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Based on a review of the facility's Emergency Plan, record review, and staff interview, it was determined that the facility failed to develop a facility-based risk assessment and include all the identified risks as a policy in its emergency plan. Failure to establish emergency plans based on a facilities-based risk assessment poses a potential danger. It may cause harm to the patients and staff during an emergency if the specific needs of both the patient and staff are not identified as part of the EP plan.

Findings include:

Observations made during a document review on December 4, 2024, revealed that the facility failed to write a policy for each of the hazards identified in the facility-based risk assessment. The HVA identified mass casualty as a risk for the facility but did not create a plan for dealing with this risk.

Employees #1 and #2 confirmed during the exit conference that the HVA/risk assessment identified risks not addressed in the policies.

Based on the document review, it was determined that the facility did not identify exit corridors for some patients. Failure to correctly identify exit corridors could result in patients being unable to find the nearest exit in the event of a fire.

NFPA 101 Life Safety Code 2012 edition, Chapter 19 Existing Health Care Occupancies
Section 19.2.5.6 Corridor Access.19.2.5.6.1* Every habitable room shall have an exit access door leading directly to an exit access corridor unless otherwise provided in 19.2.5.6.2, 19.2.5.6.3, and 19.2.5.6.4.
19.2.1 General.
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.
7.8.1 General.
7.8.1.1*
Illumination of means of egress shall be provided in accordance with Section 7.8 for every building and structure where required in Chapters 11 through 43. For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, aisles, corridors, ramps, escalators, walkways, and exit passageways leading to a public way.
The means of egress (i.e., exit access, exit, and exit discharge) encompasses practically all spaces where persons can be present. The subject addressed by Section 7.8 is illumination of means of egress. It would seem that the title of Section 7.8 indicates that such illumination needs to be provided throughout all portions of the exit access, the exit, and the exit discharge, but this is not so. Illumination is required throughout the exit (e.g., an enclosed exit stair or exit passageway). Yet, 7.8.1.1 clarifies that, for the purposes of applying the requirements of Section 7.8, the portions of the exit access and exit discharge requiring illumination are only the "designated" egress paths, such as aisles, corridors, stairs, and ramps. "Designated" is meant to indicate designation by the authority having jurisdiction (AHJ). For example, most authorities having jurisdiction do not designate the space within an individual's work cubicle as a portion of the exit access required to be illuminated, but the aisles serving multiple cubicles are typically designated as requiring illumination.
Illumination of means of egress is not required unless specifically called for in the appropriate occupancy chapter. However, all occupancy chapters do require illumination, but there are a few exemptions. For example, in new assembly occupancies, 12.2.8 exempts private-party tents not larger than 1200 ft2 (112 m2) from the illumination requirement. Subsection __.2.8 (e.g., 36.2.8 for new mercantile occupancies) of each occupancy chapter provides illumination requirements.
7.8.1.2
Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use, unless otherwise provided in 7.8.1.2.2. 7.8.1.2.1 Artificial lighting shall be employed at such locations and for such periods of time as are necessary to maintain the illumination to the minimum criteria values herein specified.
7.10.1.1 Where Required. Means of egress shall be marked in accordance with Section 7.10 where required in Chapters 11 through 43. 7.10.1.2 Exits. 7.10.1.2.1* Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access. 7.10.1.2.2* Horizontal components of the egress path within an exit enclosure shall be marked by approved exit or directional exit signs where the continuation of the egress path is not obvious.

Findings include:

Observations during the tour conducted on December 3-5, 2024, revealed that the Med Surgery and Labor and Delivery areas were modified in August 2022 per documents provided by the facility. Both places were left with hallways containing patient rooms that do not lead to a marked exit corridor. Hallways on both sides and connecting Med Surg and Labor and Delivery do not have any visible exit signs from the patient room exit doors. The facility could not provide documents proving review by the Authority Having Jurisdiction (AHJ)approval showing the State Department of Health approval or notification or a Waiver approval from CMS from the Life Safety Code.

Employees #1 and #2 confirmed they could not find documents proving a building permit was acquired. The city AHJ did not review and approve variations from the Life Safety Code or International Building Code. CMS did not provide documents waiving the requirements for compliance with the Life Safety Code..

