HospitalInspections.org

Building A3-Main Hospital

Through observation during the survey, December 10 and 11, 2013, it was determined that the facility failed to maintain the doors to the corridor.

During the walk through of the facility, with the Maintenance Director;
1) The door to room #2519 failed to latch into the frame when closed
2) The "registration" area contained four (4) doors which;
a) Failed to properly latch into the frame when closed
b) Contained large gaps at the top of the doors which failed to maintained a positive smoke seal.
The area noted in (2) did not contain smoke detection and opened to a corridor system to an exit. The "registration areas" did not contain doors on the backside of each room and opened into a larger office with cubicles and staff areas. The area did not meet the requirements of 18.3.6.1 or the exceptions to 18.3.6.1.

Building A3-Main Hospital

Through observation during the survey, December 10 and 11, 2013, it was determined that the facility failed to construct smoke barriers to provide at least a smoke resistance rating.

During the walk through of the facility, with the Maintenance Director, three (3) smoke barrier walls contained wire penetrations or openings without fire caulking or other approved method of maintaining the fire rating of the wall:
1) Two (2) unsealed wire penetrations in the smoke barrier wall adjacent tothe kitchen
Note: Corrected during survey
2) The smoke barrier wall outside of the labratory (section where the addition was added) contained several areas of missing drywall or unsealed penetrations;
a) large five foot by six foot (5'x6') area missing drywall at the north end
b) one (1) ductwork penetration at the south end of the wall
c) two (2) large sections opf drywall missing at the "Info systems" wall.

Building A3-Main Hospital

Through observation during the survey, December 10 and 11, 2013, it was determined that the facility failed to maintain the hazardous area separation as required.

During the walk through of the facility, with the Maintenance Director, the boiler room, #1410A, contained one (1) unsealed four inch (4") sprinkler pipe penetration through the onr hour (1) rated wall assembly.

Building A3-Main Hospital

Through observation during the survey, December 10 and 11, 2013, it was determined that the facility failed to arrange the exit access so that exits are readily accessible at all times.

During the walk through of the facility, with the Maintenance Director;
1) The facility utilized a delayed egress lock on the second (2nd) floor egress door. The delayed egress contained a "pre-alarm" on the door which alarmed for the first three (3) seconds before initiating the irreversible process.
Per section 7.2.1.6.1(c) states in part "The initiation of the release process shall activate an audible alarm in the vicinity of the door."
2) The exit path, exterior sidewalk outside of the the operating rooms, contained a layer of snow , approximateli one inch (1") deep, on the sidewalk which prevented a clear egress path to a public way.

Building AB-Hwy 50

Through observation during the survey, December 10 and 11, 2013, it was determined the facility failed to test the connect all battery back-up lighting as required.

During the re-certification survey, with the Maintenance Director, documentation was not available to indicate that the battery back up emergency lights were tested every month for thirty (30) seconds and yearly for ninety (90) minutes.
Per NFPA 101, section 7.9.3.

Building A3-Main Hospital

Through record review during the survey, December 10 and 11, 2013, it was determined that the facility failed to conduct fire drills at least quarterly on each shift.

During the review of the facility records, with the Maintenance Director, documentation was not available to verify the facility conducted a fire drill on all shifts during the 2013 calendar year. Documentation could not be located for fire drills for;
1) Missing 1st quarter 2nd shift drill
2) Missing 1st quarter 3rd shift drill
3) Missing 2nd quarter 2nd shift drill
4) Missing 3rd quarter 1st shift time of drill on documentation (drill completed 9-17-13)
5) Missing 3rd quarter 2nd shift time of drill on documentation (drill completed 9-30)

Building A3-Main Hospital

Through observation and record review during the survey, December 10 and 11, 2013, it was determined that the facility is not testing the smoke detection system in accordance with the manufacturer's specifications.

During the review of records, with the Maintenance Director, the annual fire alarm inspection stated that three (3) duct detectors (#M1-30, #M1-33, and #M1-34) could not be tested due to they were located in a "sterile" area. These three (3) duct detectors were located in the OR suite and could not be tested due to surgeries being conducted. Documentation was not available to indicate that the duct detectors had been tested after the annual inspection.
Per NFPA 72, section 7-3.2

Building AA-Buena Vista

Through a review of the records during the survey, December 10 and 11, 2013, it was determined that the facility failed to maintain the fire alarm system.

