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Based on observation and interview, the facility failed to maintain the two hour rated building separation to the adjacent Medical Clinic building, in accordance with NFPA 101 - 2012 edition, Sections 19.1.1.4.1, 19.1.1.4.1.1 and 8.3.3.1. This deficiency had the potential to affect 8 of the 8 inpatients, as well as an undetermined number of staffs and visitors.

Findings include:

On 2/21/2017 at 10:15 am, observation revealed on the ground floor in the two hour fire barrier above the corridor ceiling near the conference room that two 4 inch diameter insulated pipe penetrations were not fire stopped with UL tested assembly. This deficient practice was confirmed by Staff K (Maintenance), Staff L (Maintenance) and Staff N (Facility Director) at the time of discovery.

Based on observation and staff interview, the facility did not provide full exit width of a required exit door. This does not conform to NFPA 101 (2012 edition), 19.2.3.6.

FINDINGS INCLUDE:

On 02/20/2017 at 2 PM, observation revealed in Room 250, that the exit door does not fully open to 90 degrees. The exit door width is too small. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Director of Surgery).

Based upon observation and interview, the facility failed to provide exit access that is arranged so that exits are readily accessible at all times in accordance with NFPA 101 (2012 ed.), 19.2.5.2 . This deficiency had the potential to affect 8 of 8 inpatients and an undeterminable number of outpatients, staffs and visitors.

FINDINGS INCLUDE:

On 02/21/2017 at 11:30 am, observation revealed that the across corridor door to the OR from the ER was locked. This created a dead end corridor greater than 30 feet. This deficient practice was confirmed by Staff K (Maintenance), Staff L (Maintenance) and Staff N (Facility Director) at the time of discovery.

Based on observation and interview, the facility failed to maintain the exit stair protection with an opening from an unoccupied space as required by NFPA 101 - 2012 edition, Sections 7.1.3.2.1(9)(c). This deficiency had the potential to affect 8 of the 8 inpatients, as well as an undetermined number of staffs and visitors.

Findings include:

1. On 2/21/2017 at 9:30 am, observation revealed in the unoccupied Penthouse Mechanical Room that was used to store approximately 75 rubber made V-bets hanged on 3 large combustible wood storage board . This deficient practice was confirmed by Staff K (Maintenance), Staff L (Maintenance) and Staff N (Facility Director) at the time of discovery.

2. On 2/21/2017 at 9:15 am, observation revealed in the lower level unoccupied storage room in front of the mechanical room that was used to store PVC foam and combustible insulations. This deficient practice was confirmed by Staff K (Maintenance), Staff L (Maintenance) and Staff N (Facility Director) at the time of discovery.

Based on observation and interview, the facility did not enclose hazardous rooms with a smoke-tight room enclosure in a sprinkled smoke zone and door closers were missing. This observed situation was not compliant with NFPA 101 (2012 ed.), 19.3.2.1

FINDINGS INCLUDE:

1. On 02/20/2017 at 1:25 PM, observation revealed in the 'old' OR, which is being used as a sterile storage room, that the room had become a hazardous storage area. The room did not have 1 hour rated walls. The rated wall exceeded the 100 square inches of electrical box outlets in 100 square feet of wall area. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff T, (Director of Surgery).

2. On 2/20/2017 at 1:42 PM, observation revealed that room 200, the endo storage room (an old bathroom) was greater than 50 square feet and the quantity of combustibles made the room hazardous. The door did not have a door closer on it. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff T, (Director of Surgery).

Based on observation and interview, the facility failed to maintain hazardous areas in accordance with the requirements of NFPA 101 - 2012 edition, sections 19.3.2.1 and 8.4. This deficiency had the potential to affect 8 of the 8 inpatients, as well as an undetermined number of staffs and visitors.

Findings include:

On 2/21/2017 at 10:35 am, observation revealed on the ground floor PT/OT room, that the hazardous room was protected with a sprinkler system but was not smoke tight. The door was not equipped with an automatic or self closing door closing device. The room was used to store three large combustible cardboard boxes. This deficient practice was confirmed by Staff K (Maintenance), Staff L (Maintenance) and Staff N (Facility Director) at the time of discovery.