Based on a record review, it was determined that the facility failed to perform quarterly inspections of its sprinkler systems. Failing to perform the required inspections may cause harm to patients and staff.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.1. "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, 2011 Edition, "Standard for the Inspection, Testing , and Maintenance of Water-Based Fire Protection Systems." NFPA 25, 2011 Edition, "Water Based Extinguishment Systems," requires monthly, quarterly, and annual testing of automatic sprinkler systems.

Findings Include:

Observations while on tour on December 3-5, 2024, revealed the facility failed to show proof of quarterly testing of the sprinkler systems in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. The facility was conducting Simi annual testing but did not have quarterly testing conducted by the vendor as required in NFPA 25.

Employees #1 and #2 confirmed during the exit conference that the facility failed to conduct the required quarterly testing of the sprinkler systems.

Based on the document review, the facility did not have a policy addressing suppression systems that were out of service. Failure to address requirements for suppression systems out of service could result in a fire not being stressed, putting patients and staff members in danger if a fire were to occur.

NFPA 101 Life Safety Code 2012 edition
Chapter 9 Building Service and Fire Protection Equipment
Section 9.6.1.6* Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated, or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

NFPA 25 2011 edition. standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Chapter 15 Impairments. Section 15.4 Impaired Equipment.
15.4.1 The impaired equipment shall be considered to be the water-based fire protection system or part thereof that is removed from service. 15.4.2 The impaired equipment shall include, but shall not be limited to, the following:
(1) Sprinkler systems.
(2) Standpipe systems
(3 )Fire hose systems
(4) Underground fire service mains
(5) Fire pumps
(6) Water storage tanks
(7) Water spray fixed systems
(8) Foam-water systems
(9) Fire service control valves
Section 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 has been determined.
(2) The areas or buildings involved have been inspected, and the increased risks have been 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, the 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.
(9) All necessary tools and materials have been assembled on the impairment site.

Findings include:

Observation during document review on December 3- 5, 2024, revealed that the facility had a policy addressing out-of-service fire alarm systems but did not address out-of-service suppression systems. The policy did not discribe actions to take and how to do fire watch.

Employees #1 and #2 confirmed during the exit conference that policy addressing fire alarms did not address fire protection / suppression systems

Based on observation, it was determined that the facility had fire doors that did not fully close and latch upon release. Failing to protect resident sleeping rooms from heat or smoke will harm residents and staff.

NFPA 101, Life Safety Code, 2012 edition, Chapter 19, Section 19.3.6.3.5. "Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction."
NFPA 101, Life Safety Code, 2012 edition, Chapter 19, Section 19.3.6.3 Corridor Doors
Section 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1-3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Doors shall be provided with a means suitable for keeping the door closed.

Findings Include:

During a facility tour conducted on December 3-5, 2024, revealed two fire/smoke barrier doors did not close and latch when released from the hold-open magnets. These doors did not pass annual inspections by the facility

Employees #1 and #2 confirmed some doors did not close and latch during testing

Based on observation, interview, and record review, it was determined that the facility failed to inspect and maintain its fire /smoke dampers or fusible links. Failure to inspect and maintain the facility's smoke dampers may harm the patients and staff.

NFPA 101 Life Safety Code, 2012 Edition Chapter 21, section 21.5.2.1 "Heating, ventilating and air conditioning shall comply with the provisions of section 9.2 and shall be installed in accordance with the manufacture's specifications" Section 9.2.1 " Air Conditioning, Heating, Ventilating, Ductwork, and Related Equipment." Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90 A." "Standard for Installation of Air Conditioning and Ventilating Systems, NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protective's.

NFPA 90 A 2012 Edition Section 5.4.8 Maintenance Section 5.4.8.1 Fire dampers and ceiling dampers shall be maintained in accordance with NFPA 80 Standard for Fire Doors and Other opening Protective's. Section 5.4.8.2 Smoke dampers shall be maintained in accordance with NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protective's.

NFPA 80 Standard for Fire Doors and Other opening Protective's Chapter 19 Installation, Testing, and Maintenance of Fire Dampers, Section 19.4* Periodic Inspection and Testing The test and inspection frequency shall be every 4 years, except in hospitals, where the frequency shall be every six years.

