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Based upon random observation, the surveyor finds that hazardous areas are not enclosed in accordance with 19.3.2.1. The surveyor notes that the building is partially sprinklered and that existing hazardous areas have to comply as a fire rated enclosure with fire rated, self closing doors.

The findings are:

A. On November 8, 2012 at 2:15pm while accompanied by the Maintenance supervisor, the Sterilizer room located adjacent to the Central Sterile Supply room was observed that does not comply with 19.3.2.1 due to the following:

1. The "Patient Education" room (referenced from the facility Life Safety floor plans) is not separated from the Central Sterile Supply/Sterilizer room due to holes and gaps within the fire rated wall separation.
2. An open copper pipe penetrates a fire rated wall of the Sterilizer room.
3. The ceiling of the Sterilizer room contains holes surrounding junction boxes.
4. The Sterilizer room contains an open flexible duct hanging from the ceiling.

B. On November 8, 2012 at 1:15pm while accompanied by the Maintenance supervisor, the Clean Linen Folding Storage room (referenced on the Life Safety floor plan) was observed to contain a dampered duct penetration through a fire rated wall with a continuous gap surrounding the duct penetration. This installation does not comply with NFPA 90A.

Failure to provide and maintain separation between hazardous areas and all other areas could result in spread of fire and smoke throughout the building.

Based upon random observation, the surveyor finds that the fire alarm system does not comply with NFPA 72.

The finding is:

A. On November 8, 2012 at 11:30am during the survey walk through accompanied by the Maintenance Supervisor, it was observed that the facility failed to provide automatic smoke detection at the fire alarm control panel to comply with NFPA 72, 1999, 1-5.6.

This condition may affect all building occupants due to delay in notification of a fire to the monitoring service if the facility's fire alarm system is compromised at the main panel.

Based on document review, not all portions of the facility's commercial cooking equipment is installed and maintained in accordance with NFPA 96.

The finding includes:

A. At 3pm on 11/08/12, during the document review process, accompanied by the Maintenance Supervisor, it was discovered that all recent reports from the kitchen hood suppression system service vendor, stated that the activation of the kitchen hood suppression system does not automatically activate the building fire alarm system to comply with NFPA 96 1998 7-6.2. This could affect any patients, staff, or visitors in the building because a fire in the Kitchen could occur without their knowledge.

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A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

B. On 11/08/12 at 12:15pm while accompanied by the Maintenance Supervisor, it was observed that the following condition is not met C220: CFR 485.623. The extent and complexity of facilities must be determined by the services offered. Physical facilities must be large enough, numerous enough, appropriately designed and equipped, and of appropriate complexity to provide the services offered in accordance with Federal and State laws, regulations and guidelines and accepted standards of practice for that location or service. Surveyor observed the following:
1. O.R. Suite Recovery room lacks what is needed to meet minimum state requirements:
a. Entry to the room does not facilitate one way flow.
b. Minimum of one bed per O.R. with 4 ' -0 "clearance on the sides and
6 ' -0 " clearance at the foot.
c. Adequate storage and work space.

This condition may compromise the integrity of infection control within the O.R. Suite.

C. On 11/08/12 at 2:15pm while accompanied by the Maintenance Supervisor, it was observed that the following condition is not met C-222 CFR 485.623(b) (1) Facilities must be maintained to ensure an acceptable level of safety and quality. Supplies must be maintained to ensure an acceptable level of safety and quality. Equipment must be maintained to ensure an acceptable level of safety and quality.

1. "Central Supply" is to contain a clean and soiled side of the room. This is indicated on a table with a sign having arrows. A wall switch contains an on/off timer for a fan. The surveyor felt no air flow from clean to soiled within the room. The facility representative was unable to determine how air flow from clean to soiled is achieved and was unable to determine the air change per hour.

This condition may compromise the integrity of wrapped sterile instruments and supplies.

A. Based on document review and staff interview, the emergency generator is not inspected and tested in accordance with NFPA 99. These deficiencies could affect all patients, staff, or visitors in the building because the emergency generator could fail to operate under emergency conditions.

The finding includes:

1. During the document review process on November 9, 2012 at 9:00am accompanied by the Maintenance Supervisor, it was determined that the emergency generator is not tested under load for 30 minutes each month, to comply with NFPA 99 1999 3-4.4.1.1. and NFPA 110 1999 6-4.2., because no records of any such inspections were available.

2. During the document review process on November 9, 2012 at 9:00am accompanied by the Maintenance Supervisor, it was determined that the emergency generator is not exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours to comply with NFPA 110 6-4.2.2 because no records of any such testing was available.

These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised without the facility being aware that the emergency generator is not functioning properly.

