HospitalInspections.org

Based on observation and interview it was determined door wedges were used to hold open two sets of fire doors located near the Radiology Department. The use of door wedges on fire doors has the potential to affect the health and safety of all patients and building occupants because the wedges prevent the fire doors from automatically closing in the event of a fire, allowing passage of fire and smoke from one smoke compartment to another. The failed practice had the potential to affect three of three patients in the facility on 06/27/11 and all staff, visitors, and patients admitted to the facility. The facility had an average census of 3.8 patients a month. The findings follow:

A. On a tour of the facility on 06/29/11 at 1030, two sets of fire doors located near Radiology were observed with door wedges. The fire doors were installed with automatic closing devices. The door wedges prevented the doors from automatically closing. In addition, the closing device on one door was disconnected from the door.
B. In an interview on 06/29/11 at 1035 the Director of Maintenance stated he had recently discovered the automatic closing devices on the fire doors were not interconnected with the fire alarm system and were not capable of staying open without the door wedges. He stated the doors were normally open due the volume of persons walking through the area.

Based on observation and interview, it was determined combustible materials were stored in rooms not protected as a hazardous area by fire rated construction or sprinkler system in a storage room located in the Surgery Department. Storage of combustible materials in an unprotected room had the potential to affect the health and safety of surgery patients in the area due to the potential spread of fire and smoke beyond the storage room into the surgical suite. The failed practice has the potential to affect all patients admitted for surgery. There were no patients admitted for surgery on 06/28/11. The findings follow:

A. On a tour of the surgical suite on 06/28/11 at 1015, combustible materials including a Christmas tree, decorations, a stuffed animal, and plastic plants were observed in a storage room located by the exit door to the exterior of building in the surgical corridor. The room was not separated with fire rated construction or protected with a sprinkler system. The door to the room was not fire rated and was not self-closing.
B. On 06/28/11 at 1030 the QA/PI (Quality Assessment/Process Improvement)
Coordinator verified the presence of the combustible materials in the storage room.

Based on fire drill documentation review and interview, it was determined the facility failed to conduct two of five required quarterly fire drills for the 1st (day) shift and five of five required fire drills for the 2nd (night) shift from January 2010 to March 2011 and the documentation did not include an evaluation of staff response to the drill or evaluation of the building fire alarm system notification devices. Failure to conduct fire drills had the potential to affect the safety of all building occupants because the effectiveness of the fire plan and staff training in the event of a fire event could not be evaluated. The failed practice had the potential to affect three of three patients in the facility on 06/27/11 and all staff, visitors, and patients admitted to the facility. The facility had an average census of 3.8 patients a month. The findings follow:

A. Review of the records for fire drills on 06/27/11 at 1450 revealed documentation of fire drills consisted of a sign-in sheet of drill participants. There was no evaluation of staff response to the fire drill or the function of the notification devices. The documentation revealed fire drills were documented by sign in sheets for the first shift only on 03/10/10, 10/13/10, and 03/23/11.
B. In an interview on 06/28/11 at 1100 the Director of Maintenance verified there was no further fire drill documentation available for review.

Based on fire alarm system inspection documentation review and interview it could not be determined the facility performed annual inspection of all fire alarm devices since 00. The failed practice had the potential to affect the health and safety of all building occupants because the function and reliability of all fire alarm system devices could not be assured. The failed practice had the potential to affect three of three patients in the facility on 06/27/11 and all staff, visitors, and patients admitted to the facility. The facility had an average census of 3.8 patients a month. The findings follow:

A. A review of fire alarm inspection reports on 6/28/11 at 0930 revealed a work order dated 09/12/10 from the contracted fire alarm service for a completed inspection. However, this report documented the testing of the fire alarm devices occurred on 09/30/09. There was no documentation of testing of the fire alarm devices for since 09/12/10.
B. In an interview conducted on 06/28/11 at 1000, the Director of Maintenance stated he had requested the current full inspection report from the fire alarm inspection company but the only most recent avaiable for review was the report dated 09/12/10. He stated there was no further documentation available for review.

