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Based on observation, interview with staff, the facility failed to provide building construction type and height that meets one of the following. 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1. Findings include:

The vertical opening in the floors that serve as a pipe chase for plumbing, electrical conduit, and convectors located above ceiling are not sealed with material capable of maintaining the fire resistance of the fire barrier. The foam sealant used around the pipe located under the convectors shall be removed and a fire sealant with mineral wool shall be replaced. This was observed through out the facility.

The Lab (4,701 square feet) is located on the first floor of a two story portion of the facility, and has an unprotected steel frame and is not fire sprinklered. Construction is Type II(000). Table 19.1.6.2. Construction Type Limitations requires Type II(000) to be fire sprinklered for one and two story structures.

Based on observation and interview with staff, the facility failed to provide corridors separated from use areas by walls constructed with at least a one-half hour fire resistance rating per 19.3.6.2.1. Findings:

The West Tower (1983 construction) is concrete frame, non-combustible. Construction is Type I(332). Only portions of this tower are sprinklered on the 2nd, 3rd, and 4th Floors so these floors are considered non-sprinklered. Section 19.3.6.2.1 requires these corridors be rated at least one-half hour. 1) Minor unrated penetrations in these rated walls were found. 2) Storage Room on 4th Floor, north end, has corridor walls that do not extend up to the roof deck to provide the required one-half hour rating.

Based on observation and interview with staff, the facility failed to provide door provided with a means suitable for keeping the door closed. Findings:

The doors into the Engineering Department, Gift Shop Office, and MRI were found not to have latching hardware.

Based on observation and interview with staff, the facility failed to provide smoke barriers constructed to provide at least a one-half hour fire resistance rating. Findings:

Non-rated expanding foam was found in the smoke compartment wall above Door 1-47.

Need fire rated sealant, and tape and bed joints above smoke compartment Door 1-49.

McMahon Memorial Tower - 3rd Floor Geropsyche Unit: an unrated fire sprinkler penetration exists through the smoke compartment wall above the corridor door.

Based on observation and interview with staff, the facility failed to provide hazardous areas protected in accordance with 19.3.2.1. Findings:

Storage Room door across from Room 3-300 needs door closer.

McMahon Memorial Tower - 3rd Floor Geropsyche Unit: Clean Utility Room door needs door closer.

Based on observation and interview with staff, the facility failed to provide a suite of sleeping room of not more than 5,000 square feet. 19.2.5.2, 19.2.45.6. Findings:

The First Floor Intensive Care Unit is a suite of sleeping rooms having a total of 6,478 square feet, more than the maximum 5,000 square feet allowed by 19.2.5.6.

The First Floor Cardiac Care Unit is a suite of sleeping rooms having a total of 6,438 square feet, more than the maximum 5,000 square feet allowed by 19.2.5.6.

Based on observation and interview with staff, the facility failed to provide a Fire Alarm maintenance and testing program that complies with applicable requirements of NFPA 70 and 72. 9.6.1.4 Findings include:

Smoke detectors were found in numerous locations less than 36" from HVAC Diffusers. Example, the smoke detector in the cath lab corridor was one foot from the diffuser. Smoke detectors are required to be at least three feet from diffusers.

Smoke evacuation equipment installed on the fire alarm system have not been tested . The Directory of points on the fire alarm system is not complete. Provide a directory that lists all equipment and compare to annual test for accuracy and test all equipment annually.

Based on observation and interview with staff, the facility failed to provide an automatic sprinkler system maintained in reliable operating condition. Findings:

Electrical wiring was found resting on fire sprinkler piping in violation of NFPA 25, Section 5.2.2.2. Examples: 4th floor office wing to acute bed area; Soiled Room 4-102; electrical conduit was found tied to fire sprinkler piping outside Nursery on 2nd Floor.

Based on observation and interview with staff, the facility failed to provide ventilation complying with NFPA 101, Section 9.2 Heating, Air Conditioning, and Air Conditioning; NFPA 90A Standard for the Installation of Air Conditioning and Ventilating Systems, and ASHRAE Handbook - HVAC Systems and Equipment, 1996. Findings:

Exhaust fans were found not to be working. Examples: toilet exhaust in Patient Rooms 4-441, 3-325, 4th floor Bio-Hazard, and Storage 3-133.