Based upon random observation, the surveyor finds that hazardous areas are not enclosed in accordance with 19.3.2.1. The surveyor notes that the building is partially sprinklered and that existing hazardous areas have to comply as a fire rated enclosure with fire rated, self closing doors.

The findings are:

A. On November 8, 2012 at 2:15pm while accompanied by the Maintenance supervisor, the Sterilizer room located adjacent to the Central Sterile Supply room was observed that does not comply with 19.3.2.1 due to the following:

1. The "Patient Education" room (referenced from the facility Life Safety floor plans) is not separated from the Central Sterile Supply/Sterilizer room due to holes and gaps within the fire rated wall separation.
2. An open copper pipe penetrates a fire rated wall of the Sterilizer room.
3. The ceiling of the Sterilizer room contains holes surrounding junction boxes.
4. The Sterilizer room contains an open flexible duct hanging from the ceiling.

B. On November 8, 2012 at 1:15pm while accompanied by the Maintenance supervisor, the Clean Linen Folding Storage room (referenced on the Life Safety floor plan) was observed to contain a dampered duct penetration through a fire rated wall with a continuous gap surrounding the duct penetration. This installation does not comply with NFPA 90A.

Failure to provide and maintain separation between hazardous areas and all other areas could result in spread of fire and smoke throughout the building.

Based upon random observation, the surveyor finds that the fire alarm system does not comply with NFPA 72.

The finding is:

A. On November 8, 2012 at 11:30am during the survey walk through accompanied by the Maintenance Supervisor, it was observed that the facility failed to provide automatic smoke detection at the fire alarm control panel to comply with NFPA 72, 1999, 1-5.6.

This condition may affect all building occupants due to delay in notification of a fire to the monitoring service if the facility's fire alarm system is compromised at the main panel.

Based on document review, not all portions of the facility's commercial cooking equipment is installed and maintained in accordance with NFPA 96.

The finding includes:

A. At 3pm on 11/08/12, during the document review process, accompanied by the Maintenance Supervisor, it was discovered that all recent reports from the kitchen hood suppression system service vendor, stated that the activation of the kitchen hood suppression system does not automatically activate the building fire alarm system to comply with NFPA 96 1998 7-6.2. This could affect any patients, staff, or visitors in the building because a fire in the Kitchen could occur without their knowledge.

.

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

B. On 11/08/12 at 12:15pm while accompanied by the Maintenance Supervisor, it was observed that the following condition is not met C220: CFR 485.623. The extent and complexity of facilities must be determined by the services offered. Physical facilities must be large enough, numerous enough, appropriately designed and equipped, and of appropriate complexity to provide the services offered in accordance with Federal and State laws, regulations and guidelines and accepted standards of practice for that location or service. Surveyor observed the following:
1. O.R. Suite Recovery room lacks what is needed to meet minimum state requirements:
a. Entry to the room does not facilitate one way flow.
b. Minimum of one bed per O.R. with 4 ' -0 "clearance on the sides and
6 ' -0 " clearance at the foot.
c. Adequate storage and work space.

This condition may compromise the integrity of infection control within the O.R. Suite.

C. On 11/08/12 at 2:15pm while accompanied by the Maintenance Supervisor, it was observed that the following condition is not met C-222 CFR 485.623(b) (1) Facilities must be maintained to ensure an acceptable level of safety and quality. Supplies must be maintained to ensure an acceptable level of safety and quality. Equipment must be maintained to ensure an acceptable level of safety and quality.

1. "Central Supply" is to contain a clean and soiled side of the room. This is indicated on a table with a sign having arrows. A wall switch contains an on/off timer for a fan. The surveyor felt no air flow from clean to soiled within the room. The facility representative was unable to determine how air flow from clean to soiled is achieved and was unable to determine the air change per hour.

This condition may compromise the integrity of wrapped sterile instruments and supplies.

A. Based on document review and staff interview, the emergency generator is not inspected and tested in accordance with NFPA 99. These deficiencies could affect all patients, staff, or visitors in the building because the emergency generator could fail to operate under emergency conditions.

The finding includes:

1. During the document review process on November 9, 2012 at 9:00am accompanied by the Maintenance Supervisor, it was determined that the emergency generator is not tested under load for 30 minutes each month, to comply with NFPA 99 1999 3-4.4.1.1. and NFPA 110 1999 6-4.2., because no records of any such inspections were available.

2. During the document review process on November 9, 2012 at 9:00am accompanied by the Maintenance Supervisor, it was determined that the emergency generator is not exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours to comply with NFPA 110 6-4.2.2 because no records of any such testing was available.

These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised without the facility being aware that the emergency generator is not functioning properly.