Section 19.4.4 if the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in place if so equipped. Section 19.4.5 The operational test of the fire damper shall verify that there is no damper interference due to rusted, bent, misaligned, or damaged frame or blades, or defective hinges or other moving parts. Section 19.4.6 The damper frame shall not b penetrated by any foreign objects that would effect fire damper operations. Section 19.4.7 The fusible link shall be reinstalled after testing is complete. Section 19.4.8.1 if the link is damaged or painted, it shall be replaced with a link of the same size, temperature and rating. Section 19.4.9 All inspections and testing shall be documented, indicating the location of the fire damper or combination fire/smoke damper, date of inspection, name of inspector, and deficiencies discovered. Section 19.4.9.1 The documentation shall have a space to indicate when and how the deficiencies were corrected. Section 19.4.11 Periodic inspections and testing of a combination fire/smoke damper shall also meet the inspection and testing requirements contained in Chapter 6 of NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protective's.

NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protective's Chapter 6 Installation, Testing and Maintenance smoke dampers. Section 6.5.2 Each damper shall be tested and inspected one year after installation. The test and inspection frequency shall then be every 4 years, except hospitals, where the frequency shall be every 6 years.

Section 6.5 Periodic Inspection and Testing. Section 6.5.11 All inspections and testing shall be documented, indicating the location of the fire damper or combination fire/smoke damper, date of inspection, name of inspector, and deficiencies discovered. Section 19.4.9.1 The documentation shall have a space to indicate when and how the deficiencies were corrected. Section 6.5.11

Section 6.6 Maintenance.

Section 6.6.1 Any reports of abrupt changes in airflow or noise from the duct system shall be investigated to verify that it is not related to damper operation. Section 6.6.2* All exposed moving parts of the damper shall be dry lubricated as required by the manufacturer. Section 6.6.3 if the damper is not operable, repairs shall begin as soon a s possible. Section 6.6.4 Following any repairs, the damper shall be tested for proper operation in accordance with Section 6.6.5 Smoke damper actuation shall be initiated at a time interval recommended by the actuator manufacturer. Section 6.6.6 All maintenance shall be maintained and records shall be retained in accordance with 6..5.11 and 6.5.12.

Findings Include:

The facility documentation reviewed on December 3-5, 2024, revealed that the facility had fire or smoke dampers. Still, no documentation indicated that the smoke dampers had been maintained in the past six years. The paperwork provided only showed documentation of testing conducted in 2014.

Employees #1 and #2 confirmed they did not have proof of damper testing in the last six years.

Based on the document review, it was determined that the facility did not provide an up-to-date patient smoking policy for the hospital. Failure to have a current smoking policy could harm patients if it violates state law and could result in a fire from mishandled smoking materials.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.7.4 "Smoking regulations shall be adopted and shall include not less than the following provisions:
Smoking Regulations:
Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking. (2) In healthcare occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required. (3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 19.7.4 (3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. (6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available in all areas where smoking is permitted.

Findings include:

Observations during a review of facility documentation conducted on December 3-5, 2024, revealed that the policy reviewed had not been updated since April 4, 2008, and did not include the current state regulations or the above-listed required information from NFPA 101, the Life Safety Code.

Employees #1 and #2 confirmed that the smoking policy provided was last reviewed in 2008 and did not include the required information.

Based on Observation, it was determined that the facility allowed the use of power strips but did not mount to the equipment in the operating rooms. Failure to properly use power strips and outlets could lead to electrical overload or fire, harming the patients and staff.

NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2 , "All Patient Care Areas," Sections 6.3.2.2..6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.
CMS S&C: 14-46-LSC- Life Safety Code surveyors assess the use of power strips in healthcare facilities. However, the following guidance is provided as reference for healthcare surveyors as they survey physical environment along with other CoP requirements. Any observed power strip deficiencies should be conveyed to the LSC surveyors for citation.
If line-operated medical equipment is used in a patient care room/area, inside the patient care vicinity:
o UL power strips would have to be a permanent component of a rack-, table-, pedestal-, or cart-mounted & tested medical equipment assembly
o Power strips providing power to medical equipment in a patient care room/area must be UL 1363A or UL 60601-1
o Power strips cannot be used for non-medical equipment
If line-operated medical equipment is used in a patient care room/area, outside the patient care vicinity:
o UL power strips could be used for medical & non-medical equipment with precautions as described in the memo
o Power strips providing power to medical equipment in a patient care room/area must be UL 1363A or UL 60601-1
o Power strips providing power to non-medical equipment in a patient care room/area must be UL 1363
If line-operated medical equipment is not used in a patient care room/area, inside and outside the patient care vicinity:
o UL power strips could be used with precautions
Power strips providing power to non-medical equipment in a patient care room/area must be UL 1363. In non-patient care areas/rooms, other UL strips could be used with the general precautions.