During the review of the facility records, with the Maintenance Director;
1) Documentation during the annual fire alarm system test, dated October 28, 2013, indicated that the smoke detector in the elevator machine room did not recall the elevator as required. Documentation was not available to indicate that the repair had been made to the recal function.
2) One (1) manual pull station was obstructed by a plant in the main lobby.
Per NFPA 72, sections 2-8.2.1 and

This deficiency effected one smoke compartment of the structure.

Building A3-Main Hospital

Through observation during the survey,December 10 and 11, 2013, it was determined that the facility failed to install an automatic sprinkler system per NFPA 13.

During the walk through of the facility, with the Maintenance Director;
1) One (1) sprinkler head, located outside of the elevator, is located more than seven foot six inches (7'6") off fo the double door.
2) X-ray room #2 contained two (2) sprinkler heads which were obstructed by the x-ray machine rack system.
Per NFPA 13, section 5-6
3) Three (3) combustible awnings located outside of the cafateria where attached to the building and extended more than four feet (4') from the building.
Per 19.3.5.1, 9.7.1.1 and NFPA 13 1999 Edition 5-13.8.1.

Building A3-Main Hospital

Through observation and record review during the survey, December 10 and 11, 2013, it was determined the facility failed to inspect, test and maintain the automatic sprinkler system per NFPA 25.

During the walk through and documentation review of the facility, with the Maintenance Director, documentation was not available to indicate the quarterly testing of the sprinkler system alarm devices and main drain as required.
Per 1999 Edition of NFPA 25, Chapter 2, section 2-3.3.

Building AA-Buena Vista

Through observation during the survey, December 10 and 11, 2013, it was determined the facility failed to maintain the automatic sprinkler system in reliable operating condition per the 1999 Edition of NFPA 25.

During the walk through and documentation review, with the Maintenance Director, the annual inspection paperwork, dated October 28, 2013, indicated deficiencies and paperwork was not available to indicate the repairs were corrected.
1) The anti freeze system tested low, indicated a 13 degree F range, and that the antifreeze needed to be replaced.
2) One (1) sprinkler head, located in the west attic on the southeast end, contained corrosion.
3) Backflow test, completed on October 28, 2013, indicated the backflow failed the yearly test on check valve #1 and #2. The tag on the backflow stated "failed" and documentation was not available to indicate a repair of the backflow.

This deficiency effected the entire structure.

Building AA- Buena Vista

Through observation during the survey, December 10 and 11, 2013, it was determined the facility failed to maintain all portable fire extinguishers as required.

During the walkthrough of the facility, with the Maintenance Director, one (1) extinguisher, located adjacent to the main check in reception desk, was onstructed by a christmas tree.
Per NFPA 10, section E-2.

Building A3-Main Hospital

Through observation during the survey, October 10 and 11, 2013, it was determined that the facility failed to continuously maintain the means of egress free of all obstructions or impediments to full instant use in case of fire or other emergency.

During the walkthrough of the facility, with the Maintenance Director, the facility contained storage of items in the corridor in the following locations;
1) One (1) bed and two (2) laundry carts were stored in the corridor outside of the x-ray suite west corridor.
2) The corridor adjacent to the emergency room contained two (2) wheelchairs, one (1) resident bed, and (1) rollaway x-ray machine stored in the corridor for more than thirty (30) minutes.
Note: x-ray machine and wheelchairs were moved during the survey.
Per 7.1.10 " Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use. " The following areas contained the "chart keepers"
3) The egress path through the dining room contained chairs and tables obstructing the egress path and dimishing the width of the corridor to less than eight feet (8'). The path is designated as an egress and muist be maintained as a corridor.

Building A3-Main Hospital

Through observation during the survey, December 10 and 11, 2013, it was determined that the facility was allowing the use of flammable decorations.

During the walk through of the facility, with the Maintenance Director, the facility contained christmas decorations throughout the facility. Documentation was not available to indicate the decorations met the requirements of NFPA 701.
1) Four (4) christmas trees located throughout the facility outside of X-ray waiting, X-ray suite, emergency room, second floor corridor.
2) Christmas decoration throughtout the facility such as garalnd on the wall in the labratory, stockings on the wall in the emergency room, decorations on the wall in the x-ray suite.

