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1) Based on observation and interview with staff, the facility failed to provide exit components that are provide with a continuous path of escape, and provide protection against fire or smoke from other parts of the building in accordance with NFPA 101 19.3.1.1 Findings include:

a) The magnetic door lock installed is not installed in accordance with NFPA 101 7.2.1.6 Special Locking Arrangements and on the door adjacent to the release device, there was no readily visible, durable sign in letters not less than 1 in. (2.5 cm) high and not less than 1/8 in. (0.3 cm) in stroke width on a contrasting background that reads as follows: PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS. The door also was not installed on the fire alarm system.

1)Based on observation and interview with staff, the facility failed to conduct Fire drills that are held at unexpected times under varying conditions, at least quarterly on each shift. 19.7.1.2
Findings include:

a) Fire Drill for the last quarter of 2013 was not available or held.

1) Based on observation and interview with staff, the facility failed to provide heating, ventilating, and air conditioning that comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2 Findings include:

a) The exhaust designed and installed for the emergency room area was not working on July 17, 2014.

b) The outside air damper installed on the room units that provides outside air for each patient room was not open.

c) The facility could not provide a "Test and Balance" report that describes how many air exchanges each room in the hospital has.

d) The return for the HVAC Equipment adjacent to the nurses station was flush to the floor. The return was not at least 4 inches above the floor line.

1) Based on observation and interview with staff, the facility failed to provide Piped in medical gas systems that comply with NFPA 99, Chapter 4. Findings include:

a) The bottled reserve system, located at the bulk oxygen site is not protected with a cover and the bottom of the bottles are not protected from rusting in accordance with 4-3.5.2.2.

b) The facility does not have a piped in medical vacuum system in accordance with NFPA 99 1999 edition chapter 4-3.2 for patient rooms and Emergency Department.

1) Based on observation, review of Building Plans and interview with staff, the internal governing structure, responsible for elements of hospital operation, building design, purchasing specifications, inspection procedures, and maintenance schedules, failed to delegate to staff for hiring of consultants, architects, engineers, to submit remodeling, modification, renovation plans or to change room use to Authority Having Jurisdiction in accordance with Hospital Standards Chapter 667-47. The design of the building was altered in the following areas that impacted the Performance Design in accordance with NFPA 101 2000 Life Safety Code 5.8.14. Findings include:

a) On July 17, 2013 at 11: 30 a.m. an ambulance pulled up to the building under the breeze way at the entrance of the Emergency Department. The ambulance left the vehicle running and filled the hospital with exhaust fumes from the diesel engine.

1) Based on observation, interview with staff, and review of the generator logs, the facility failed to inspected weekly and exercised the generator under load 30 minutes per month in accordance with NFPA 99. 3.4.4.1. Findings include:

a) The generator logs did not have the % of load for each month. The generator shall be exercised under load at least 30 % or greater of the plate rating.

1) Based on observation and interview with staff, the facility failed to provide electrical wiring and equipment that is in accordance with NFPA 70, National Electrical Code. 9.1.2. Findings include:

a) The Bio -Medical Equipment Program does not meet NFPA 99 chapter 7-6.2.1.2 (b). Equipment in Critical Care areas are required to be tested semi annually. All equipment in Critical Care areas at this facility (Emergency Department) were tested annually.

b) The facility failed to ensure that the Bio-Medical Test Contractor is providing a safe and effective program. The facility did not reviewed test results from the contractor against the manufactures requirements for comparison or any other method that would ensure safe and effective operation in accordance with manufacture requirements. The governing body has the responsibility for assuring that hospital services are provided in compliance with the Medicare Conditions of Participation and according to acceptable standards of practice, irrespective of whether the services are provided directly by hospital employees or indirectly by contract. The governing body must take actions through the hospital's QAPI program to: assess the services furnished directly by hospital staff and those services provided under contract, identify quality and performance problems, implement appropriate corrective or improvement activities, and to ensure the monitoring and sustainability of those corrective or improvement activities.

c) The facility failed to have a Impedance Testing Program in accordance with NFPA 99 1999 edition chapter 3-3.3.2.4. The facility failed to have a testing program for devices when installed (receptacles, power circuits, task illumination, etc) and additional testing preformed after documented data is collected.

d) The facility failed to have a sign that informs First Responders
(Fire Department) that there is two sources of power supplying the building NEC 70 230.2 (E) requires that when a building is supplied by more than one service or any combination of branch feeders, a permeant plaque or directory shall be installed at each service disconnect location denoting all other service, feeds, and branch circuits supplying that building.