Based on observation and interview with staff, the facility failed to provide Means of egress that are continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 7.1.10 Findings include:

Equipment (Fusion Pumps) was stored in the corridor of CO-ICU and Chest Pain Management. This is a recurring condition that exists through-out the facility.

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

The main Gas Shut off valve to the Liquid Oxygen Storage Tank was not labeled and staff could not demonstrate which valve shut off the system with out getting above the ceiling.

There was no policy that required staff to notify the Vendor to refill the tank or at what level to call the vendor.

Based on observation and interview with staff, the facility failed to protect Anesthetizing locations in accordance with NFPA 99, Standard for Health Care Facilities. Findings include:

1 The Governing Board of the Hospital failed to recognize, enforce and determine adequate regulations for safe practices in anesthetizing locations. The facility failed to designate anesthetizing locations 12-2.7. The hazards involved in the use of inhalation anesthetic agents can be successfully mitigated only when all of the areas of hazard are fully recognized by all personnel, and when the physical protection is complete and is augmented by attention to detail by all personnel of administration as to designated areas, and of the maintenance personnel having responsibility for the functioning of anesthetizing locations.

(A)Operating Rooms Humidifiers to the air handler 5,6,7,8 were unhooked several years ago. NFPA 99 1999 edition chapter 5-6.1.1 requires Humidifying Equipment for anesthetizing locations be kept in operable condition during surgery.

(B)The facility was providing procedures in the Cath Lab that required anesthesia. On occasions, staff explained that sometimes the equipment in this room (Cath lab) provides resolution for a procedure that is needed. The rooms were not within parameters for humidity control, smoke evacuation nor the rest of the requirements for anesthetizing locations found in NFPA 99 5-4 through 5-4.1.6 and could not be verified.

(C)The fire loss prevention training required for the environment where anesthesia is provided failed to include Physicians and Surgeons. There is no fire loss prevention procedures in the cath lab in accordance with NFPA 99 12-4.1.2.10 for any of the staff. The facility shall provide a Fire Loss Prevention program that is reviewed monthly and procedures reviewed annually.

(D)The facility could not provide documentation that smoke evacuation equipment was functioning in the operating rooms. 4 of the 12 OR Rooms are not provided with smoke evacuation.

(E)The humidity logs were not within parameters, the Policies and Procedures used were not adopted and reviewed by the governing body.

(F)Staff could not provide Qualification and Training logs that included periodic review of manufacturer's safety guidelines and usage associated with requirements for physicians. Personnel involved in the use of energy-delivering devices; including, but not limited to, electrosurgical units, surgical lasers, electrocautery and fiberoptics, shall receive periodic training in fire suppression NFPA 99 7-6.5.

(G)The facility failed to mark and identify the use of the Emergency Stop Buttons in the operating room suite. Training requires that all equipment, material, and procedures be in-serviced to all staff.

Based on observation and interview with staff, the facility failed to provide Qualification and Training logs that included periodic review of manufacturer's safety guidelines and usage associated with usage by physicians and staff through-out the hospital. Personnel involved in the use of energy-delivering devices; including, but not limited to electrosurgical units,surgical lasers, electrocautery, and fiberoptics, battery one time use cauterizing tool shall receive periodic training in fire suppression NFPA 99 7-6.5. Findings include:

The staff in the Emergency Room Suite was not in-serviced with the hazards associated with the use of the battery cauterizing tool in combination with flammable preps and alcohols.

Respiratory Staff , ICU Director,Emergency Room Director, Director of Nurses, and Maintenance staff were not familiar with the capabilities of the Life Support Equipment (Ventilators). The staff was not aware of the internal or external battery life of the Vents used in Patient Care Areas.

In the event of a complete power failure, the Emergency Preparedness Senior Management failed to ensure that staff is familiar with equipment. Senior Management shall re-evaluate and oversee the training of personnel to verify System Demonstrations 7-6.2.1.7. of all equipment.

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

The patient rooms located on 3 north were not provided with emergency electrical receptacles in the patient rooms at the head of of the bed. The facility failed to up grade the patient rooms when renovating and installing new Automatic Transfer Switches and Generators, etc.

Open junction boxes were found above the ceiling in the facility.

