HospitalInspections.org

Based on observation the facility failed to provide adequate smoke barriers.

The inspector observed, while accompanied by the Administrator-BHC, Operations Manager, QA Risk Manager, Plant Services, Outside Facilities Maintenance Supervisor, and Director of Plant Service during the hours of the inspection from 1:15 pm to 5:00 pm on 3/26/2013 that there were the following issues. They were penetrations in the smoke barrier at the following locations: 1) outside of the boardroom, 2) at unit 300, 3) at H&P Exam Room, and 4) outside the Maintenance Office.

Based on observation the facility failed to provide adequate smoke barriers.

The inspector observed, while accompanied by the Mechanical Supervisor, Building Supervisor, and two Carpenters during the hours of the inspection from 8:00 am to 6:00 pm on 3/27/2013 that there were penetrations in the smoke barriers at the following locations: 1) in the basement at the entry to the west, semi-circular security area, 2) in the wall of the Old Death Chart Room, and 3) at the northwest corner of the Air One Equipment Room. 3) 1 st floor, at the north cross corridor smoke barrier door between the hallway /storage (near the loading dock) and the laundry suite. 4) 1 st floor, at the west cross corridor smoke barrier door between the kitchen prep area and the corridor. 5) 1 st floor, at the north cross corridor smoke barrier door between the monument stair and the laundry suite. 6) Second floor at the south cross corridor smoke barrier door between the storage room and the house keeping room. 7) 4th floor at the smoke barrier cross corridor door between circular patient suite and the stair. 8) 4th floor at the smoke barrier cross corridor door between circular patient suite and the conference room.

There was door closer missing at the following location: 1) 1st floor at the Administration suite the storage room near the copy/file room.

There were doors or frame fire rated labels missing at the following locations: 1) 3 third floor at the smoke barrier cross corridor door between circular patient suite and the stair. 2) 5th floor at the equipment room.

There was smoke detector missing at the following location: 1) 1st floor at the smoke barrier cross corridor door between ER suite and the elevator bank.

Based on observation the facility failed to provide adequate hazardous area separation.

The inspector observed, while accompanied by the Administrator-BHC, Operations Manager, QA Risk Manager, Plant Services, Outside Facilities Maintenance Supervisor, and Director of Plant Service during the hours of the inspection from 1:15 pm to 5:00 pm on 3/26/2013 that there was a missing closer on the Rec. Therapy Storage Room.

Based on observation the facility failed to provide adequate illumination at exterior exits.

The inspector observed, while accompanied by the Administrator-BHC, Operations Manager, QA Risk Manager, Plant Services, Outside Facilities Maintenance Supervisor, and Director of Plant Service during the hours of the inspection from 1:15 pm to 5:00 pm on 3/26/2013 that there were exits that did not have two sources of illumination at the following locations the 300, 400, and 500 wing exterior exits.

Based on observation the facility failed to provide a complete sprinkler system.

The inspector observed, while accompanied by the Mechanical Supervisor, Building Supervisor, and two Carpenters during the hours of the inspection from 8:00 am to 6:00 pm on 3/27/2013 that there were the following issues.

A.) There were missing sprinkler head at the following locations: 1) Cat ATS under a duct larger than 4 feet, 2) the Electrical Substation, 3) vestibule at the main entrance, 4) top and bottom of stair on the north side of the administrative area, 5) electrical room at N.E. corner of the E.D., 6) mechanical room to west of C.T. rooms under a duct larger than 4 feet wide, and 7) storage south of the mechanical shop.

B.) There were missing escutcheon plates at the following locations: 1) mechanical shop, and 2) hot lab.

C.) There were sprinkler heads at the following location that were less than 4 inches from the wall: 1) 2nd floor, nourishment room at west circular patient suite, 2) 2nd floor, alcove adjacent to smoke barrier doors at entry to the three circular patient suites, and 3) 3rd floor, electrical room at waiting room, 3300.

D.) At the 2nd floor, 2 North Telephone Closet there were wires wrapped around the sprinkler head.

Escutcheons are part of the listed assembly per 1999 NFPA 13 ?3-2.7.2.

Sprinklers shall be located a minimum of 4 in. (102 mm) from a wall. - NFPA 13, 1999, 5-6.3.3.

Sprinklers shall be installed under fixed obstructions over 4 ft (1.2 m) wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors. - NFPA 13, 1999, 5-5.5.3.1.

Based on observation the facility failed to provide adequate medical gas system.

