HospitalInspections.org

Based on observation and interview, the facility failed to ensure that smoke doors closed and latched in two locations on the lower level. In the event of a fire, this allows the passage of smoke from one smoke compartment to another, which leads to potential harm from fire/smoke to ten (10) residents as identified by the patient census list provided by the Plant Operations Supervisor. The findings are:

A. On 09/09/15 at11:12 am, observed the smoke doors in the 400 wing near room 409 did not latch when closed.

B. On 09/09/15 at 11:15 am, observed the door to patient room 404 did not close and latch due to the privacy drape for bed A was caught up by the door when closing.

C. On 09/09/15 at 11:16 am, during interview, the Plant Operations Supervisor stated the latch bar is bent on the smoke door and the curtain track needs to be relocated, confirming these findings.

Based on observation and interview, the facility failed to ensure that the smoke barriers were sealed with no penetrations in five locations. This failed practice allows the spread of fire/smoke to other areas, which has the potential to harm all forty two (42) patients, as identified by the patient census list provided by thePlant Operations Supervisor on 09/09/15. The findings are:

A. On 09/09/15 at 10:35 am, observed penetrations in the smoke barrier above the ceiling at the smoke doors seperating the 200/300 wing on the lower level.

B. On 09/09/15 at 10:37 am, observed penetrations in the smoke barrier above the ceiling in the corridor near patient room 308 on the lower level.

C. On 09/09/15 at11:02 am, observed penetrations in the smoke barrier above the ceiling by the elevators on the 300 wing lower level.

D. On 09/09/15 at11:25 am, observed penetrations in the smoke barrier above the ceiling at the smoke doors seperating the 400 wing and Dining area lower level.

E. On 09/09/15 at 2:54 pm, observed penetrations in the smoke barrier above the ceiling by the smoke doors seperating the physical therapy and the leased space on the upper level.

F. On 09/09/15 at 2: 57 pm, during interview, the Plant Operations Supervisor stated he was not aware of the penetrations and confirmed that the penetrations do exist.

Based on observation and interview, the facility failed to ensure the 1 hour rated fire walls (walls that will not allow the passage of fire). in five location on both the upper and lower levels were intact with no penetrations or openings. In the event of a fire, these penetrations allow the passage of fire/smoke to other areas, which has the potential to harm all forty two (42) patients as identified by the patient census list provided by the Plant Operations Supervisor on 09/09/15. The findings are:

A. On 09/09/15 at 10:00 am, observed penetrations in the 1 hr (hour) rated fire wall above the ceiling in the corridor near patient room 208 on the lower level.

B. On 09/09/15 at10:30 am, observed penetrations in the 1 hr. rated fire wall above the ceiling at the 200 wing nurses station on the lower level.

C. On 09/09/15 at 10:42 am, observed penetration in the 1 hr. rated ceiling in the pool pump room on the lower level.

D. On 09/09/15 at 2:22 pm, observed penetrations in the 1 hr. rated wall above the ceiling in the old pain clinic at the smoke doors on the upper level.

E. On 09/09/15 at 3:41 pm, observed penetrations in the 1 hr. rated ceiling and east wall in the boiler room.

F. On 09/09/15 at 1545 pm during interview, the Plant Operations Supervisor stated he was not aware of the penetrations. He confirmed that the penetrations do exist.

Based on record review and staff interview the facility failed to ensure the Fire Drill records were filled out correctly and complete. This failed practice indicates that fire drills were not conducted quarterly on each shift as required. This failed practice may leave the staff untrained in the fire and evacuation procedures in the event of a fire or other emergency, leading to potential harm to all forty two (42) patients as identified by the patient census list provided by the Plant Operations Supervisor on 09/09/15. The findings are:

A. Record review of the Fire Drill records, indicates that the dates and times on the fire drill records were incomplete, indicating fire drills were not conducted at least quarterly on each shift.

The facility has two shifts, Shift 1: 6 am to 6pm and Shift 2: 6pm to 6 am

B. On 09/09/15 at 9:00 am, during interview, the Plant Operations Supervisor stated the Security personnel conduct the fire drills. He viewed these records and confirmed the dates and times were incomplete.

