HospitalInspections.org

Based on observation, testing, and interview, the provider failed to ensure separation was maintained between the healthcare occupancy and business occupancy at one of two openings between the two occupancies (south entry between waiting rooms). Findings include:

1. Observation at 12:30 p.m. on 3/27/18 revealed a single-leaf ninety minute fire rated door located in the two-hour fire rated wall separating the healthcare occupancy hospital from the clinic business occupancy. Testing of that door at the time of operation revealed the door could just be pushed open and was not latched into the door frame. Further inspection revealed the latching hardware was out of adjustment and would not allow the positive latching hardware to latch into the door frame.

Interview with the administrator at the time of the exit interview at 3:45 p.m. on 3/27/18 confirmed that condition. He revealed he was unaware that door was required to have latching hardware. He further indicated he believed the magnetic lock installed on the door was adequate for meeting the latching requirement.

This deficiency has the potential to affect one of three smoke compartments in the healthcare occupancy.

Based on observation and record review, the provider failed to meet the minimum construction standards of the 2012 Life Safety Code (LSC). The building was not equipped with a complete automatic fire sprinkler system. Findings include:

1. Observation on 3/27/18 at 1:00 p.m. revealed the building was a two story, protected, non-combustible, Type II (111) structure without a complete automatic sprinkler system. Record review of the previous survey conducted on 7/12/16 confirmed that finding.

The building meets the FSES. Please mark an "F" in the completion date column (X5).

Based on observation and interview, the provider failed to ensure doors equipped with door closures opening into the stairwell enclosure were kept in the closed position unless held open with approved hold devices for 5 of 11 doors opening into stair enclosure (all five doors in the basement). Findings include:

1. Observation at 2:10 p.m. on 3/27/18 in the basement revealed five doors opening into the stair well enclosure. The enclosure connected to all three floors of the healthcare occupancy. Those doors were held open with miscellaneous storage items that would not be considered approved hold open devices.

Interview with the administrator at the time of the exit interview at 3:45 p.m. on 3/27/18 confirmed that condition. He revealed he was aware the doors were being held open. He indicated they were being held open to help provide better ventilation to the rooms located in the basement.

This deficiency has the potential to affect one of five exits from the healthcare occupancy.

Based on observation and interview, the provider failed to ensure the stairway enclosure was properly maintained at one of one stairwell enclosure. Findings include:

1. Observation at 1:45 p.m. on 3/27/18 revealed a stairwell enclosure serving all three floors of the hospital. Miscellaneous items were being stored in the stairwell enclosure. The stairwell should not have been used to store items and should have been kept free and clear of obstructions at all times.

Interview with the administrator at the time of the exit interview at 3:45 p.m. on 3/27/18 confirmed that condition. He indicated he was unaware that items could not be stored in the stairwell enclosure.

This deficiency has the potential to affect one of five exits from the hospital.

Based on observation, testing, and interview, the provider failed to ensure the horizontal exit was maintained between the hospital and nursing home at one of one horizontal exit. Findings include:

1. Observation at 2:30 p.m. on 3/27/18 revealed set of double cross-corridor ninety minute fire rated doors located in the two-hour fire horizontal exit separating the hospital from the nursing home. Testing of those doors at the time of observation revealed the south leaf door could just be pushed open and would not latch into the door frame. Further inspection revealed the latching hardware was out of adjustment and would not allow the positive latching hardware to latch into the door frame.

Interview with the administrator at the time of the exit interview at 3:45 p.m. on 3/27/18 confirmed that condition. He revealed he was unaware that door was not latching properly. He further indicated he was unsure when the last time that door was checked to ensure it was latching properly. A preventative maintenance plan was not available to check when the last time those doors were inspected.

This deficiency has the potential to affect one of three smoke compartments in the hospital.

Based on observation and record review, the provider failed to install a paved path of exit discharge to the public way at one exit (south exit stair enclosure) of the building. Findings include:

1. Observation at 1:30 p.m. on 8/27/18 revealed the exit from the south exit stair enclosure had a landing that ended approximately 100 feet from the nearest street. Review of the previous survey conducted on 7/12/16 confirmed that finding.

The building meets the FSES. Please mark an "F" in the completion date column (X5).

Based on observation and interview, the provider failed to ensure adequate illumination of the means of egress was provided at two of five exit discharge locations (stair exit and east exit). Findings include:

1. Observation at 1:45 p.m. on 3/27/18 revealed an exit out of the stairwell enclosure. The exit discharge was provided with a single bulb light fixture. Lighting should be provided so that minimum lighting was still provided in the event a single lighting source was lost. That lighting should also be capable of providing one and one-half hours of emergency lighting upon loss of normal power.