The inspector observed, while accompanied by the Mechanical Supervisor, Building Supervisor, and two Carpenters during the hours of the inspection from 8:00 am to 6:00 pm on 3/27/2013 that there was the following issues.

A.) It was that there was incorrect signage at the nitrous closet door.

CAUTION
Medical Gases
NO Smoking or Open Flame
Room may have Insufficient Oxygen
Open Door and Allow Room to Ventilate before Entering

See NFPA 99, 2002: 5.1.3.1.5.

B.) Also, the inspector observed, while accompanied by the Mechanical Supervisor, Building Supervisor, and two Carpenters during the hours of the inspection from 8:00 am to 6:00 pm on 3/27/2013 that there were vehicles parked within 10 feet of the bulk oxygen tank enclosure.
C.) There was dissimilar metal contact between the copper med gas lines and steel at 2nd floor, 2 North B, cross corridor, smoke compartment doors.

" The minimum distance from any bulk oxygen system to any public sidewalk or parked vehicle shall be 10 ft. " - NFPA 50, 2001, 2.2.12.

Based on observation the facility failed to provide adequate receptacles.

The inspector observed, while accompanied by the Mechanical Supervisor, Building Supervisor, and two Carpenters during the hours of the inspection from 8:00 am to 6:00 pm on 3/27/2013 that there was the following issue at the Cat Generator. There was a missing receptacle on the Life Safety Branch.

" The emergency generator location shall have task illumination, battery charger for emergency battery powered lighting unit(s), and selected receptacles at the generator set location " - NFPA 99, 1999: 3-4.2.2.2.(b)5.

Receptacle Testing in Patient Care Areas - NFFA 99, 1999, 3-3.3.3

(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

NFPA 99, 1999, 3-3.4.2.3(a) states that testing shall be performed after initial installation, replacement or servicing of a device, and that additional testing shall be performed at intervals defined by documented performance data. Since data is not typically available from the manufacturer, the facility may document the failure rates of the receptacles and provide a testing schedule that will safeguard their patients. This shall be done by the Safety Committee, approved by the Governing Board, and written into the safety policies and procedures. H.L.R. 2007, ?133.142. Until this assessment has been done, receptacle testing shall be performed in all general care areas every 12 months and in critical care areas every 6 months. (NFPA 99, 1984).

Based on observation the facility failed to provide a history of records for receptacle testing per NFPA 99: 3-3.3.3. in patient care areas.

The inspector observed, while accompanied by the Administrator-BHC, Operations Manager, QA Risk Manager, Plant Services, Outside Facilities Maintenance Supervisor, and Director of Plant Service during the hours of the inspection from 1:15 pm to 5:00 pm on 3/26/2013 that the facility had not been conducting receptacle test in patient care areas.

Testing Intervals of Biomedical Equipment

All appliances used in patient care areas shall be tested in accordance with 7-5.1.3 or 7-5.2.2.1 before being put into service for the first time and after repair or modification. Patient-care-related electrical appliances shall be retested at intervals determined by their normal location or area of normal use, but not exceeding the intervals listed below:

General care areas - 12 months
Critical care areas - 6 months
Wet locations - 6 months

NFPA 99, 1999, 7-6.2.1.2.

Based on observation the facility failed to provide adequate testing of the biomedical equipment.

The inspector observed, while accompanied by the Mechanical Supervisor, Building Supervisor, and two Carpenters during the hours of the inspection from 8:00 am to 6:00 pm on 3/27/2013 that there were the following issues. The defibrillators in the following critical locations were not being tested semi-annually: 1) PACU Adult and Pediatric, and 2) OB surgery.

It was stated by the Director of First Call that CMS had approved the manufacturer ' s maintenance schedule, and that this is contained in the Interpretive Guidelines 482.41(c)(2). The Director of First Call stated that all of the equipment in critical areas was being tested at frequencies recommended by the manufacturer and not the NFPA 99, semi-annual schedule.

The Interpretive Guidelines state: " Equipment that is critical to patient health and safety is not a candidate for an alternative, less frequent maintenance activity schedule. Such equipment must be maintained at least as often as the manufacturer recommends. " Also, the document points to NFPA 101 that references NFPA 99 and states that the most stringent maintenance requirements must be followed.

The NFPA citation above does have an exception that states: " The testing intervals listed are intended to be nominal values, and facilities shall be permitted to adopt a protocol using either longer or shorter intervals provided that there is a documented justification based on previous safety testing records for the equipment in question, unusually light or heavy utilization, or similar considerations. " - NFPA, 99, 1999, 7-6.2.1.2. Exception No. 1.