1) Based on observation and interview with staff, the facility failed to provide exit components that are provide with a continuous path of escape, and provide protection against fire or smoke from other parts of the building in accordance with NFPA 101 19.3.1.1 Findings include:

a) The magnetic door lock installed is not installed in accordance with NFPA 101 7.2.1.6 Special Locking Arrangements and on the door adjacent to the release device, there was no readily visible, durable sign in letters not less than 1 in. (2.5 cm) high and not less than 1/8 in. (0.3 cm) in stroke width on a contrasting background that reads as follows: PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS. The door also was not installed on the fire alarm system.

1)Based on observation and interview with staff, the facility failed to conduct Fire drills that are held at unexpected times under varying conditions, at least quarterly on each shift. 19.7.1.2
Findings include:

a) Fire Drill for the last quarter of 2013 was not available or held.

1) Based on observation and interview with staff, the facility failed to provide heating, ventilating, and air conditioning that comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2 Findings include:

a) The exhaust designed and installed for the emergency room area was not working on July 17, 2014.

b) The outside air damper installed on the room units that provides outside air for each patient room was not open.

c) The facility could not provide a "Test and Balance" report that describes how many air exchanges each room in the hospital has.

d) The return for the HVAC Equipment adjacent to the nurses station was flush to the floor. The return was not at least 4 inches above the floor line.

1) Based on observation and interview with staff, the facility failed to provide Piped in medical gas systems that comply with NFPA 99, Chapter 4. Findings include:

a) The bottled reserve system, located at the bulk oxygen site is not protected with a cover and the bottom of the bottles are not protected from rusting in accordance with 4-3.5.2.2.

b) The facility does not have a piped in medical vacuum system in accordance with NFPA 99 1999 edition chapter 4-3.2 for patient rooms and Emergency Department.

1) Based on observation, review of Building Plans and interview with staff, the internal governing structure, responsible for elements of hospital operation, building design, purchasing specifications, inspection procedures, and maintenance schedules, failed to delegate to staff for hiring of consultants, architects, engineers, to submit remodeling, modification, renovation plans or to change room use to Authority Having Jurisdiction in accordance with Hospital Standards Chapter 667-47. The design of the building was altered in the following areas that impacted the Performance Design in accordance with NFPA 101 2000 Life Safety Code 5.8.14. Findings include:

a) On July 17, 2013 at 11: 30 a.m. an ambulance pulled up to the building under the breeze way at the entrance of the Emergency Department. The ambulance left the vehicle running and filled the hospital with exhaust fumes from the diesel engine.

1) Based on observation, interview with staff, and review of the generator logs, the facility failed to inspected weekly and exercised the generator under load 30 minutes per month in accordance with NFPA 99. 3.4.4.1. Findings include:

a) The generator logs did not have the % of load for each month. The generator shall be exercised under load at least 30 % or greater of the plate rating.

1) Based on observation and interview with staff, the facility failed to provide electrical wiring and equipment that is in accordance with NFPA 70, National Electrical Code. 9.1.2. Findings include:

a) The Bio -Medical Equipment Program does not meet NFPA 99 chapter 7-6.2.1.2 (b). Equipment in Critical Care areas are required to be tested semi annually. All equipment in Critical Care areas at this facility (Emergency Department) were tested annually.

b) The facility failed to ensure that the Bio-Medical Test Contractor is providing a safe and effective program. The facility did not reviewed test results from the contractor against the manufactures requirements for comparison or any other method that would ensure safe and effective operation in accordance with manufacture requirements. The governing body has the responsibility for assuring that hospital services are provided in compliance with the Medicare Conditions of Participation and according to acceptable standards of practice, irrespective of whether the services are provided directly by hospital employees or indirectly by contract. The governing body must take actions through the hospital's QAPI program to: assess the services furnished directly by hospital staff and those services provided under contract, identify quality and performance problems, implement appropriate corrective or improvement activities, and to ensure the monitoring and sustainability of those corrective or improvement activities.

c) The facility failed to have a Impedance Testing Program in accordance with NFPA 99 1999 edition chapter 3-3.3.2.4. The facility failed to have a testing program for devices when installed (receptacles, power circuits, task illumination, etc) and additional testing preformed after documented data is collected.

d) The facility failed to have a sign that informs First Responders
(Fire Department) that there is two sources of power supplying the building NEC 70 230.2 (E) requires that when a building is supplied by more than one service or any combination of branch feeders, a permeant plaque or directory shall be installed at each service disconnect location denoting all other service, feeds, and branch circuits supplying that building.