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Based on record review, and interview, the facility failed to maintain the Emergency Preparedness (EP) plan. This was evidenced by the failure to provide policy and procedure indicating the facility's role and awareness in providing treatment and care under an 1135 waiver in the event of an emergency. This affected patients and staff at the Main Hospital, and could result in the facility being inadequately prepared to provide care at an alternate location during an emergency.


Findings:

During record review, and interview with administrative staff on 6/12/18, the EP policies and procedures were requested and reviewed.

Main Hospital:

At 1:35 p.m., there was no policy and procedure outlining the facility's plan in providing care and treatment at an alternate location under an 1135 waiver, in the event of an emergency. Upon interview, Administrative Staff 1 confirmed the finding.

Based on observation, document review, and interview, the facility failed to maintain the fire rated door assemblies. This was evidenced by the absence of a current annual inspection and testing certification. This affected three of three smoke compartments at the Main Hospital, and could result in the malfunction of the doors to contain fire to a compartment.

NFPA 101. Life Safety Code, 2012 Edition
19.1.1.4.1.1 Communicating openings in dividing fire barriers
required by 19.1.1.4.1 shall be permitted only in corridors
and shall be protected by approved self-closing fire door assemblies.
(See also Section 8.3.)

8.3.3 Fire Doors and Windows.
8.3.3.1 Openings required to have a fire protection rating by
Table 8.3.4.2 shall be protected by approved, listed, labeled
fire door assemblies and fire window assemblies and their accompanying
hardware, including all frames, closing devices,
anchorage, and sills in accordance with the requirements of
NFPA 80, Standard for Fire Doors and Other Opening Protective's,
except as otherwise specified in this Code.

NFPA 80, Standard for Fire Doors and Other Opening Protective's, 2010 edition.
Chapter 5 Care and Maintenance
5.1* General.
5.1.1 Application.
5.1.1.1 This chapter shall cover the care and maintenance of
fire doors and fire windows.
5.2.14 Maintenance of Closing Mechanisms
5.2.14.1 Self-closing devices shall be kept in working condition at all times.
5.2* Inspections.
5.2.1* Fire door assemblies shall be inspected and tested not
less than annually, and a written record of the inspection shall
be signed and kept for inspection by the AHJ.

Findings:

During a facility tour, document review, and interview with staff on 6/12/18, the annual inspection and testing for fire/exit doors was requested.

Main Hospital:

At 1:45 p.m., the facility was observed with four 90 minute fire rated cross-corridor doors located in all smoke compartments. No certification for annual testing and inspection was available for review. Upon interview, Staff 2 confirmed the finding, stating that no current annual testing/inspection was performed on the doors.

Based on observation, and interview, the facility failed to maintain the hazardous areas. This was evidenced by an obstructed enclosure opening door. This affected one of three smoke compartments at the Main Hospital, and could result in a delay in containing smoke and/or fire to a hazardous area.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.2 Protection from Hazards.
19.3.2.1.3 The doors shall be self-closing or automatic-closing.
19.3.2.1.5 Hazardous areas shall include, but shall not be restricted
to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Rooms with soiled linen in volume exceeding 64 gal (242 L)
(6) Rooms with collected trash in volume exceeding 64 gal
(242 L)
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including
repair shops, used for storage of combustible supplies and
equipment in quantities deemed hazardous by the authority
having jurisdiction
(8) Laboratories employing flammable or combustible materials
in quantities less than those that would be considered
a severe hazard.

Findings:

During a facility tour and interview with staff on 6/12/18, the hazardous areas were observed.

Main Hospital:

At 9:43 a.m., the Medical Storage-Supply Room, was observed. The room was greater than 50 (approximately 60) square feet in size, and contained multiple plastic wrapped medical supplies stored on shelves. The room door was equipped with a self-closing device. The door was held open to the fullest extent, and allowed to close. The door failed to fully close and latch due to the bottom of the door dragging against the floor. Upon interview, Staff 3 confirmed the finding.

Based on observation, document review, and interview, the facility failed to maintain the cooking facilities. This was evidenced by not performing the inspection and testing of the cooking area fire suppression system on a semi-annual basis. This affected one of three smoke compartments at the Main Hospital, and could potentially result in the uncontrolled spread of a grease fire in the cooking area.

NFPA 101. Life Safety Code, 2012 Edition
19.3.2.5 Cooking Facilities.
19.3.2.5.1 Cooking facilities shall be protected in accordance with 9.2.3
9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 Edition

Chapter 11 Procedures for the Use, Inspection,
Testing, and Maintenance of Equipment

11.2 Inspection, Testing, and Maintenance of Fire-Extinguishing
Systems.
11.2.1* Maintenance of the fire-extinguishing systems and
listed exhaust hoods containing a constant or fire-activated
water system that is listed to extinguish a fire in the grease
removal devices, hood exhaust plenums, and exhaust ducts
shall be made by properly trained, qualified, and certified person(
s) acceptable to the authority having jurisdiction at least
every 6 months.

