occupants of non-fire related emergencies. Refer to Reference #9.

10. On 9/21/17 at 10:30 AM, in the presence of Staff #5 and Staff #6 in Utility Room #F 335, the smoke alarm had detached from the ceiling mount. Refer to Reference #5.


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11. During a tour conducted at 10:30 AM, in the presence of Staff #5 and Staff #6, the breaker panels located within electrical room #F330 were found completely obstructed, and did not sustain a three foot frontal clearance. Refer to Reference #6.