Reference NFPA 101, 2000 Edition

9.6.2.9 Where a partial smoke detection system is required by another section of this Code, automatic detection of smoke in accordance with NFPA 72, National Fire Alarm Code, shall be provided in all common areas and work spaces, such as corridors, lobbies, storage rooms, equipment rooms, and other tenantless spaces in those environments suitable for proper smoke detector operation. Selective smoke detection unique to other sections of this Code shall be provided as required by those sections.

Reference NFPA 72, 1999 Edition

2-3.4.5 Smooth Ceiling Spacing.
2-3.4.5.1 Spot-Type Detectors.
2-3.4.5.1.1
On smooth ceilings, spacing of 30 ft (9.1 m) shall be permitted to be used as a guide. In all cases, the manufacturer's documented instructions shall be followed. Other spacing shall be permitted to be used depending on ceiling height, different conditions, or response requirements.


Based on observation and interview, the facility failed to ensure the storage room, located at the administrative area, was provided with automatic smoke detection as required by NFPA 72 (National Fire Alarm Code). Not providing automatic smoke detection within this storage room, could result in an undetected fire at this location, which would delay notification of a fire, presenting a risk of potential harm to all forty two (42) patients within the facility as identified by the patient census list provided by the Plant Operations Supervisor on 09/09/15. The findings are:

A. On 09/09/15 at 2:00 pm, observed the storage room on the upper level in the administrative area, with large quantity of combustible material, having no smoke detection device.

B. On 09/09/15 at 2:01 pm, during interview, the Plant Operations Supervisor stated he was not aware that a smoke detector was required, confirming there was no smoke detector in the storage area.
NFPA 101/2000
9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this code.
9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.

Based on observation and staff interview, the facility failed to provide a visual (strobe) device in the In-Patient therapy staff office. This office is large and congested. In the event of a fire or other emergency, the staff may not hear the audible notification located in the corridor near the office. This may result in potential harm to the staff in this office as identified by the Plant Operations Supervisor on 09/09/15. The findings are:

A. On 09/09/15 at 2:27 pm, observed no audible or visual (strobe) device in the In-Patient therapy staff office located on the upper level. This is a large and congested area.

B. On 09/09/15 at 2:28 pm, the Plant Operations Supervisor observed there was no strobe device in this area, confirming this finding.

NFPA 101/2000
9.6.2.3 A manual fire alarm box (pull station) shall be provided in the natural exit access path near each required exit from an area, unless modified by another section of this code.

Based on observation and staff interview, the facility failed to ensure that a manual pull station for the fire alarm system was installed at the exit from the boiler room. This failed practice may result in a delay in notification in the event of a fire in this location. This has the potential to harm all patients, staff and visitors by fire/smoke. The findings are:

A. On 09/09/15 at 3:00 pm, observed no manual pull station in the boiler room at or near the exit.

B. On 09/09/15 at 3:02 pm, during observation, the Plant Operations Supervisor stated he was not aware a manual pull station was required in the boiler room, confirming this finding.

Based on record review and staff interview, the facility failed to conduct annul fire alarm system inspection/testing. This failed practice may result in the fire alarm system malfunctioning in the event of a fire, which may lead to potential harm to patients, staff and visitors. The findings are:

A, Record review of the Fire Alarm System records revealed there were no records found to indicate annual inspection/testing of the fire alarm system at the Jemex Pueblo Satalite Clinic.

B. On 09/10/15 at 1:00 pm, during interview, the Safety Officer stated this is a leased space and he must contact the owner,confirming there were no records available for the fire alarm system inspection and maintenance.

NFPA 25/1998
Table 9-1 Requirements for system component Inspection, Testing and Maintenance
10-2.2 Obstruction Prevention
Systems shall be examined internally for obstructions where conditions exist that could cause obstructed piping. If the condition has not been corrected or the condition is one that could result in obstruction of piping despite any previous flushing procedures that have been performed, the system shall be examined internally for obstructions every five years. This investigation shall be accomplished by examining the interior of a dry valve or preaction valve and by removing two cross main flushing connections.

