HospitalInspections.org

Based upon observations and staff interviews on June 7, 2018 between approximately 0915 and 1530 hours the facility has failed to properly maintain the fire resistance of the structure by allowing unprotected penetrations of smoke partitions around ductwork, pipes and/or conduit. This could allow for the spread of smoke and fire in adjoining smoke barrier which could potentially endanger the patients, staff and/or visitors within the facility.

The findings include, but are not limited to:

Penetrations were observed in the walls of the main electrical room in the old building.

The above was discussed and acknowledged by the administrator and the maintenance director.

Based upon observations, documentation review and staff interviews on June 7, 2018 between approximately 0915 and 1530 hours the facility has failed to test all fire rated doors in accordance with NFPA 80. This could lead to the doors not functioning as required in a fire, endangering those inside the building.

The findings include, but are not limited to:

The facility was unable to provide documentation of annual inventory, inspection of the fire doors.

The above was discussed and acknowledged by the administrator and maintenance director.

Based upon observations and staff interviews on June 7, 2018 between approximately 0915 and 1530 hours the facility has failed to maintain the ability of doors to be held open only by devices arranged to automatically close upon activation of the fire alarm. This could result in the passage of smoke or fire from one compartment into another compartment thereby exposing residents, staff and/or visitors to the toxic products of combustion.

1) The door to the main electrical room in the old building was propped in open with a wedge.

2) The corridor door between the old building and the new building failed to close and latch. Corrected during inspection.

The above was discussed and acknowledged by the administrator and the maintenance director.

Based upon record review and staff interviews on June 7, 2018 between approximately 0915 and 1530 hours the facility has failed to have appropriate testing of the fire alarm system which result in the failure of notification to staff of smoke or fire and endanger the patients, staff and/or visitors within the facility.

The findings include, but are not limited to:

Sensitivity testing indicated ten detectors failing. Retesting after cleaning indicates two detectors still failed.

The above was discussed and acknowledged by the administrator and maintenance director.

Based upon observations, documentation review and staff interviews on June 7, 2018 between approximately 0915 and 1530 hours the facility has failed to ensure dampers in the facility were inspected and provided necessary maintenance at least every four years in accordance with National Fire Protection Association (NFPA) 90A. Life Safety Code (LSC) 9.2.1 requires heating, ventilating and air conditioning (HVAC), ductwork and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems.

NFPA 90A, 2012 Edition, Section 5.4.8.1 states fire dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. NFPA 80, 2010 Edition, Section 19.4.1 states each damper shall be tested and inspected 1 year after installation. The test and inspection frequency shall be every 6 years. If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in-place if so equipped. The damper shall not be blocked from closure in any way. All inspections and testing shall be documented, indicating the location of the fire damper, date of inspection, name of inspector and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected. This deficient practice could affect all patients, staff and visitors.

The findings include, but are not limited to:

The facility was unable to provide documentation of dampers or the testing and maintenance of dampers.

The above was discussed and acknowledged by the administrator and maintenance director.

Based on observation and staff interview on June 7, 2018 between approximately 0915 to 1530 hours the facility has failed to maintain construction of oxygen storage areas as being smoke and fire resistant. This could result in the products of combustion traveling from the hazardous area into the exit corridor in the event of a fire which could endanger patients, responders, staff, and/or visitors. In addition the facility has failed to maintain exterior storage locations as secured to prevent unauthorized access. This could allow for the tampering with or damage to of oxygen storage cylinders, which could endanger patients, staff, and/or visitors.

NFPA 99, 9.1.3.1.8 states, "Locations containing positive pressure gases other than oxygen and medical air shall have their door(s) labeled as follows:

Positive Pressure Gases
NO Smoking or Open Flame
Room May Have Insufficient Oxygen
Open Door and Allow Room to
Ventilate Before Entering

The findings include, but are not limited to:

The facility failed to provide required signage on the nitrous oxide storage room.

The above was discussed and acknowledged by the facility staff.

Based on observation, documentation review and staff interviews on June 7, 2018 between approximately 0915 to 1530 hours the facility has failed to maintain and test the emergency generator in accordance with NFPA 110. This could result in a failure of the emergency power system which would leave the facility without egress and task lighting in the event of a power failure which would endanger the patients, staff, and/or visitors within the facility.

The findings include, but are not limited to:

1) The facility was unable to provide documentation of the generators' fuel tank size and testing of the fuel.

2) Documentation from the facility's generator contractor stated the generators could only operator for 34 hours on the fuel supply at the facility.

The above was discussed and acknowledged by the administrator and maintenance director.

Based upon observation and staff interviews on June 7, 2018 between approximately 0915 - 1530 hours the facility has failed to restrict the use of powerstrips to providing power to permitted electrical equipment, using extension cords on a temporary basis and from ensuring all electrical wiring is in accordance with NFPA 70. This could result in a fire from overheating of the extension cord due to the prolonged power draw or result in an electrical hazard due to misuse, endangering the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

Powerstrips were "daisy chained" together in the Health Care Authority office. Corrected during inspection.

The above was discussed and acknowledged by the administrator and maintenance director.

Based on observation, documentation review and staff interview on June 7, 2018 between approximately 0915 to 1530 hours the facility has failed to provide policies for the testing, repairs, and modifications of patient care related electrical equipment as required. This could result in the failure of the patient care related electrical equipment to operate properly which would endanger the patients, staff, and/or visitors within the facility.

The findings include, but are not limited to:

1) The facility was unable to provide a policy for the testing, repairs, and modifications of patient care related electrical equipment.

2) The facility was unable to provide documentation of training for personnel who test and/or repair patient care related electrical equipment.

The above was discussed and acknowledged by the administrator and maintenance director.

Based on observation, documentation review and staff interview on June 7, 2018 between approximately 0915 to 1530 hours the facility has failed to provide documentation of personnel concerned with the application, maintenance, and handling of medical gases and cylinders that are trained on the risk and provide continuing education. Failure to provide training and continuing education on the safe handling and use of gases and cylinders could place patients, visitors, and staff at risk of oxygen malfunctions.

The findings include, but are not limited to:

The facility was unable to provide documentation of qualifications and training of personnel responsible for medical gas administration and the use of medical gas equipment.

The above was discussed and acknowledged by the administrator and maintenance director.

Based on observation, documentation review and staff interview on June 7, 2018 between approximately 0915 to 1530 hours the facility has failed to maintain a written policy or regulation for fire loss in operating rooms. This could result in the ignition of gases; endanger the patients, staff and/or visitors within the facility.

The findings include, but are not limited to:

The facility was unable to provide documentation of a operation room (OR) fire loss procedure which includes packaging is non-flammable, applicators are in unit doses, and that a pre-operative "time-out" is conducted prior the initiation of any surgical procedure. Interview of OR staff indicated no policy or procedure exists.

The above was discussed and acknowledged by the administrator and maintenance director.