Based on observation, interview with staff, the facility failed to provide building construction type and height that meets one of the following. 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1. Findings include:

The vertical opening in the floors that serve as a pipe chase for plumbing, electrical conduit, and convectors located above ceiling are not sealed with material capable of maintaining the fire resistance of the fire barrier. The foam sealant used around the pipe located under the convectors shall be removed and a fire sealant with mineral wool shall be replaced. This was observed through out the facility.

The Lab (4,701 square feet) is located on the first floor of a two story portion of the facility, and has an unprotected steel frame and is not fire sprinklered. Construction is Type II(000). Table 19.1.6.2. Construction Type Limitations requires Type II(000) to be fire sprinklered for one and two story structures.

Based on observation and interview with staff, the facility failed to provide corridors separated from use areas by walls constructed with at least a one-half hour fire resistance rating per 19.3.6.2.1. Findings:

The West Tower (1983 construction) is concrete frame, non-combustible. Construction is Type I(332). Only portions of this tower are sprinklered on the 2nd, 3rd, and 4th Floors so these floors are considered non-sprinklered. Section 19.3.6.2.1 requires these corridors be rated at least one-half hour. 1) Minor unrated penetrations in these rated walls were found. 2) Storage Room on 4th Floor, north end, has corridor walls that do not extend up to the roof deck to provide the required one-half hour rating.

Based on observation and interview with staff, the facility failed to provide door provided with a means suitable for keeping the door closed. Findings:

The doors into the Engineering Department, Gift Shop Office, and MRI were found not to have latching hardware.

Based on observation and interview with staff, the facility failed to provide smoke barriers constructed to provide at least a one-half hour fire resistance rating. Findings:

Non-rated expanding foam was found in the smoke compartment wall above Door 1-47.

Need fire rated sealant, and tape and bed joints above smoke compartment Door 1-49.

McMahon Memorial Tower - 3rd Floor Geropsyche Unit: an unrated fire sprinkler penetration exists through the smoke compartment wall above the corridor door.

Based on observation and interview with staff, the facility failed to provide hazardous areas protected in accordance with 19.3.2.1. Findings:

Storage Room door across from Room 3-300 needs door closer.

McMahon Memorial Tower - 3rd Floor Geropsyche Unit: Clean Utility Room door needs door closer.

Based on observation and interview with staff, the facility failed to provide a suite of sleeping room of not more than 5,000 square feet. 19.2.5.2, 19.2.45.6. Findings:

The First Floor Intensive Care Unit is a suite of sleeping rooms having a total of 6,478 square feet, more than the maximum 5,000 square feet allowed by 19.2.5.6.

The First Floor Cardiac Care Unit is a suite of sleeping rooms having a total of 6,438 square feet, more than the maximum 5,000 square feet allowed by 19.2.5.6.

Based on observation and interview with staff, the facility failed to provide a Fire Alarm maintenance and testing program that complies with applicable requirements of NFPA 70 and 72. 9.6.1.4 Findings include:

Smoke detectors were found in numerous locations less than 36" from HVAC Diffusers. Example, the smoke detector in the cath lab corridor was one foot from the diffuser. Smoke detectors are required to be at least three feet from diffusers.

Smoke evacuation equipment installed on the fire alarm system have not been tested . The Directory of points on the fire alarm system is not complete. Provide a directory that lists all equipment and compare to annual test for accuracy and test all equipment annually.

Based on observation and interview with staff, the facility failed to provide an automatic sprinkler system maintained in reliable operating condition. Findings:

Electrical wiring was found resting on fire sprinkler piping in violation of NFPA 25, Section 5.2.2.2. Examples: 4th floor office wing to acute bed area; Soiled Room 4-102; electrical conduit was found tied to fire sprinkler piping outside Nursery on 2nd Floor.

Based on observation and interview with staff, the facility failed to provide ventilation complying with NFPA 101, Section 9.2 Heating, Air Conditioning, and Air Conditioning; NFPA 90A Standard for the Installation of Air Conditioning and Ventilating Systems, and ASHRAE Handbook - HVAC Systems and Equipment, 1996. Findings:

Exhaust fans were found not to be working. Examples: toilet exhaust in Patient Rooms 4-441, 3-325, 4th floor Bio-Hazard, and Storage 3-133.