Based on observation and interview, it was determined the facility failed to perform monthly tests on two of two Line Isolation Monitors in 2010 and 2011 in accordance with NFPA 99 Section 3-3.3.4.2 (b). The failed practice had the potential to affect all patients admitted for surgery. There were no surgical cases scheduled on the day of observations. Failure to test the line isolation monitors had the potential to affect the health and safety of surgical patients because the proper function of the monitors to prevent electric shock was not evaluated. The findings follow:

A. On 06/28/11 at 1015 while touring the surgical suite, a Line Isolation Monitor was observed in Surgery 1 and the Pre-Operative/Recovery Rooms.
B. In an interview on 06/28/11 at 1100, the Director of Maintenance stated he was not aware of the requirement of monthly tests of the Line Isolation Monitors and verified there was no monthly Line Isolation Monitor testing documentation available for review

Based on Generator Log Review and interview, it was determined the facility failed to inspect the two generators serving the facility on a weekly schedule and perform exercise the generator for a full 30 minutes monthly from January 2010 to June 2011. Failure to inspect and exercise the generator as required had the potential to affect the health and safety of patients because the reliability of the generators to supply electrical power to the facility in the event of the loss of normal power was not evaluated and could not be assured. The failed practice had the potential to affect three of three patients in the facility on 06/27/11 and all staff, visitors, and patients admitted to the facility. The facility had an average census of 3.8 patients a month. The findings follow:

A. Review of the generator logs on 06/28/11 at 1045 revealed the facility was served by a "Main" generator and a "Secondary" generator serving different sections of the building. The logs for the years 2010 and 2011 revealed both generators were exercised twice a month for a total of five minutes on each day. In addition, there was no documentation of a weekly inspection of the generators in the logs.
B. In an interview on 06/28/11 at 1100, the Director of Maintenance stated the generators were programmed to run for only five minutes on each load test. He verified the generators ran for only five minutes on each monthly test, were not inspected on a weekly schedule, and stated there was no further documentation available for review.

Based on observation and interview it was determined door wedges were used to hold open two sets of fire doors located near the Radiology Department. The use of door wedges on fire doors has the potential to affect the health and safety of all patients and building occupants because the wedges prevent the fire doors from automatically closing in the event of a fire, allowing passage of fire and smoke from one smoke compartment to another. The failed practice had the potential to affect three of three patients in the facility on 06/27/11 and all staff, visitors, and patients admitted to the facility. The facility had an average census of 3.8 patients a month. The findings follow:

A. On a tour of the facility on 06/29/11 at 1030, two sets of fire doors located near Radiology were observed with door wedges. The fire doors were installed with automatic closing devices. The door wedges prevented the doors from automatically closing. In addition, the closing device on one door was disconnected from the door.
B. In an interview on 06/29/11 at 1035 the Director of Maintenance stated he had recently discovered the automatic closing devices on the fire doors were not interconnected with the fire alarm system and were not capable of staying open without the door wedges. He stated the doors were normally open due the volume of persons walking through the area.

Based on observation and interview, it was determined combustible materials were stored in rooms not protected as a hazardous area by fire rated construction or sprinkler system in a storage room located in the Surgery Department. Storage of combustible materials in an unprotected room had the potential to affect the health and safety of surgery patients in the area due to the potential spread of fire and smoke beyond the storage room into the surgical suite. The failed practice has the potential to affect all patients admitted for surgery. There were no patients admitted for surgery on 06/28/11. The findings follow:

A. On a tour of the surgical suite on 06/28/11 at 1015, combustible materials including a Christmas tree, decorations, a stuffed animal, and plastic plants were observed in a storage room located by the exit door to the exterior of building in the surgical corridor. The room was not separated with fire rated construction or protected with a sprinkler system. The door to the room was not fire rated and was not self-closing.
B. On 06/28/11 at 1030 the QA/PI (Quality Assessment/Process Improvement)
Coordinator verified the presence of the combustible materials in the storage room.

