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It was determined through observation during the survey that the facility failed to maintain the corridor doors in accordance with the Life Safety Code. This was evidenced by:

1) The corridor entry door to the pharmacy is a fire rated door that is an opening through a fire rated wall assembly; this self-closing door failed to fully close and positively latch into the door frame assembly when released from the fully open position, as required.

2) The corridor door serving the cardiac rehabilitation room was propped open with a wood wedge at the time of the survey.

The corridor door deficiency item was discussed during the survey and again during the exit conference.

It was determined through observation during the survey that the facility failed to maintain the means of egress in accordance with the Life Safety Code. This was evidenced by:

1) The cross-corridor doors separating the north-side of the OB unit from the remainder of the facility are labeled as an exit in both directions, but are locked to egress from either direction by magnetic locking devices with a keypad overrides. This setup:
a) fails to provide egress in either direction, and
b) creates a deadend corridor that is greater than thirty-feet in length on the non-OB side of the arrangement.

2) The cross-corridor doors separating the south-side of the OB unit from the remainder of the facility are labeled as an exit from the OB unit side of the doors, but are locked to egress from this direction by magnetic locking devices with a keypad overrides.

3) The cross-corridor doors separating the south-side of the ER from the remainder of the facility are labeled as an exit from the non-ER side of the doors, but are locked to egress from this direction by magnetic locking devices with a keypad overrides.

4) The cross-corridor doors separating the north-side of the ER from the remainder of the facility are labeled as an exit in both directions, but are locked to egress from either direction by magnetic locking devices with a keypad overrides.

5) The first set of exterior exit doors from the ER are labeled as an exit, but are locked to egress unless a wall-mounted override button is depressed first.

Note: In accordance with NFPA 101, section 18.2.2.2.4, the only locking arrangements available to the facility within a means of egress are "delayed egress" and "access-controlled egress" as defined by 7.2.1.6.1 and 7.2.1.6.2, respectively.

The means of egress deficiency items were discussed during the survey and again during the exit conference.

It was determined by observation, record review, and staff interview during the course of the survey that the facility failed to provide an acceptable written plan for the protection of all patients and for their evacuation in the event of an emergency in accordance with NFPA 101, section 18.7.2.2. This was evidenced by:

At the time of the survey the facility provided written policy and procedures for the evacuation of all patients in the event of a fire; however, the policy and procedures failed to contain language regarding evacuation of a smoke compartment as required.

The written policy and procedure for the evacuation of all patients in the event of a fire deficiency item was discussed during the survey and again during the exit conference.

It was determined through observation and document review during the survey that the facility failed to perform fire drills in accordance with the Life Safety Code. This was evidenced by:

Documentation was not provided at the time of the survey to show that a fire drill had taken place during the first shift in the first quarter of 2012.(Note: The facility provided drill documentation at the time of the survey for the first shift of the first quarter of 2012; however, this drill was documented during a false alarm of the fire and smoke detection system. Fire drills must be pre-planned events and the facility may not utilize false alarms of the fire and smoke detection system or real events in lieu of these pre-planned events.)

The fire drill deficiency item was discussed during the survey and again during the exit conference.

It was determined through observation and record review during the survey that the facility failed to maintain the Fire Alarm System in accordance with the Life Safety Code and NFPA 72, National Fire Alarm Code. This was evidenced by:

At the time of the survey the facility supplied documentation to reflect that the facility had been maintaining the fire alarm system in-house. Upon review of the documentation it was discovered that the facility had not been documenting the completion of all the required testing and maintenance in accordance with NFPA 72 (1999), sections 7-3.2 and 7-5.2. further, at the time of the survey the facility was unable to provide documentation that the employees completing the testing and maintenance of the system were qualified to do so in accordance with section 7-1.2.2 of the same Code referenced above.

The Fire Alarm System deficiency item was discussed during the survey and again during the exit conference.

It was determined through observation during the survey that the facility failed to install the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13 (1999). This was evidenced by:

1) The upright sprinkler head located above the large dryer in the laundry room was located approximately four-feet below the ceiling deck above the sprinkler head installation. In accordance with NFPA 13, section 5-6.4 the sprinkler head shall be located not more than 22-inches from the ceiling deck.

2) The automatic fire sprinkler protection in X-Ray room #1 was found to provide inadequate coverage to the entire room. One of the three sprinkler heads within the room had the potential to be completely obstructed by the moveable ceiling mounted equipment.

The Automatic Fire Sprinkler System deficiency items were discussed during the survey and again during the exit conference

It was determined through observation during the survey that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code (2000), NFPA 13 (1999), and NFPA 25 (1998). This was evidenced by:

1) The required escutcheon plates to pendant style sprinkler heads were missing in the following locations:
a. the ER staff lounge bathroom,
b. the OR hub (this was corrected during the survey),
c. the IT office,
d. patient room #271, and
e. patient room #273.

2) Four of four gauges on the main system riser were more than five-years old and the facility failed to provide documentation that these gauges had been re-calibrated at any time.

3) A ceiling tile was missing above the small dryers located in the laundry room, creating a large hole in the ceiling membrane, which would allow heat and the products of combustion to bypass the associated sprinkler head, rather than accumulate as necessary for proper operation of the fire sprinkler system.