Findings include:

Observations made during the tour from December 3-5, 2024, revealed that both of the operating rooms had power strips that were not mounted to a rack, table, pedestal, or cart-mounted and tested medical equipment assembly.

Employees # 1 and #2 confirmed the improper use of power strips by not having them permanently mounted to equipment in the operating rooms.

Based on Observation, the facility failed to store full oxygen (O2) cylinders properly. This could result in the combustible items becoming oxygen-saturated and easily ignitable which could cause a fire to start prematurely. Failing to store oxygen properly could result in personnel entering the area unaware of the hazards.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 11 Section 11.6.2.3 (11) Free standing cylinders shall be properly chained or supported in a proper cylinder stand or cart."

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 11 Section 11.6.5. Special Precautions - Storage of Cylinders and Containers. Section 11.6.5.4 #3 During summer, screened against continuous exposure to direct rays of the sun in those localities where extreme temperatures prevail.
NFPA Chapter 5 section 5.1.3.3.1.7
Cylinders in use and in storage shall be prevented from reaching temperatures in excess of 54°C (130°F).
NFPA 99: Health Care Facilities Code, 2012 Edition - Chapter 11 Gas Equipment Section 11.3.4.1 'A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure. 11.3.4.2 The sign shall include the following wording as a minimum: CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING"
NFPA 99: Health Care Facilities Code, 2012 Edition - Chapter 11 Gas Equipment Section 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
Findings include:
While on tour conducted on December 3-5, 2024, observation revealed the following locations with Oxygen being stored properly in areas within 5 feet of combustible materials combustible construction and not labeled correctly in the following areas.
1. Emergency room storage room: two full bottles in the empty rack
2. The Care Coordinator Office is not labeled full or empty and within 5 feet of combustibles

Oxygen storage on the helicopter pad reveals one cylinder on a cart exposed to direct sunlight. The facility was not able to prove that the temperature in direct sunlight would not reach 130°.

All the oxygen storage areas did not have proper labeling on the doors.

Employees #1 and #2 confirmed throughout the tour that oxygen is improperly stored throughout the facility.

Based on record review and interviews with staff, it was determined the facility failed to have a documented fire loss prevention program in operating rooms. Failure to establish procedures for operating room emergencies and periodic evaluations made of hazards that could be encountered during surgical procedures could lead to patient injury or death.

NFPA 99 2012 Edition, Section 15.13 Fire Loss Prevention in Operating Rooms. Section 15.13.1.1 "An evaluation shall be made of hazards that could be encountered during surgical procedures." Section 15.13.1.2 "The evaluation shall include hazards associated with the properties of electricity, hazards associated with the operation of surgical equipment, and hazards associated with the nature of the environment." Section 15.13.3.8 "Health care organizations shall establish policies and procedures outlining safety precautions related to the use of flammable liquid or aerosol germicides or antiseptics used in anesthetizing locations, as required in 15.14.1, whenever the use of electrosurgery, cautery, or a laser is contemplated." Section 15.13.3.9.1 "Procedures for operating room/surgical suite emergencies shall be developed." Section 15.13.3.9.2 "Procedures shall include alarm actuation, evacuation, and equipment shutdown procedures and provisions for control of emergencies that could occur in the operating room, including specific detailed plans for control operations by an emergency control group within the organization or a public fire department." Section 15.13.3.10.1 "New operating room/surgical suite personnel, including physicians and surgeons, shall be taught general safety practices for the area and specific safety practices for the equipment and procedures they will use."

Findings include:

During a review of the facility's documentation conducted on December 3-5, 2024, it was revealed that the policy pertaining to fire loss did not address fires in the operating rooms.

Employees #1 and #2 confirmed during the exit conference that the policy provided for a fire did not address a fire in the operating rooms..