Based on record review and staff interview, the facility failed to provide a five year obstruction test of the fire sprinkler sytem. This failed practice may result in decreased water flow, causeing the fire sprinkler system to fail in the event of a fire. This has the potential to harm all forty two (42) patients at the main hospital (and patients, staff and visitors at satalite clinics) as identified by the patient census list provided by the Plant Operations Supervisor on 09/09/15. The findings are:

A. Record review revealed there were no records available to indicate the 5 year sprinkler obstruction test was conducted at the main hospital.

B. On 09/09/15 at 8:45 am, during interview the Plant Operations Supervisor stated he was not able to locate records, confirming there were no records available to indicate the 5 year obstruction test was conducted.

C. Record review of the Fire Sprinkler records, there were no records available to indicate the 5 year sprinkler obstruction test was conducted at the Lovelace Rehabilitation Hospital Enchanted Hills Satalite Clinic.

D. Record review of the Fire Sprinkler records indicated the last inspection was dated 09/17/15. There were no other records found to indicate annual and quarterly inspections were conducted in 2015, at the Lovelace Rehabilitation Hospital Enchanted Hills Satalite Clinic.

E. On 09/10/15 at 10:45 am, during interview, the Safety Officer stated this is a leased space and must contact the owner, confirming this finding.

F. Record review of the Sprinkler records, indicate the last inspection indicated a quarterly inspection, dated 06/04/15, there were no other records available, at the Lovelace Rehabilitation Hospital Santa Fe Satalite Clinic.

G. On 09/10/15 at 2:50 pm, during interwiew, the Safety Officer stated this is a leased space and must contact the owner, confirming this finding.

Based on observation and staff interview, the facility failed to ensure the exhaust fan was functioning in the Housekeeping closet located in the 200 wing. This failed practice would not exhaust noxious/toxic fumes from chemicals stored, allowing them to escape into the corridor, which may lead to potential harm to twelve (12) patients within the 200 wing, as identified by the patient census list provided by the Plant Operation Supervisor on 09/09/15. The findings are:

A. On 09/09/15 at 10:37 am, observed the exhaust fan located in the Housekeeping closet on the 200 wing was not functioning.

B. On 09/09/15 at 10:38, during interview, the Plant Operations Supervisor stated he was not aware the fan was not working, confirming the exhaust fan was not working

Based on observation and staff interview, the facility failed to ensure the floor of the oxygen storage room on the 400 wing, was either smooth concrete or ceramic tile. The existing floor is carbon based tile. This failed practice has the potential to support combustion if there is a leak from an oxygen cylinder, which may lead to potential harm to forty two (42) patients, as identified by the patient census list provided by the Plant Operations Supervisor on 09/09/15. The findings are:

A. On 09/09/15 at 11:10 am, observed the floor of the oxygen storage room was covered with carbon based tile.

B. On 09/09/15 at 11:12 am, the Plant Operations Supervisor stated he was aware of
that the floor of the oxygen storage room was covered with carbon based tile, confirming this finding.

NFPA 105/1999
6.5 Periodic Inspection and Testing.
6.5.1 Smoke dampers for dedicaied and non dedicated smoke control systems shall be inspected and tested in accordance with NFPA 92A, Standard for Smoke Control Systems Utilizing Barriers and Pressure Differences.

6.5.2 Each damper shall be tested and inspected one year after installation. The testy and inspection frequency shall then be every four years, except in hospitals, where the frequency shall be every six years.

6.5.3 Care shall be exercised that all tests are completed in a safe manner wearing the appropriate personal protective equipment.

6.5.4 Full unobstructed access to the damper shall be verified and corrected as required.

6.5.5 Where a fusible linkis installed on a combination fire/smoke damper, the fusible link shall be removed for testing the damper for full closure simulating a fire condition per the requirements and frequenncies of 19.5.4 of NFPA 80 Standard for Fire Doors and Other Opening Protectives.

6.5.6 The test shall be conducted with normal HVAC flow.

6.5.7 The openings of the damper shall verify that there is no damper interference due to rust or bent, misalligned, or damaged frame or blades, or defective hinges or other moving parts.