4) At the time of the survey the facility failed to provide documentation to reflect that the required five-year internal inspection of the Fire Department Connection check valve, in accordance with NFPA 25, section 9-4.2.1, had been completed.

The Automatic Fire Sprinkler System deficiency items were discussed during the survey and again during the exit conference.

It was determined through observation during the survey that the facility failed to maintain the MedGas storage location in accordance with the Life Safety Code (2000), NFPA 99 (1999), Healthcare Facilities, and NFPA 50 (1996), Standard for Bulk Oxygen Systems at Consumer Sites. This was evidenced by:

1) The electrical light switch, an electrical outlet, and an electrical sensor box located in the MedGas storage room were found to be located lower than the allowable 5-feet above floor level.
Note: In accordance with NFPA 99, Health Care Facilities, 4-3.1.1.2(a)4, "electrical installation in storage locations...shall be installed in fixed locations not less than 152 cm (5 ft) above the floor."

2) The uninsulated portions of the bulk oxygen storage site on the north side of the building failed to meet the distance requirements from combustibles, as set forth in NFPA 50. This was evidenced by:
a) the bulk storage location was within 25-feet of three (3) juniper tress, which are considered fuels that would burn slowly, and
b) the bulk storage location was within approximately 45 feet of a wood-roofed pump house and associated bridge to the North, both considered fuels that would burn rapidly.

The MedGas storage location deficiency items were discussed during the survey and again during the exit conference.

Through observation and staff interview during the survey it was determined that the facility failed to maintain the anesthetizing locations per NFPA 99. This was evidenced by:

Four of four operating rooms and one of one caesarian section room, all of which are anesthetizing locations, did not contain exhaust capabilities in case of a fire originating in the room.
Note: Per NFPA 99, 1999 Edition 5-4.1.2 "Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion."

The anesthetizing location deficiency item was discussed during the survey and again during the exit conference.

It was determined through observation and through staff interview during the course of the survey that the facility failed to install the emergency backup generator that provides emergency lighting for egress in accordance with NFPA 101, Life Safety Code and NFPA 110, Standard for Emergency and Standby Power Systems. This was evidenced by the following:

1) The facility failed to provide a battery-backed up emergency light at the generator location, capable of providing 90-minutes of illumination, as required.

2) The facility failed to provide a battery-backed up emergency light at the transfer switch location, capable of providing 90-minutes of illumination, as required.

The generator deficiency items were discussed during the survey and again during the exit conference.

It was determined through observation during the survey that the facility failed to maintain the generator and related equipment in accordance with the Life Safety Code (2000), NFPA 99 (1999), Healthcare Facilities, and NFPA 110 (1999), Standard for Emergency and Standby Power Equipment. This was evidenced by:

At the time of the survey the facility supplied documentation to reflect that the facility had been maintaining the generator and related equipment in-house. Upon review of the documentation it was discovered that the facility had not been documenting the completion of all the required testing and maintenance in accordance with the manufacturer's requirements. Of the manufacturer's requirements not completed by the facility, the most significant was the lack of an annual oil change. If the facility plans to continue in-house maintenance of the generator and related equipment, it must complete and document the completion of all the maintenance activities required by the manufacturer, in accordance with NFPA 110, section 6-1.1.

The generator deficiency items were discussed during the survey and again during the exit conference.

Through observation during the survey, it was determined that the facility failed to install and maintain the electrical system in accordance with NFPA 70. This was evidenced by:

1) There was an extension cord utilized as permanent wiring running through he ceiling in the kitchen to provide power to a pump.

2) There was an extension cord being used in place of the permanent wiring of the structure to power a calculator in the HR office.

Note: Per NFPA 70 1999 Edition, Chapter 4, Article 400, Paragraph 400.8, (" ... flexible cords and cables shall not be used for the following: (1) as a substitute for the fixed wiring of a structure ... ")

The electrical system deficiency items were discussed during the survey and again during the exit conference.

It was determined by observation, staff interview, and through record review during the course of the survey that the facility failed to provide an acceptable fire watch policy in the event the automatic fire sprinkler system is out of service for more than 4 hours in a 24-hour period. This was evidenced by the following:

At the time of the survey the facility provided a policy and documentation enacting the policy regarding the requirement set forth in NFPA 101, 9.7.6.1, wherein it states that when a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the building shall be evacuated or an approved fire watch system is provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service. The documentation failed to:
a) reflect that the affected area must be inspected, at a minimum, every fifteen minutes, and
b) reflect a required procedure, wherein facility staff are to advise the Authority Having Jurisdiction (CDPHE) whenever the facility is on a fire watch, as required.
Note: In accordance with the Colorado Department of Public Health and Environment, Health Facilities and Emergency Medical Service Division's (Authority Having Jurisdiction) policy manual in regards to Life Safety Code Fire Watch Requirements (enacted in January of 2010), a full inspection of the affected areas within this facility shall take place at a minimum of every fifteen minutes.

The fire watch policy deficiency item was discussed during the survey and again during the exit conference.