Building A3-Main Hospital

Through observation and record review during the survey, December 10 and 11, 2013, 2010, it was determined that the facility failed to provide curtains that comply with NFPA 701 in all areas.

During record review and walk through of the facility, with the Maintenance Director, curtains located throughout the facility did not contain tags or markings showing that they met NFPA 701 requirements.
1) Draperies in the sleep lab rooms
2) One (1) loose hanging quilt outside of the cafateria
3) One (1) loose hanging quilt located outside of the elevators on the first (1st) floor

Building A3-Main Hospital

Through record review during the survey, December 10 and 11, 2013, it was determined that the facility failed to maintain the generator emergency function.

During the review of the facility record and observation, with the Maintenance Director:
1) Documentation was not available to indicate the monthly amperage readings during the monthly load test of the emergency generator.
2) Documentation was not available to indicate a yearly load bank test had been conducted.
The Maintenance Director stated that they know that the facility does not hit the thirty percent (30%) load on a monthly basis to disregard the yearly load bank test.
Per 2000 Edition of NFPA 101, chapter 20 section 20.2.9.2, NFPA 99 3-4.4.1.1, and 1999 Edition of NFPA 110 6-4.2 " Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
a. Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
b. Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. "
And section 6.4.2.2 " Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours. "

Building A3-Main Hospital

Through observation during the survey, December 10 and 11, 2013, it was determined the facility failed to maintain all battery back-up lighting as operational.

During operational testing, with the Maintenance Director, three (3) emergency lights failed to operate when the test button was pushed.
1) Two (2) emergency lights in room #1412
2) One (1) emergency light in room #1413

Building A3-Main Hospital

Through observation during the survey, December 10 and 11, 2013, it was determined that the facility failed to install and maintain the electrical system in accordance with NFPA 70.

During the walk through of the facility with the Maintenance Director, the facility utilized extension cords or power-strips as a substitute for the fixed wiring of the structure.
1) One (1) extension cord in use in FBC managers office #2406
2) One (1) refrigerator plugged into a powerstrip in the FBC area
Per NFPA 70, Chapter 4, Article 400, Paragraph 400.8, (" ... flexible cords and cables shall not be used for the following: (1) as a substitute for the fixed wiring of a structure ... ").

Building A3-Main Hospital

Through observation during the survey, December 10 and 11, 2013, it was determined that the facility failed to maintain the doors to the corridor.

During the walk through of the facility, with the Maintenance Director;
1) The door to room #2519 failed to latch into the frame when closed
2) The "registration" area contained four (4) doors which;
a) Failed to properly latch into the frame when closed
b) Contained large gaps at the top of the doors which failed to maintained a positive smoke seal.
The area noted in (2) did not contain smoke detection and opened to a corridor system to an exit. The "registration areas" did not contain doors on the backside of each room and opened into a larger office with cubicles and staff areas. The area did not meet the requirements of 18.3.6.1 or the exceptions to 18.3.6.1.

Building A3-Main Hospital

Through observation during the survey, December 10 and 11, 2013, it was determined that the facility failed to construct smoke barriers to provide at least a smoke resistance rating.

During the walk through of the facility, with the Maintenance Director, three (3) smoke barrier walls contained wire penetrations or openings without fire caulking or other approved method of maintaining the fire rating of the wall:
1) Two (2) unsealed wire penetrations in the smoke barrier wall adjacent tothe kitchen
Note: Corrected during survey
2) The smoke barrier wall outside of the labratory (section where the addition was added) contained several areas of missing drywall or unsealed penetrations;
a) large five foot by six foot (5'x6') area missing drywall at the north end
b) one (1) ductwork penetration at the south end of the wall
c) two (2) large sections opf drywall missing at the "Info systems" wall.

Building A3-Main Hospital

Through observation during the survey, December 10 and 11, 2013, it was determined that the facility failed to maintain the hazardous area separation as required.

During the walk through of the facility, with the Maintenance Director, the boiler room, #1410A, contained one (1) unsealed four inch (4") sprinkler pipe penetration through the onr hour (1) rated wall assembly.

Building A3-Main Hospital

Through observation during the survey, December 10 and 11, 2013, it was determined that the facility failed to arrange the exit access so that exits are readily accessible at all times.