Therefore, the facility must provide documented justification based on previous safety testing records for equipment in critical areas showing that annual testing is sufficient for the utilization, heavy or light, for each model of equipment.

Based on observation the facility failed to provide an adequate electrical system.

The inspector observed, while accompanied by the Administrator-BHC, Operations Manager, QA Risk Manager, Plant Services, Outside Facilities Maintenance Supervisor, and Director of Plant Service during the hours of the inspection from 1:15 pm to 5:00 pm on 3/26/2013 that there were the following issues. First, at the H&P Exam Room above the smoke barrier doors there were two j-boxes without covers. Second, the receptacles in the patient wings 300, 400, and 500 were not hospital grade

All receptacles, whether four or more, shall be listed " hospital grade " and so identified. Each receptacle shall be grounded by means of an insulted copper conductor sized in accordance the Table 250-122. NFPA 70, 1999, 517-18 (b).

Based on observation the facility failed to provide an adequate electrical system.

The inspector observed, while accompanied by the Mechanical Supervisor, Building Supervisor, and two Carpenters during the hours of the inspection from 8:00 am to 6:00 pm on 3/27/2013 that there were the following issues.

A.) In critical areas (surgery and PACU) the critical outlets did not have permanent labels indicating panel and breaker.
B.) There was an open electrical box above the smoke barrier at the entrance to the cardio surgery suite and the CICU.

" In critical care areas, emergency system receptacles must be identified, indicating the panel board and circuit number supplying them in accordance with NFPA 70, 2002: 517-19(a). Panel board and circuit numbers shall be permanently engraved on the cover plates or applied with laminated labels that have permanent adhesive. The face plate label shall be non-removable or engraved. " - HLR, 133.162 (d)(5)(H)(vi). Here non-removable means that it cannot be peeled off with a fingernail.

Based on observation the facility failed to provide adequate separation between alcohol base hand rubs and electrical switches and receptacles of 6 inches.

The inspector observed, while accompanied by the Mechanical Supervisor, Building Supervisor, and two Carpenters during the hours of the inspection from 8:00 am to 6:00 pm on 3/27/2013 that there were alcohol based hand rubs within 6 inches of electrical switches or receptacles at the following locations: 1) Soiled Utility, 5 north, 2) 2nd floor, 2 North B, Nurse Station, 3) 2nd floor, patient room 2521, and 4) basement, Soiled Utility.

Based on observation the facility failed to provide adequate smoke barriers.

The inspector observed, while accompanied by the Administrator-BHC, Operations Manager, QA Risk Manager, Plant Services, Outside Facilities Maintenance Supervisor, and Director of Plant Service during the hours of the inspection from 1:15 pm to 5:00 pm on 3/26/2013 that there were the following issues. They were penetrations in the smoke barrier at the following locations: 1) outside of the boardroom, 2) at unit 300, 3) at H&P Exam Room, and 4) outside the Maintenance Office.

Based on observation the facility failed to provide adequate smoke barriers.

The inspector observed, while accompanied by the Mechanical Supervisor, Building Supervisor, and two Carpenters during the hours of the inspection from 8:00 am to 6:00 pm on 3/27/2013 that there were penetrations in the smoke barriers at the following locations: 1) in the basement at the entry to the west, semi-circular security area, 2) in the wall of the Old Death Chart Room, and 3) at the northwest corner of the Air One Equipment Room. 3) 1 st floor, at the north cross corridor smoke barrier door between the hallway /storage (near the loading dock) and the laundry suite. 4) 1 st floor, at the west cross corridor smoke barrier door between the kitchen prep area and the corridor. 5) 1 st floor, at the north cross corridor smoke barrier door between the monument stair and the laundry suite. 6) Second floor at the south cross corridor smoke barrier door between the storage room and the house keeping room. 7) 4th floor at the smoke barrier cross corridor door between circular patient suite and the stair. 8) 4th floor at the smoke barrier cross corridor door between circular patient suite and the conference room.

There was door closer missing at the following location: 1) 1st floor at the Administration suite the storage room near the copy/file room.

There were doors or frame fire rated labels missing at the following locations: 1) 3 third floor at the smoke barrier cross corridor door between circular patient suite and the stair. 2) 5th floor at the equipment room.

There was smoke detector missing at the following location: 1) 1st floor at the smoke barrier cross corridor door between ER suite and the elevator bank.