Based on fire drill documentation review and interview, it was determined the facility failed to conduct two of five required quarterly fire drills for the 1st (day) shift and five of five required fire drills for the 2nd (night) shift from January 2010 to March 2011 and the documentation did not include an evaluation of staff response to the drill or evaluation of the building fire alarm system notification devices. Failure to conduct fire drills had the potential to affect the safety of all building occupants because the effectiveness of the fire plan and staff training in the event of a fire event could not be evaluated. The failed practice had the potential to affect three of three patients in the facility on 06/27/11 and all staff, visitors, and patients admitted to the facility. The facility had an average census of 3.8 patients a month. The findings follow:

A. Review of the records for fire drills on 06/27/11 at 1450 revealed documentation of fire drills consisted of a sign-in sheet of drill participants. There was no evaluation of staff response to the fire drill or the function of the notification devices. The documentation revealed fire drills were documented by sign in sheets for the first shift only on 03/10/10, 10/13/10, and 03/23/11.
B. In an interview on 06/28/11 at 1100 the Director of Maintenance verified there was no further fire drill documentation available for review.

Based on fire alarm system inspection documentation review and interview it could not be determined the facility performed annual inspection of all fire alarm devices since 00. The failed practice had the potential to affect the health and safety of all building occupants because the function and reliability of all fire alarm system devices could not be assured. The failed practice had the potential to affect three of three patients in the facility on 06/27/11 and all staff, visitors, and patients admitted to the facility. The facility had an average census of 3.8 patients a month. The findings follow:

A. A review of fire alarm inspection reports on 6/28/11 at 0930 revealed a work order dated 09/12/10 from the contracted fire alarm service for a completed inspection. However, this report documented the testing of the fire alarm devices occurred on 09/30/09. There was no documentation of testing of the fire alarm devices for since 09/12/10.
B. In an interview conducted on 06/28/11 at 1000, the Director of Maintenance stated he had requested the current full inspection report from the fire alarm inspection company but the only most recent avaiable for review was the report dated 09/12/10. He stated there was no further documentation available for review.

Based on observation and interview, it was determined the facility failed to perform monthly tests on two of two Line Isolation Monitors in 2010 and 2011 in accordance with NFPA 99 Section 3-3.3.4.2 (b). The failed practice had the potential to affect all patients admitted for surgery. There were no surgical cases scheduled on the day of observations. Failure to test the line isolation monitors had the potential to affect the health and safety of surgical patients because the proper function of the monitors to prevent electric shock was not evaluated. The findings follow:

A. On 06/28/11 at 1015 while touring the surgical suite, a Line Isolation Monitor was observed in Surgery 1 and the Pre-Operative/Recovery Rooms.
B. In an interview on 06/28/11 at 1100, the Director of Maintenance stated he was not aware of the requirement of monthly tests of the Line Isolation Monitors and verified there was no monthly Line Isolation Monitor testing documentation available for review

Based on Generator Log Review and interview, it was determined the facility failed to inspect the two generators serving the facility on a weekly schedule and perform exercise the generator for a full 30 minutes monthly from January 2010 to June 2011. Failure to inspect and exercise the generator as required had the potential to affect the health and safety of patients because the reliability of the generators to supply electrical power to the facility in the event of the loss of normal power was not evaluated and could not be assured. The failed practice had the potential to affect three of three patients in the facility on 06/27/11 and all staff, visitors, and patients admitted to the facility. The facility had an average census of 3.8 patients a month. The findings follow:

A. Review of the generator logs on 06/28/11 at 1045 revealed the facility was served by a "Main" generator and a "Secondary" generator serving different sections of the building. The logs for the years 2010 and 2011 revealed both generators were exercised twice a month for a total of five minutes on each day. In addition, there was no documentation of a weekly inspection of the generators in the logs.
B. In an interview on 06/28/11 at 1100, the Director of Maintenance stated the generators were programmed to run for only five minutes on each load test. He verified the generators ran for only five minutes on each monthly test, were not inspected on a weekly schedule, and stated there was no further documentation available for review.