Based on observation and interview with staff, the facility failed to provide Means of egress that are continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 7.1.10 Findings include:

Equipment (Fusion Pumps) was stored in the corridor of CO-ICU and Chest Pain Management. This is a recurring condition that exists through-out the facility.

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

The main Gas Shut off valve to the Liquid Oxygen Storage Tank was not labeled and staff could not demonstrate which valve shut off the system with out getting above the ceiling.

There was no policy that required staff to notify the Vendor to refill the tank or at what level to call the vendor.

Based on observation and interview with staff, the facility failed to protect Anesthetizing locations in accordance with NFPA 99, Standard for Health Care Facilities. Findings include:

1 The Governing Board of the Hospital failed to recognize, enforce and determine adequate regulations for safe practices in anesthetizing locations. The facility failed to designate anesthetizing locations 12-2.7. The hazards involved in the use of inhalation anesthetic agents can be successfully mitigated only when all of the areas of hazard are fully recognized by all personnel, and when the physical protection is complete and is augmented by attention to detail by all personnel of administration as to designated areas, and of the maintenance personnel having responsibility for the functioning of anesthetizing locations.

(A)Operating Rooms Humidifiers to the air handler 5,6,7,8 were unhooked several years ago. NFPA 99 1999 edition chapter 5-6.1.1 requires Humidifying Equipment for anesthetizing locations be kept in operable condition during surgery.

(B)The facility was providing procedures in the Cath Lab that required anesthesia. On occasions, staff explained that sometimes the equipment in this room (Cath lab) provides resolution for a procedure that is needed. The rooms were not within parameters for humidity control, smoke evacuation nor the rest of the requirements for anesthetizing locations found in NFPA 99 5-4 through 5-4.1.6 and could not be verified.

(C)The fire loss prevention training required for the environment where anesthesia is provided failed to include Physicians and Surgeons. There is no fire loss prevention procedures in the cath lab in accordance with NFPA 99 12-4.1.2.10 for any of the staff. The facility shall provide a Fire Loss Prevention program that is reviewed monthly and procedures reviewed annually.

(D)The facility could not provide documentation that smoke evacuation equipment was functioning in the operating rooms. 4 of the 12 OR Rooms are not provided with smoke evacuation.

(E)The humidity logs were not within parameters, the Policies and Procedures used were not adopted and reviewed by the governing body.

(F)Staff could not provide Qualification and Training logs that included periodic review of manufacturer's safety guidelines and usage associated with requirements for physicians. Personnel involved in the use of energy-delivering devices; including, but not limited to, electrosurgical units, surgical lasers, electrocautery and fiberoptics, shall receive periodic training in fire suppression NFPA 99 7-6.5.

(G)The facility failed to mark and identify the use of the Emergency Stop Buttons in the operating room suite. Training requires that all equipment, material, and procedures be in-serviced to all staff.

Based on observation and interview with staff, the facility failed to provide Qualification and Training logs that included periodic review of manufacturer's safety guidelines and usage associated with usage by physicians and staff through-out the hospital. Personnel involved in the use of energy-delivering devices; including, but not limited to electrosurgical units,surgical lasers, electrocautery, and fiberoptics, battery one time use cauterizing tool shall receive periodic training in fire suppression NFPA 99 7-6.5. Findings include:

The staff in the Emergency Room Suite was not in-serviced with the hazards associated with the use of the battery cauterizing tool in combination with flammable preps and alcohols.

Respiratory Staff , ICU Director,Emergency Room Director, Director of Nurses, and Maintenance staff were not familiar with the capabilities of the Life Support Equipment (Ventilators). The staff was not aware of the internal or external battery life of the Vents used in Patient Care Areas.

In the event of a complete power failure, the Emergency Preparedness Senior Management failed to ensure that staff is familiar with equipment. Senior Management shall re-evaluate and oversee the training of personnel to verify System Demonstrations 7-6.2.1.7. of all equipment.

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

The patient rooms located on 3 north were not provided with emergency electrical receptacles in the patient rooms at the head of of the bed. The facility failed to up grade the patient rooms when renovating and installing new Automatic Transfer Switches and Generators, etc.

Open junction boxes were found above the ceiling in the facility.