Based on record review and interview, the facility failed to maintain and test emergency lights in anesthetizing locations in accordance with the requirements of NFPA 101 (2012 edition), Section 19.3.2.3 , NFPA 99 (2012 edition), Section 6.3.2.2.11.5. This deficiency had the potential to affect 8 of 8 inpatients and an undeterminable number of outpatients, staffs and visitors.

Findings include:

On 2/20/2017 at 2:38 PM, during review of the facility emergency light testing records it was discovered that tests were not conducted for the emergency lights located inside the two first floor operating rooms for a minimum of 30 seconds each month and 30 minutes annually within the last year. This deficient practice was confirmed by Staff K (Maintenance), Staff L (Maintenance), Staff M (Maintenance) and Staff N (Facility Director) at the time of discovery.

Based on record review and interview, the facility failed to provide and maintain cooking facilities in accordance with the requirements of NFPA 101 - 2012 edition, Sections 19.3.2.6.1 and 9.2.3; NFPA 96 - 2011 edition, Table 11.4, Section 11.6.1. and 11.6.13. This deficiency had the potential to affect an undeterminable number of inpatients, outpatients, staffs and visitors.

Findings include:

1. On 2/20/2017 at 1:35 PM, review of the documents revealed that the facility did not keep any documentation for the kitchen range hood system inspection at least every six months as required by NFPA 96 - 2011 edition, Table 11.4. When asked, Staff N mentioned that the range hood system is equipped with a self cleaning system and they ran the cleaning system every evening. This deficient practice was confirmed by Staff K (Maintenance), Staff L (Maintenance), Staff M (Maintenance) and Staff N (Facility Director) at the time of discovery.

2. On 2/21/2017 at 11:00 am, observation revealed inside the kitchen, that the name of the person that performed the hood system cleaning work, and the date of inspection were not maintained on the premises. This deficient practice was confirmed by Staff K (Maintenance), Staff L (Maintenance), Staff M (Maintenance) and Staff N (Facility Director) at the time of discovery.

Based on record observation and interview, the facility failed to provide a visible fire-alarm notification device in a public area as required by NFPA 101 (2012 edition), Sections 19.3.4 and 9.6, and NFPA 72 (2010 edition), Sections 18.6. This deficiency had the potential to affect 8 of 8 inpatients and an undeterminable number of outpatients, staffs and visitors.

Findings include:

On 2/21/2017 at 10:30 am, observation revealed in the ground floor women locker room that the women locker room was used as both a locker room and an employee break area. A visible fire alarm notification device was not provided inside the womens locker room. This deficient practice was confirmed by Staff K (Maintenance), Staff L (Maintenance) and Staff N (Facility Director) at the time of discovery.

Based on record review and interview, the facility failed to test smoke detectors for sensitivity as required by NFPA 101 (2012 edition), Sections 19.3.4 and 9.6, and NFPA 72 (2010 edition), Sections 14.4.5.3, 14.4.5.3.1 and 14.4.5.3.2. This deficiency had the potential to affect 8 of 8 inpatients and an undeterminable number of outpatients, staffs and visitors.

Findings include:

On 2/20/2017 at 2:30 PM, during review of the facility fire alarm testing records it was discovered that none of the smoke detectors located in the facility were tested for sensitivity within the last two years. When asked, Staff N mentioned that they assumed smoke detectors sensitivity tests were not required as they had an addressable fire alarm control unit. This deficient practice was confirmed by Staff K (Maintenance), Staff L (Maintenance) and Staff N (Facility Director) at the time of discovery.

Based on record review and interview, the facility failed to test smoke detectors for sensitivity as required by NFPA 101 (2012 edition), Sections 19.3.4 and 9.6, and NFPA 72 (2010 edition), Sections 14.4.5.3, 14.4.5.3.1 and 14.4.5.3.2. This deficiency had the potential to affect 8 of 8 inpatients and an undeterminable number of outpatients, staffs and visitors. This deficient practice was confirmed by Staff K (Maintenance), Staff L (Maintenance) and Staff N (Facility Director) at the time of discovery.