Findings:

During a facility tour, document review, and interview with staff on 6/12/18, the kitchen cooking area was observed, and service records were requested.

Main Hospital:

At 12:25 p.m., the Dietary Cooking Area was observed with an Ansul-hood fire suppression system. The current inspection was dated 3/6/18. No previous semi-annual inspection was available for review. Upon interview, Staff 3 confirmed the finding.

Based on observation, document review, and interview, the facility failed to maintain the fire alarm system (FAS). This was evidenced by the failure to perform a semi-annual FAS inspection. This affected three of three smoke compartments at the Main Hospital, and could result in a system malfunction or delay in notification in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with section 9.6
9.6.1* General.
9.6.1.5* To ensure operational integrity, the fire alarm system
shall have an approved maintenance and testing program
complying with the applicable requirements of NFPA 70, National
Electrical Code, and NFPA 72, National Fire Alarm and Signaling
Code.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition.
Chapter 14 Inspection, Testing, and Maintenance
14.1 Application.
14.1.1 The inspection, testing, and maintenance of systems,
their initiating devices, and notification appliances shall comply
with the requirements of this chapter.
14.3 Inspection.
14.3.1* Unless otherwise permitted by 14.3.2 visual inspections
shall be performed in accordance with the schedules in
Table 14.3.1 or more often if required by the authority having
jurisdiction.
14.3.2 Devices or equipment that is inaccessible for safety
considerations (e.g., continuous process operations, energized
electrical equipment, radiation, and excessive height)
shall be permitted to be inspected during scheduled shutdowns
if approved by the authority having jurisdiction.
14.3.4 The visual inspection shall be made to ensure that
there are no changes that affect equipment performance.

Table 14.3.1 Visual Inspection Frequencies-semiannually
3. Batteries
4. Transient suppressors
5. Fire alarm control unit trouble signals
7. In- building fire emergency voice/alarm communications equipment
8. Remote annunciators
9. Initiating devices
10. Guard's tour equipment
11. Combination systems (a) Fire extinguisher electronic monitoring device/systems
(b) Carbon monoxide detectors/systems
12. Interface equipment
13. Alarm notification appliances
14. Exit marking audible notification appliances
15. Supervising station alarm systems-transmitters
16. Special procedures
17. Supervising station alarm systems-receivers
18. Public emergency alarm reporting system transmission equipment
20. Mass notification system, non-supervised systems installed prior to adoption of this edition

14.6.2 Maintenance, Inspection, and Testing Records.
14.6.2.1 Records shall be retained until the next test and for
1 year thereafter.
14.6.2.4* A record of all inspections, testing, and maintenance
shall be provided that includes the following information regarding
tests and all the applicable information requested in
Figure 14.6.2.4:
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance,
tests, or combination thereof, and affiliation, business
address, and telephone number
(6) Name, address, and representative of approving agency(
vies)
(7) Designation of the detector(S) tested
(8) Functional test of detectors
(9)*Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat
detectors
(12) Functional test of mass notification system control units
(13) Functional test of signal transmission to mass notification
systems
(14) Functional test of ability of mass notification system to
silence fire alarm notification appliances
(15) Tests of intelligibility of mass notification system speakers
(16) Other tests as required by the equipment manufacturer ' S
published instructions
(17) Other tests as required by the authority having jurisdiction
(18) Signatures of tester and approved authority representative
(19) Disposition of problems identified during test (e.g., system
owner notified, problem corrected/successfully retested,
device abandoned in place)

Findings:

During a facility tour, document review, and interview with staff on 6/12/18, the FAS was observed and records were requested.

Main Hospital:

At 12:40 p.m., the facility was observed with an automatic FAS. The current Annual Fire Alarm Inspection/Testing Report was dated 5/3/18. No semi-annual inspection prior to the annual testing was available for review. Upon interview, Staff 3 confirmed that the FAS is inspected and tested on an annual basis.

Based on observation, the facility failed to maintain the integrity of the building corridor construction. This was evidenced by an unsealed ceiling penetration. This affected one of three smoke compartments at the Main Hospital, and could result in the passage of smoke to other areas in the event of a fire, leading to a full facility evacuation.

Findings:

During a tour of the facility with staff on 6/12/18, the corridor walls and ceiling were observed.

Main Hospital:

At 10:30 a.m., there was an approximately one inch diameter penetration, located in the corridor ceiling by the IT Room.

Based on observation and interview, the facility failed to maintain the corridor door openings. This was evidenced by doors that had air-transfer grilles. This affected one of three smoke compartments at the Main Hospital, and could result in the inability to contain smoke and/or fire to a room.