Based on observation the facility failed to provide adequate hazardous area separation.

The inspector observed, while accompanied by the Administrator-BHC, Operations Manager, QA Risk Manager, Plant Services, Outside Facilities Maintenance Supervisor, and Director of Plant Service during the hours of the inspection from 1:15 pm to 5:00 pm on 3/26/2013 that there was a missing closer on the Rec. Therapy Storage Room.

Based on observation the facility failed to provide adequate illumination at exterior exits.

The inspector observed, while accompanied by the Administrator-BHC, Operations Manager, QA Risk Manager, Plant Services, Outside Facilities Maintenance Supervisor, and Director of Plant Service during the hours of the inspection from 1:15 pm to 5:00 pm on 3/26/2013 that there were exits that did not have two sources of illumination at the following locations the 300, 400, and 500 wing exterior exits.

Based on observation the facility failed to provide a complete sprinkler system.

The inspector observed, while accompanied by the Mechanical Supervisor, Building Supervisor, and two Carpenters during the hours of the inspection from 8:00 am to 6:00 pm on 3/27/2013 that there were the following issues.

A.) There were missing sprinkler head at the following locations: 1) Cat ATS under a duct larger than 4 feet, 2) the Electrical Substation, 3) vestibule at the main entrance, 4) top and bottom of stair on the north side of the administrative area, 5) electrical room at N.E. corner of the E.D., 6) mechanical room to west of C.T. rooms under a duct larger than 4 feet wide, and 7) storage south of the mechanical shop.

B.) There were missing escutcheon plates at the following locations: 1) mechanical shop, and 2) hot lab.

C.) There were sprinkler heads at the following location that were less than 4 inches from the wall: 1) 2nd floor, nourishment room at west circular patient suite, 2) 2nd floor, alcove adjacent to smoke barrier doors at entry to the three circular patient suites, and 3) 3rd floor, electrical room at waiting room, 3300.

D.) At the 2nd floor, 2 North Telephone Closet there were wires wrapped around the sprinkler head.

Escutcheons are part of the listed assembly per 1999 NFPA 13 ?3-2.7.2.

Sprinklers shall be located a minimum of 4 in. (102 mm) from a wall. - NFPA 13, 1999, 5-6.3.3.

Sprinklers shall be installed under fixed obstructions over 4 ft (1.2 m) wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors. - NFPA 13, 1999, 5-5.5.3.1.

Based on observation the facility failed to provide adequate medical gas system.

The inspector observed, while accompanied by the Mechanical Supervisor, Building Supervisor, and two Carpenters during the hours of the inspection from 8:00 am to 6:00 pm on 3/27/2013 that there was the following issues.

A.) It was that there was incorrect signage at the nitrous closet door.

CAUTION
Medical Gases
NO Smoking or Open Flame
Room may have Insufficient Oxygen
Open Door and Allow Room to Ventilate before Entering

See NFPA 99, 2002: 5.1.3.1.5.

B.) Also, the inspector observed, while accompanied by the Mechanical Supervisor, Building Supervisor, and two Carpenters during the hours of the inspection from 8:00 am to 6:00 pm on 3/27/2013 that there were vehicles parked within 10 feet of the bulk oxygen tank enclosure.
C.) There was dissimilar metal contact between the copper med gas lines and steel at 2nd floor, 2 North B, cross corridor, smoke compartment doors.

" The minimum distance from any bulk oxygen system to any public sidewalk or parked vehicle shall be 10 ft. " - NFPA 50, 2001, 2.2.12.

Based on observation the facility failed to provide adequate receptacles.

The inspector observed, while accompanied by the Mechanical Supervisor, Building Supervisor, and two Carpenters during the hours of the inspection from 8:00 am to 6:00 pm on 3/27/2013 that there was the following issue at the Cat Generator. There was a missing receptacle on the Life Safety Branch.

" The emergency generator location shall have task illumination, battery charger for emergency battery powered lighting unit(s), and selected receptacles at the generator set location " - NFPA 99, 1999: 3-4.2.2.2.(b)5.

Receptacle Testing in Patient Care Areas - NFFA 99, 1999, 3-3.3.3

(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

NFPA 99, 1999, 3-3.4.2.3(a) states that testing shall be performed after initial installation, replacement or servicing of a device, and that additional testing shall be performed at intervals defined by documented performance data. Since data is not typically available from the manufacturer, the facility may document the failure rates of the receptacles and provide a testing schedule that will safeguard their patients. This shall be done by the Safety Committee, approved by the Governing Board, and written into the safety policies and procedures. H.L.R. 2007, ?133.142. Until this assessment has been done, receptacle testing shall be performed in all general care areas every 12 months and in critical care areas every 6 months. (NFPA 99, 1984).