Findings include:

On 2/20/2017 at 2:30 PM, during review of the facility fire alarm testing records it was discovered that none of the smoke detectors located in the facility were tested for sensitivity within the last two years. When asked, Staff N mentioned that they assumed smoke detectors sensitivity tests were not required as they had an addressable fire alarm control unit.

Based on observation and interviews, the facility did not provide the correct installation of the sprinkler system per NFPA 13 and per NFPA 101(ed. 2012), 19.3.5.3.

FINDING INCLUDE:

On 2/21/2017 at 3:35 PM, observation revealed that in the Rehab suite near the vertical storage of a table, that a curtain blocked the sprinkler. The curtain did not have large enough (less than 1/2 inch diameter) holes in the curtain. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff N, (Facilities Director).

Based on observation and interview, the facility did not provide a sprinkler system with no obstructions near the sprinkler head in accordance with NFPA 101 (2012 ed.), 19.3.5.1 and NFPA 13 (2010 ed.), 8.6.5.2.1.1 (Table 8.6.5.2.1), 8.6.5.2.2 and 8.6.5.2.2.1. This deficiency had the potential to affect 8 of the 8 inpatients, as well as an undetermined number of staffs and visitors.

FINDINGS INCLUDE:

1. On 2/21/2017 at 12:02 PM, observation revealed on the first floor in the ambulance garage entrance room, that a 12 inch deep HVAC duct was located 12 inches away and 6 inches below the adjacent sprinkler deflector and would restrict the proper flow of sprinkler water to the other side of the duct. This deficient practice was confirmed by Staff K (Maintenance), Staff L (Maintenance) and Staff N (Facility Director) at the time of discovery.

2. On 2/21/2017 at 11:02 am, observation revealed on the first floor in the sleep study room number one toilet, that a shower curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to other side of the curtain. This deficient practice was confirmed by Staff K (Maintenance), Staff L (Maintenance) and Staff N (Facility Director) at the time of discovery.

3. On 2/21/2017 at 11:02 am, observation revealed on the first floor in the sleep study room number two toilet, that a shower curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to the other side of the curtain. This deficient practice was confirmed by Staff K (Maintenance), Staff L (Maintenance) and Staff N (Facility Director) at the time of discovery.

Based on observation and interview, the facility failed to provide corridor wall separations in accordance with the requirements of NFPA 101 - 2012 edition, Sections 19.3.6.1. This deficiency had the potential to affect 8 of the 8 inpatients, as well as an undetermined number of staffs and visitors.

Findings include:

On 2/21/17 at 11:45 am, observation revealed in the first floor medical cart room that the room was open to the corridor system and did not meet one of the exceptions for a space to be allowed to be open to the corridor system. This deficient practice was confirmed by Staff K (Maintenance), Staff L (Maintenance) and Staff N (Facility Director) at the time of discovery.

Based on observation and interview, the facility did not provide corridor doors with a means suitable for keeping the door closed in accordance with the requirements of NFPA 101 - 2012 edition, sections 19.3.6.3.5. This deficiency had the potential to affect 8 of the 8 inpatients, as well as an undetermined number of staffs and visitors.

Findings include:

1. On 2/21/2017 at 1:35 PM, observation revealed in the first floor house keeping room, that the corridor door was not equipped with a latching mechanism for keeping the door closed. This deficient practice was confirmed by Staff K (Maintenance), Staff L (Maintenance) and Staff N (Facility Director) at the time of discovery.

2. On 2/21/2017 at 7:26 AM, observation revealed that the door from the corridor into the dining room did not latch. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff N, (Facilities Director).

Based on observation and interviews, the facility did not provide the ability to travel 200 feet to enter a different smoke zone per NFPA 101, 2012 edition, 19.3.7.1(1).