19.3.6.4 Transfer Grilles.
19.3.6.4.1 Transfer grilles, regardless of whether they are
protected by fusible link-operated dampers, shall not be used
in corridor walls or doors.
19.3.6.4.2 Doors to toilet rooms, bathrooms, shower rooms,
sink closets, and similar auxiliary spaces that do not contain
flammable or combustible materials shall be permitted to
have ventilating louvers or to be undercut.

Findings:

During a tour of the facility, and interview with staff on 6/12/18, the corridor doors were observed.

Main Hospital:

At 10:35 a.m., the IT Room and doors, were observed. The room contained multiple electronic equipment and bundles of wiring. The two entry doors had open air-transfer vents at the bottom of each of the doors, that were approximately six inches by 12 inches in size. Upon interview, Staff 1 confirmed the finding.

Based on observation, and interview, the facility failed to maintain the portable space heating devices. This was evidenced by a heater that exceeded the allowable 212 degree range. This affected one of three smoke compartments at the Main Hospital, and could potentially result in the ignition of an electrical fire.

Findings:

During a tour of the facility, and interview with Staff on 6/12/18, the portable electrical heating devices were observed.

Main Hospital:

At 9:55 a.m., the portable electrical heating equipment in the Nursing Office, was observed. A 1500 watt portable heater was connected to a wall outlet, had a label that indicated 230 degrees Fahrenheit. Upon interview, Staff 3 confirmed the finding.

Based on observation, and interview, the facility failed to maintain the emergency power supply (EPS). This was evidenced by combustible storage in the EPS Enclosure Room. This affected three of three smoke compartments at the Main Hospital, and could result in the malfunction of the generator due to a fire hazard.

NFPA 101 Life Safety Code, 2012 edition
19.5.1 Utilities, Utilities shall comply with the provisions of section 9.1
19.5.1.1 Utilities shall comply with the provisions of section 9.1
9.1.3.1 Emergency Generators and standby power systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition.
7.11 Protection.
7.11.1 The room in which the EPS equipment is located shall not be used for other purposes that are not directly related to the EPS. Parts, tools, and manuals for routine maintenance and repair shall be permitted to be stored in the EPS room.

Findings:

During a tour of the facility and interview with staff on 6/12/18, the EPS Enclosure Room, was observed.

Main Hospital:

At 10:50 a.m., the EPS Enclosure Room for the 350 kilowatt permanent diesel generator, was observed. Approximately eight rolls of floor carpeting were stored along side the diesel generator. Upon interview, Staff 1 confirmed the finding.

Based on observation, and interview, the facility failed to maintain the electrical wiring and connections. This was evidenced by the unapproved use of extension cords. This affected one of three smoke compartments at the Main Hospital, and could potentially result in electrical shock, or the ignition of an electrical fire.

Findings:

During a tour of the facility, and interview with Staff on 6/12/18, the electrical wiring and connections were observed.

Main Hospital:

At 9:40 a.m., the electrical equipment in the Admit Office, was observed. Two extension cords, one orange and one yellow colored, were used to power electronic equipment. Upon interview, Staff 3 confirmed the finding.

Based on observation, document review, and interview, the facility failed to maintain oxygen safety. This was evidenced by the absence of a continuing in-service safety/risk training program for all personnel associated with the use of oxygen delivery equipment and maintenance. This affected three of three smoke compartments at the Main Hospital, and could result in the unsafe handling and maintenance of oxygen delivery equipment.

NFPA 99, Health Care Facilities Code, 2012 Edition.
11.5.2 Gases in Cylinders and Liquefied Gases in Containers.
11.5.2.1 Qualification and Training of Personnel.
11.5.2.1.1* Personnel concerned with the application and
maintenance of medical gases and others who handle medical
gases and the cylinders that contain the medical gases shall be
trained on the risks associated with their handling and use.
11.5.2.1.2 Health care facilities shall provide programs of continuing education for their personnel.
11.5.2.1.3 Continuing education programs shall include periodic
review of safety guidelines and usage requirements for
medical gases and their cylinders.
11.5.2.1.4 Equipment shall be serviced only by personnel
trained in the maintenance and operation of the equipment.

11.5.2.1.5 If a bulk cryogenic system is present, the supplier
shall provide annual training on its operation.

Findings:

During observation, document review, and interview with staff on 6/12/18, the oxygen delivery equipment was observed, and training records were requested.

Main Hospital:

At 12:15 p.m., the facility was observed with portable oxygen tanks and piped/manifold oxygen supplied by a bulk cryogenic system. No documentation was available for a current safety/risk training for all personnel associated with the handling and maintenance of the oxygen delivery systems. Upon interview, Staff 1, confirmed the finding.