Based on observation the facility failed to provide a history of records for receptacle testing per NFPA 99: 3-3.3.3. in patient care areas.

The inspector observed, while accompanied by the Administrator-BHC, Operations Manager, QA Risk Manager, Plant Services, Outside Facilities Maintenance Supervisor, and Director of Plant Service during the hours of the inspection from 1:15 pm to 5:00 pm on 3/26/2013 that the facility had not been conducting receptacle test in patient care areas.

Testing Intervals of Biomedical Equipment

All appliances used in patient care areas shall be tested in accordance with 7-5.1.3 or 7-5.2.2.1 before being put into service for the first time and after repair or modification. Patient-care-related electrical appliances shall be retested at intervals determined by their normal location or area of normal use, but not exceeding the intervals listed below:

General care areas - 12 months
Critical care areas - 6 months
Wet locations - 6 months

NFPA 99, 1999, 7-6.2.1.2.

Based on observation the facility failed to provide adequate testing of the biomedical equipment.

The inspector observed, while accompanied by the Mechanical Supervisor, Building Supervisor, and two Carpenters during the hours of the inspection from 8:00 am to 6:00 pm on 3/27/2013 that there were the following issues. The defibrillators in the following critical locations were not being tested semi-annually: 1) PACU Adult and Pediatric, and 2) OB surgery.

It was stated by the Director of First Call that CMS had approved the manufacturer ' s maintenance schedule, and that this is contained in the Interpretive Guidelines 482.41(c)(2). The Director of First Call stated that all of the equipment in critical areas was being tested at frequencies recommended by the manufacturer and not the NFPA 99, semi-annual schedule.

The Interpretive Guidelines state: " Equipment that is critical to patient health and safety is not a candidate for an alternative, less frequent maintenance activity schedule. Such equipment must be maintained at least as often as the manufacturer recommends. " Also, the document points to NFPA 101 that references NFPA 99 and states that the most stringent maintenance requirements must be followed.

The NFPA citation above does have an exception that states: " The testing intervals listed are intended to be nominal values, and facilities shall be permitted to adopt a protocol using either longer or shorter intervals provided that there is a documented justification based on previous safety testing records for the equipment in question, unusually light or heavy utilization, or similar considerations. " - NFPA, 99, 1999, 7-6.2.1.2. Exception No. 1.

Therefore, the facility must provide documented justification based on previous safety testing records for equipment in critical areas showing that annual testing is sufficient for the utilization, heavy or light, for each model of equipment.

Based on observation the facility failed to provide an adequate electrical system.

The inspector observed, while accompanied by the Administrator-BHC, Operations Manager, QA Risk Manager, Plant Services, Outside Facilities Maintenance Supervisor, and Director of Plant Service during the hours of the inspection from 1:15 pm to 5:00 pm on 3/26/2013 that there were the following issues. First, at the H&P Exam Room above the smoke barrier doors there were two j-boxes without covers. Second, the receptacles in the patient wings 300, 400, and 500 were not hospital grade

All receptacles, whether four or more, shall be listed " hospital grade " and so identified. Each receptacle shall be grounded by means of an insulted copper conductor sized in accordance the Table 250-122. NFPA 70, 1999, 517-18 (b).

Based on observation the facility failed to provide an adequate electrical system.

The inspector observed, while accompanied by the Mechanical Supervisor, Building Supervisor, and two Carpenters during the hours of the inspection from 8:00 am to 6:00 pm on 3/27/2013 that there were the following issues.

A.) In critical areas (surgery and PACU) the critical outlets did not have permanent labels indicating panel and breaker.
B.) There was an open electrical box above the smoke barrier at the entrance to the cardio surgery suite and the CICU.

" In critical care areas, emergency system receptacles must be identified, indicating the panel board and circuit number supplying them in accordance with NFPA 70, 2002: 517-19(a). Panel board and circuit numbers shall be permanently engraved on the cover plates or applied with laminated labels that have permanent adhesive. The face plate label shall be non-removable or engraved. " - HLR, 133.162 (d)(5)(H)(vi). Here non-removable means that it cannot be peeled off with a fingernail.