Findings:

On 2/21/2017 at 10:55 AM, observation revealed the door leading from the ambulance garage into the Emergency Department corridor was locked. The door locking arrangement did not meet 19.2.2.2.5.2 and 19.2.2.2.6. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff N, (Director Facilities).

Based on observation and interview, the facility failed to maintain fire rating of the smoke barrier wall in accordance with NFPA 101 - 2012 edition, Sections 19.3.7.3 and 8.5. This deficiency had the potential to affect 8 of the 8 inpatients, as well as an undetermined number of staffs and visitors.

Findings include:

1. On 2/21/2017 at 10:20 am, observation revealed in the ground floor smoke barrier wall above the corridor ceiling near cafeteria that a 2 inch diameter hole was not sealed with a UL tested assembly. This deficient practice was confirmed by Staff K (Maintenance), Staff L (Maintenance) and Staff N (Facility Director) at the time of discovery.

2. On 2/21/2017 at 11:50 am, observation revealed in the first floor smoke barrier wall above the corridor ceiling near room number 115 that a 2 1/2 diameter PVC pipe penetration was not fire stopped with a UL tested assembly. This deficient practice was confirmed by Staff K (Maintenance), Staff L (Maintenance) and Staff N (Facility Director) at the time of discovery.

Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with neutral airflow between the corridor and rooms, and ventilation systems in accordance with NFPA 101 (2012 ed.), 19.5.2.1, 9.2 and NFPA 90A (2012 ed.), 4.3.12.1.1. This deficiency had the potential to affect 8 of 8 inpatients and an undeterminable number of outpatients, staffs and visitors.


FINDINGS INCLUDE:

On 02-20-2017 at 3:00 PM, observation revealed on the patient floors, that airflow between the corridor and the room was not neutral. Some rooms are using the corridor as a supply air plenum and other rooms are using the corridor as a return air plenum. This deficient practice was confirmed by Staff K (Maintenance), Staff L (Maintenance) and Staff N (Facility Director) at the time of discovery.

Based on observation and interview, the facility failed to provide proper distribution of the soiled and trash utility container in accordance with the requirements of NFPA 101 - 2012 edition, section 19.7.5.7.1. This deficiency had the potential to affect 8 of the 8 inpatients, as well as an undetermined number of staffs and visitors.

FINDINGS INCLUDE:

1. On 02/20/2017 at 1:45 PM, observation revealed in the endo decontamination room, that two 18 gallon trash cans and one 32 gallon soiled linen container were next to each other and together they exceeded 32 gallons in a 64 square foot area. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Director of Surgery).

2. On 2/21/2017 at 1:30 PM, observation revealed that one 128 gallon trash container full of soiled linen was stored outside of a protected hazardous room inside the first floor ante room in front of the OR suite. This deficient practice was confirmed by Staff K (Maintenance), Staff L (Maintenance) and Staff N (Facility Director) at the time of discovery.

Based on observation and staff interview, the facility did not label the zone valve near the endo room. This does not conform to NFPA 99 (2012 edition), 5.1.11.2.1.

FINDINGS INCLUDE:

On 02/20/2017 at 2:30 PM, observation revealed in the corridor near the endo procedure room, a zone valve label was difficult to read indicating which room it served. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff N (Facilities Director).

Based on observation and interviews, the facility did not provide the correct clearance in front of electrical panels. This observed situation was not compliant with NFPA 70 (2011), 110-26.

FINDING INCLUDE:

On 02/20/2017 at 2:10 PM, observation revealed in Operating Room 250, that the portable air conditioner blocked the access to the electrical panel. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff T (Director of Surgery).

Based on observation and staff interview, the facility did not have battery powered lights in a deep sedation or an anesthesia location. This does not conform to NFPA 99 (2012 edition), 6.3.2.2.11.

FINDINGS INCLUDE:

On 02/20/2017 at 3:12 PM, observation revealed in the endo procedure room, which administers anesthesia, that a battery powered lighting unit was not provided. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff N (Facilities Director).