Interview with the administrator at the time of the exit interview at 3:45 p.m. on 3/27/18 confirmed that condition. He was not aware that exit discharge was not in compliance with the minimum lighting requirements.

This deficiency has the ability to affect two of five exits from the hospital.

Based on observation, testing, and interview, the provider failed to ensure emergency lighting was properly maintained in one randomly observed location (hospital waiting area). Findings include:

1. Observation at 12:30 p.m. on 3/27/18 revealed a combination exit sign and dual bulb emergency lighting fixture in the waiting room. Testing of that fixture with the provided test button revealed the lighting would not turn on indicating it was not functioning properly. Automatic emergency lighting should have been provided in all means of egress from the building for a minimum of one and a half hours.

Interview with the administrator at the time of the exit interview at 3:45 p.m. on 3/27/18 confirmed that condition. He indicated he was unaware that fixture was not functioning properly.

Based on observation, testing, and interview, the provider failed to ensure separation was properly maintained from rooms designated as hazardous areas in one randomly observed location (boiler room in basement). Findings include:

1. Observation at 2:10 p.m. on 3/27/18 revealed a boiler room in the basement. The door to that room was equipped with a door closer. The door was held open with an unapproved hold open device. Removing the unapproved device revealed the door would not close under power of the door closer installed on the door. The door would rub on the floor and stick open.

Interview with the administrator at 3:45 p.m. on 3/27/18 confirmed that condition. He indicated he was unaware the door to the boiler room was not functioning properly. He indicated he was unsure when the last time the door was checked to ensure it was working properly. No preventive maintenance plan was available to check how often and when it was last checked.

This deficiency has the potential to affect one of one stair enclosure.

Based on document review and interview, the provider failed to ensure the fire alarm system was inspected and maintained in accordance with NFPA 72, National Fire Alarm and Signaling Code for one of many inspection, testing, and maintenance requirements for fire alarm systems (sensitivity testing of fire alarm initiation devices). Findings include:

1. Document review at 2:15 p.m. on 3/27/18 revealed an inspection report prepared by Adtech Inc dated 6/27/17. That report did not include sensitivity testing for fire alarm initiation devices installed in the facility. Further review of historic fire alarm inspection reports revealed sensitivity testing was last conducted on 6/25/13. Sensitivity testing should have been permitted to extend to the maximum duration of five years if all nuisance alarms were documented. No documentation was provided of the nuisance alarms or which devices had caused nuisance alarms that might have indicate the sensitivity of devices might need calibration.

Interview with the administrator at the time of the exit interview at 3:45 p.m. on 3/27/18 confirmed that condition. He indicated he was unaware of the inspection reports and that further documentation was missing. He believed Adtech Inc was performing all required testing and maintenance.

This deficiency has the potential to affect three of three smoke compartments.

Based on observation and interview, the provider failed to ensure the fire alarm system was installed in one of many areas required to be provided with initiating devices (reception desk room). Findings include:

1. Observation at 11:45 a.m. on 3/27/18 revealed a reception desk room at the main entry. The room was provided with a sliding glass reception window. The window was not provided with a closer and would be considered open to the corridor. All spaces that open to the corridor should have been provided with a smoke detection fire alarm initiating device.

Interview with the administrator at the time of the exit interview at 3:45 p.m. on 3/27/18 confirmed this condition. He indicated he was unaware that space open to the corridor was required to have smoke detection.

This deficiency has the potential to affect one of three smoke compartments.

Based on observation and interview, the provider failed to ensure smoke barriers were properly maintained in one of one smoke barrier wall separating the north wing from the south wing. Findings include:

1. Observation at 12:45 p.m. on 3/27/18 revealed a smoke barrier wall separating the north and south wing. Further investigation above the lay in ceiling above the cross-corridors installed in the smoke barrier revealed unsealed penetrations through the smoke barrier wall for communication cables. Those penetrations should have been properly sealed with a fire rated caulking material.

Interview with the administrator at the time of the exit interview at 3:45 p.m. on 3/27/18 confirmed that condition. He indicated he was unaware of the unsealed penetrations in the smoke barrier.

This deficiency has the potential to affect two of three smoke compartments on either side of this smoke barrier wall.