6.5.8 The damper frame shall not be penetrated by any foreign objects that would affect proper damper operations.

6.5.9 The damper shall be verified to not be blocked from closure in any way.

6.5.10 The fusible link shall be reinstalled after testing is complete. If the link is damaged or painted, it shall be replaced with a link of the same size, temperature rating and load rating.

6.5.11 All inspections and testing shall be documented indicating the location of the 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.

6.5.12 All documentation shall be maintained by the property owner and available for review by the authority having jurisdiction.

Based on record review and staff interview, there were no records to indicate that the fire/smoke dampers were ever inspected/tested. This may lead to failure of a fire/smoke damper which would allow the spread of fire/smoke to other areas of the building. This may lead to potential harm to all forty two (42) patients as identified by the patient census list provided by the Plant Operations Supervisor on 09/09/15. The findings are:

A. Record review of the fire/smoke damper inspection/testing records revealed there are no records to indicate the fire/smoke dampers have been inspected/tested every six years as required.

B. On 09/09/15 at 9:01 am, during interview, the Plant Operations Supervisor was unable to produce records indicating the inspection/testing of the dampers was conducted, confirming this finding.

Based on observation and staff interview, the facility failed to ensure electrical junction boxes (J Boxes) were covered with approved metal covers to prevent wiring from being exposed. in two locations. This failed practice has the potential to cause an electrical fire, which may result in harm to all forty two (42) patients, as identified by the patient census list provided by the Plant Operations Supervisor on 09/09/15. The findings are:

A. On 09/09/15 at 10:33 am, observed an open J Box with exposed electrical wires above the ceiling near the 200 wing nurses station on the lower level.

B. On 09/09/15 at 2:45 pm, observed an open J Box with exposed electrical wires above the ceiling near the exit from Physical therapy on the upper level.

C. On 09/09/15 at 2:49 pm, during interview, the Plant Operations Supervisor stated he was unaware of the open J Boxes. He viewed the open J Boxes, confirming these findings.


NFPA 70, 1999 Edition
384-13 ...All panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors.


Based on observation and interview, the facility failed to ensure electrical circuit breakers were identified in accordance with NFPA 70 (National Electrical Code). It is essential all circuit breakers within electrical panels are properly identified as to what they serve, so in the event of emergency, selected electrical circuits can be turned off. This failed practice could result in the incorrect breakers being turned off in the event of fire or other emergency, which presents a risk of potential harm to all forty two (42) patients as identified by the patient census list provided by thePlant Operations Supervisor on 09/09/15. The findings are:

A. On 09/09/15 at 3:06 pm, observed the circuit breakers were not identified in electric panel GBS-24-4 in electrical room 1 on the upper level.

B. On 09/09/15 at 3:07 pm, during interview, the Plant Operations Supervisor stated "I am probably going to have to hire an electrician to correct that."


NFPA 70 National Electric Code

210.8 Ground Fault Circuit Interrupter Protection for Personnel
210.8 (B) Other than dwelling units. All 125 volt, single phase, 15 and 20 ampere receptacles installed in the locations specified in 210.8 (B)(1) through (8) shall have ground fault circuit interrupter protection for personnel.
(1) Bathrooms
(2) Kitchens
(3) Rooftops
(4) Outdoors

Exception 1: to (3) and (4): Receptacles that are not readily accessible and are supplied by a branch circuit dedicated to electric snow melting, de-icing, or pipeline and vessel heating equipment shall be permitted to be installed in accordance with 426.28 or 427.22 as applicable.

Exception 2: to (4): In industrial establishments only, where the conditions of maintenance and supervision ensure that only qualified personnel are involved, an assured equipment grounding conductor program as specified in 590.6(B)(2)shall be permitted for only those receptacles outlets used to supply equipment that would create a greater hazard if power is interrupted or having a design that is not compatible with GFCI protection.

(5) Sinks - where receptacles are installed within 6 ft. of the outside edge of the sink.

Exception 1 to (5): In industrial laboratories, receptacles used to supply equipment where removal of power would introduce a greater hazard shall be permitted to be installed without GFCI protection.