During the walk through of the facility, with the Maintenance Director;
1) The facility utilized a delayed egress lock on the second (2nd) floor egress door. The delayed egress contained a "pre-alarm" on the door which alarmed for the first three (3) seconds before initiating the irreversible process.
Per section 7.2.1.6.1(c) states in part "The initiation of the release process shall activate an audible alarm in the vicinity of the door."
2) The exit path, exterior sidewalk outside of the the operating rooms, contained a layer of snow , approximateli one inch (1") deep, on the sidewalk which prevented a clear egress path to a public way.

Building AB-Hwy 50

Through observation during the survey, December 10 and 11, 2013, it was determined the facility failed to test the connect all battery back-up lighting as required.

During the re-certification survey, with the Maintenance Director, documentation was not available to indicate that the battery back up emergency lights were tested every month for thirty (30) seconds and yearly for ninety (90) minutes.
Per NFPA 101, section 7.9.3.

Building A3-Main Hospital

Through record review during the survey, December 10 and 11, 2013, it was determined that the facility failed to conduct fire drills at least quarterly on each shift.

During the review of the facility records, with the Maintenance Director, documentation was not available to verify the facility conducted a fire drill on all shifts during the 2013 calendar year. Documentation could not be located for fire drills for;
1) Missing 1st quarter 2nd shift drill
2) Missing 1st quarter 3rd shift drill
3) Missing 2nd quarter 2nd shift drill
4) Missing 3rd quarter 1st shift time of drill on documentation (drill completed 9-17-13)
5) Missing 3rd quarter 2nd shift time of drill on documentation (drill completed 9-30)

Building A3-Main Hospital

Through observation and record review during the survey, December 10 and 11, 2013, it was determined that the facility is not testing the smoke detection system in accordance with the manufacturer's specifications.

During the review of records, with the Maintenance Director, the annual fire alarm inspection stated that three (3) duct detectors (#M1-30, #M1-33, and #M1-34) could not be tested due to they were located in a "sterile" area. These three (3) duct detectors were located in the OR suite and could not be tested due to surgeries being conducted. Documentation was not available to indicate that the duct detectors had been tested after the annual inspection.
Per NFPA 72, section 7-3.2

Building AA-Buena Vista

Through a review of the records during the survey, December 10 and 11, 2013, it was determined that the facility failed to maintain the fire alarm system.

During the review of the facility records, with the Maintenance Director;
1) Documentation during the annual fire alarm system test, dated October 28, 2013, indicated that the smoke detector in the elevator machine room did not recall the elevator as required. Documentation was not available to indicate that the repair had been made to the recal function.
2) One (1) manual pull station was obstructed by a plant in the main lobby.
Per NFPA 72, sections 2-8.2.1 and

This deficiency effected one smoke compartment of the structure.

Building A3-Main Hospital

Through observation during the survey,December 10 and 11, 2013, it was determined that the facility failed to install an automatic sprinkler system per NFPA 13.

During the walk through of the facility, with the Maintenance Director;
1) One (1) sprinkler head, located outside of the elevator, is located more than seven foot six inches (7'6") off fo the double door.
2) X-ray room #2 contained two (2) sprinkler heads which were obstructed by the x-ray machine rack system.
Per NFPA 13, section 5-6
3) Three (3) combustible awnings located outside of the cafateria where attached to the building and extended more than four feet (4') from the building.
Per 19.3.5.1, 9.7.1.1 and NFPA 13 1999 Edition 5-13.8.1.

Building A3-Main Hospital

Through observation and record review during the survey, December 10 and 11, 2013, it was determined the facility failed to inspect, test and maintain the automatic sprinkler system per NFPA 25.

During the walk through and documentation review of the facility, with the Maintenance Director, documentation was not available to indicate the quarterly testing of the sprinkler system alarm devices and main drain as required.
Per 1999 Edition of NFPA 25, Chapter 2, section 2-3.3.

Building AA-Buena Vista

Through observation during the survey, December 10 and 11, 2013, it was determined the facility failed to maintain the automatic sprinkler system in reliable operating condition per the 1999 Edition of NFPA 25.

During the walk through and documentation review, with the Maintenance Director, the annual inspection paperwork, dated October 28, 2013, indicated deficiencies and paperwork was not available to indicate the repairs were corrected.
1) The anti freeze system tested low, indicated a 13 degree F range, and that the antifreeze needed to be replaced.
2) One (1) sprinkler head, located in the west attic on the southeast end, contained corrosion.
3) Backflow test, completed on October 28, 2013, indicated the backflow failed the yearly test on check valve #1 and #2. The tag on the backflow stated "failed" and documentation was not available to indicate a repair of the backflow.