Based on observation, policy review, and interview, the provider failed to ensure staff were following the adopted smoking policy in one randomly observed area (garage located on hospital campus). Findings include:

1. Observation on 3/28/18 at 10:15 a.m. revealed a garage used to store miscellaneous supplies for hospital and nursing home operations. Further observation revealed the maintenance supervisor also had his desk in that garage. A strong smell of smoke was noted when entering the garage. That garage was located on the hospital campus. Smoking should have not been permitted in a hazardous location. Due to the amount of combustible materials being stored in the garage it would have been considered a hazardous area.

Interview at the above time with the central supply director revealed:
*She agreed with the smell of smoke in the garage.
*It was not the first time she had smelled smoke.

Interview on 3/28/18 at 4:30 p.m. with the administrator revealed he:
*Agreed all of the buildings and property of the facility was a smoke-free area.
*Had also observed the maintenance supervisor smoking in the garage.
*Had asked him to not smoke in the garage.
*Had not followed up to ensure the maintenance supervisor had not continued to smoke in the garage.

Review of the provider's revised 10/1/17 Smoking Regulations for Employees, Patients, and Visitors revealed:
*It was the policy of the facility to have provided a smoke-free environment.
*Smoking regulations have been established to comply with South Dakota State Codified Law 34-46-14.
*Procedure for employee/visitor smoking privileges and restrictions:
-"Bennett County Hospital, Nursing Home and Rural Health Clinic is a NON-SMOKING facility. This includes all ground owned or rented by Bennett County Hospital, Nursing Home and Rural Health Clinic."

This deficiency had the potential to affect the northeast portion of the hospital located adjacent to the garage.

Based on observation and interview, the provider failed to ensure portable space heaters were not used in patient care areas in one randomly observed location (Emergency room [ER]). Findings include:

1. Observation at 12:15 p.m. on 3/27/18 revealed a soiled utility room in the west ER room. Further observation revealed a portable unit heater was being stored in that room. Portable unit heaters are not permitted to be used in patient care areas. Interview with ER staff revealed ventilation in that ER area could get pretty cold in the winter. No documentation could be presented indicating the temperature of the ER rooms where the space heaters were used.

Interview with the administrator at the time of the exit interview at 3:45 p.m. on 3/27/18 confirmed that condition. He indicated he was unaware portable space heaters were being used. He indicated he had not heard any issues about it being too cold in the ER rooms.

This deficiency has the potential to affect one of three smoke compartments.

Based on observation, testing, and interview, the provider failed to ensure the building electrical system was maintained in one randomly observed location (outlet in emergency department soiled utility room). Findings include:

1. Observation at 12:00 p.m. on 3/27/18 revealed a soiled utility room in the emergency department. A quad receptacle located about 18 inches above the soiled utility room sink had a portion of the receptacle housing broken. The broken outlet might have the potential to create unsafe operation. Testing of that outlet with outlet tester revealed that outlet was also not ground-fault circuit interrupter (GFCI) protected. All electrical outlets within six feet of water source have to be GFCI protected.

Interview with the administrator at the time of the exit interview at 3:45 p.m. on 3/27/18 confirmed that condition. He indicated he was unaware that outlet was broken, or that it was not GFCI protected.

This deficiency has the potential to affect one of three smoke compartments.

Based on observation and interview, the provider failed to ensure electrical wiring and equipment was maintained in accordance with NFPA 70, the National Electrical code, in one randomly observed location (extension cord in oxygen storage room). Findings include:

1. Observation at 1:30 p.m. on 3/27/18 revealed an extension cord plugged into an outlet in the oxygen storage room. The cord then ran through the room through the exhaust fan house to the exterior. Extension cords are not an acceptable means of permanent wiring and should only be used on a temporary basis. They should be removed from outlets and properly stored when not in-use to avoid damage and potential circuit arcing.

Interview with the administrator at 3:45 p.m. on 3/27/18 revealed he was aware of the extension cord. He indicated it was used to provide power for the ambulance. That would not be considered a temporary use. He indicated he believed extension cords were permitted if not used in patient care areas.

This deficiency has the potential to affect one of three smoke compartments.

Based on observation and interview, the provider failed to ensure gas cylinders were properly stored in an enclosed area to prevent unauthorized access in one of two oxygen storage areas (outside storage area). Findings include:

1. Observation at 1:30 p.m. on 3/27/18 revealed an outside oxygen cylinder storage area between the hospital and nursing home. Over forty E-sized cylinders and over ten H-sized cylinders were being stored outside. The majority of these cylinders were full. Those oxygen cylinders were not stored in any sort of enclosure that would prevent unauthorized access.

Interview with the administrator at the time of the exit interview at 3:45 p.m. on 3/27/18 revealed he was unaware those cylinders should have been stored in an enclosure to prevent unauthorized access.