Exception 2 to (5): For receptacles located in patient bed locations of general care or critical care areas of health care facilities other than those covered under 210.8(B)(1), GFCI protection shall not be required.

(6) Indoor wet locations
(7) Locker rooms with associated showering facilities
(8) Garages, service bays, and similar areas where electrical diagnostic equipment, electrical hand tools, or portable lighting equipment are to be used.

314.25: Covers and Canopies. In completed installations, each box shall have a cover, faceplate, lampholder, or luminary canopy, except where the installation complies with 410.24(B)

406.5(F): Receptacles shall be enclosed so that live wiring terminals are not exposed to contact.

Based on observation and staff interview the facility and the satalite clinics failed to ensure that Ground Fault Circuit Interrupter outlets were installed within 6 feet of a water source in several locations. This failed practice may lead to potential harm by electric shock to patients, staff and visitors. The findings are:

A. On 09/09/15 at 11:20 am, observed there was no GFCI outlet within 6 ft. of a sink in the 400 wing Medication room.

B. On 09/09/15 at 11:42 am, observed the ice machine in the 500 wing was plugged into a standard wall outlet, not a GFCI outlet.

C. On 09/09/15 at 2:02 pm, observed the water cooler in the Administrative area was plugged into a standard wall outlet, not a GFCI outlet.

D. On 09/09/15 at 2:32 pm, observed the washing machine in the Physical Therepy laundry was plugged into a standard wall out, not a GFCI outlet.

E. On 09/09/15 at 2:35 pm, observed there was no GFCI outlet within 6 ft. of a sink in the Physical Therapy kitchen.

F. On 09/09/15 at 2:37 pm, observed the water cooler in the Physical Therapy area was plugged into a standard wall outlet, not a GFCI outlet.

G. On 09/09/15 at 2:50 pm, during observation, the Hydrocollator [a thermostatically controlled water bath for placing bentonite-filled cloth heating pads] in the Physical Therapy Room, was plugged into a standard wall outlet, not a GFCI outlet.

H. On 09/09/15 at 2:55 pm, during interview, the Plant Operations Supervisor stated he was not aware that GFCI outlets were required in the above areas, confirming these findings.

I. On 09/10/15 at 10:00am, at the Lovelace Rehabilitation Hospital Enchanted Hills Satallite Clinic observed the water cooler in the lobby, was plugged into a standard wall outlet, not a GFCI outlet,

J. On 09/10/15 at 10:02 am, at the Lovelace Rehabilitation Hospital Enchanted Hills Satallite Clinic, observed the Hydrocollator (a thermastatically controlled water bathe for placing bentonite-filled cloth heating pads) was plugged into a standard wall outlet, not a GFCI outlet.

K. On 09/10/15 at 10:03 am, during interview, the Safety Officer stated he was not aware that GFCI outlets were required, confirming no GFCI outlets in the lobby for the water cooler and in the therapy room for the hydrocolator in the Enchanted Hills Satalite Clinic..

L. On 09/10/15 at 11:09 am, at the Lovelace Rehabilitation Hospital Jemez Pueblo Satallite Clinic, observed the water cooler plugged into a standard wall outlet, not a GFCI outlet.

M. On 09/10/15 at 11:11 am, at the Lovelace Rehabilitation Hospital Jemez Pueblo Satallite Clinic, observed the Hydrocollator ( a thermastatically controlled water bathe for placing bentonite-filled cloth heating pads) was plugged into a standard wall outlet, not a GFCI outlet.

N. On 09/10/15 at 11:15 am, during interview, the Safety Officer stated he was not aware that GFCI outlets were required, confirming no GFCI outlet for the water cooler and the hydrocolator in the Jemez Pueblo Satalite Clinic.

O. On 09/10/15 at 12:25 pm, at the Lovelace Rehabilitation Hospital Santa Fe Satallite Clinic, observed the water cooler was plugged into a standard wall outlet, not a GFCI outlet.

P. On 09/10/15 at 12:29 pm, the Safety Officer stated he was not aware that GFCI outlets were required, confirming no GFCI outlet for water cooler in the Santa Fe Satalite Clinic.


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