This deficiency effected the entire structure.

Building AA- Buena Vista

Through observation during the survey, December 10 and 11, 2013, it was determined the facility failed to maintain all portable fire extinguishers as required.

During the walkthrough of the facility, with the Maintenance Director, one (1) extinguisher, located adjacent to the main check in reception desk, was onstructed by a christmas tree.
Per NFPA 10, section E-2.

Building A3-Main Hospital

Through observation during the survey, October 10 and 11, 2013, it was determined that the facility failed to continuously maintain the means of egress free of all obstructions or impediments to full instant use in case of fire or other emergency.

During the walkthrough of the facility, with the Maintenance Director, the facility contained storage of items in the corridor in the following locations;
1) One (1) bed and two (2) laundry carts were stored in the corridor outside of the x-ray suite west corridor.
2) The corridor adjacent to the emergency room contained two (2) wheelchairs, one (1) resident bed, and (1) rollaway x-ray machine stored in the corridor for more than thirty (30) minutes.
Note: x-ray machine and wheelchairs were moved during the survey.
Per 7.1.10 " Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use. " The following areas contained the "chart keepers"
3) The egress path through the dining room contained chairs and tables obstructing the egress path and dimishing the width of the corridor to less than eight feet (8'). The path is designated as an egress and muist be maintained as a corridor.

Building A3-Main Hospital

Through observation during the survey, December 10 and 11, 2013, it was determined that the facility was allowing the use of flammable decorations.

During the walk through of the facility, with the Maintenance Director, the facility contained christmas decorations throughout the facility. Documentation was not available to indicate the decorations met the requirements of NFPA 701.
1) Four (4) christmas trees located throughout the facility outside of X-ray waiting, X-ray suite, emergency room, second floor corridor.
2) Christmas decoration throughtout the facility such as garalnd on the wall in the labratory, stockings on the wall in the emergency room, decorations on the wall in the x-ray suite.

Building A3-Main Hospital

Through observation and record review during the survey, December 10 and 11, 2013, 2010, it was determined that the facility failed to provide curtains that comply with NFPA 701 in all areas.

During record review and walk through of the facility, with the Maintenance Director, curtains located throughout the facility did not contain tags or markings showing that they met NFPA 701 requirements.
1) Draperies in the sleep lab rooms
2) One (1) loose hanging quilt outside of the cafateria
3) One (1) loose hanging quilt located outside of the elevators on the first (1st) floor

Building A3-Main Hospital

Through record review during the survey, December 10 and 11, 2013, it was determined that the facility failed to maintain the generator emergency function.

During the review of the facility record and observation, with the Maintenance Director:
1) Documentation was not available to indicate the monthly amperage readings during the monthly load test of the emergency generator.
2) Documentation was not available to indicate a yearly load bank test had been conducted.
The Maintenance Director stated that they know that the facility does not hit the thirty percent (30%) load on a monthly basis to disregard the yearly load bank test.
Per 2000 Edition of NFPA 101, chapter 20 section 20.2.9.2, NFPA 99 3-4.4.1.1, and 1999 Edition of NFPA 110 6-4.2 " Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
a. Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
b. Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. "
And section 6.4.2.2 " Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours. "

Building A3-Main Hospital

Through observation during the survey, December 10 and 11, 2013, it was determined the facility failed to maintain all battery back-up lighting as operational.

During operational testing, with the Maintenance Director, three (3) emergency lights failed to operate when the test button was pushed.
1) Two (2) emergency lights in room #1412
2) One (1) emergency light in room #1413

Building A3-Main Hospital

Through observation during the survey, December 10 and 11, 2013, it was determined that the facility failed to install and maintain the electrical system in accordance with NFPA 70.

During the walk through of the facility with the Maintenance Director, the facility utilized extension cords or power-strips as a substitute for the fixed wiring of the structure.
1) One (1) extension cord in use in FBC managers office #2406
2) One (1) refrigerator plugged into a powerstrip in the FBC area
Per NFPA 70, Chapter 4, Article 400, Paragraph 400.8, (" ... flexible cords and cables shall not be used for the following: (1) as a substitute for the fixed wiring of a structure ... ").