HospitalInspections.org

Based on record review and interview with staff, it was determined the facility failed to document the annual testing of the emergency battery backup lights. Failing to maintain emergency lighting units in time of an emergency has potential harm to the patients in an emergency power outage.

NFPA 101, Life Safety Code, 2012, Chapter 19, Section 19.2.9.1 "Emergency lighting shall be provided in accordance with Section 7.9". Section 7.9.3 " Periodic Testing of Emergency Lighting Equipment" " Section 7.9.3.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows: (1) Functional Testing shall be conducted monthly with a minimum of 3 weeks and a maximum of 5 weeks between tests. , for not less than 30 seconds except as otherwise permitted by 7.9.3.1.1.(2) The Test interval shall be permitted to be extended beyond 30 days with the approval of authority having jurisdiction.(3) Functional testing shall be conducted annually for a minimum of 1/1/2 hours if the emergency lighting system is battery powered. (4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1 (1) and (3). (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction."

Findings include:

The emergency battery backup lights documentaton was requested on August 12, 2019. The documentation reviewed was missing the annual testing for 2019. The last annual documentation was completed on 03/20/2018.

The Resource Chief Executive Officer (CEO) and the Director of Plant Ops acknowledged during the exit conference on August 13, 2019, the emergency battery backup lights were missing the annual testing for 2019. The last annual documentation was completed on 03/20/2018.

Based on observation and interview with staff, it was determined the facility failed to provide fire protection coverage for the home therapy oven. Failing to completely protect cooking equipment could result in fire, which could cause potential harm to the patients in time of a fire.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.6 "Cooking facilities shall be protected in accordance with 9.2.3." Section 9.2.3, "Commercial cooking equipment shall be in accordance with NFPA 96, Standard For Ventilation Control and Fire Protection of Commercial Cooking Operations." NFPA 96, Chapter 7, Section 10.1.2, "Cooking equipment that produces grease-laden vapors (such as but not limited to, deep fat fryers, ranges, griddles, and broilers, woks, tilting skillets, and braising pans) shall be protected by approved extinguishing equipment." 19.3.2.5.2 * "Where residential cooking equipment is used for food warming or limited cooking, the equipment shall not be required to be protected in accordance with 9.2.3, and the presence of the equipment shall not require the area to be protected as a hazardous area."

Findings Include:

Observation on tour of the facility on August 12, 2019, revealed the therapy oven located in the Therapy ADL Suite had grease on the hood. The therapy oven, a residential oven, and not a commercial oven with hood, was not protected by an approved extinguishing equipment.

The Resource CEO and the Director of Plant Operations acknowledged during the exit conference on August 13, 2019, that the therapy oven located in the Therapy ADL Suite had grease on the hood. The therapy oven is not a commercial oven with a hood, and was not protected by an approved extinguishing equipment.

Based on observation and interview with staff, it was determined the facility failed to maintain the sprinkler heads and assure that all parts of the sprinkler system were in accordance with the UL Listing. Failing to maintain sprinkler heads, missing escutcheon plates, which are part of the U.L. Listing of the sprinkler assembly, could allow heat and smoke to effect other areas of the building. This could cause potential harm to the patients.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.1, "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.1.1 "Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems." NFPA 13, Chapter 6, Section 6.2.7 "Plates, escutcheons or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler." Section 6.2.7.2* "Escutcheons used with recessed, flush-type, or concealed sprinklers shall be part of a listed sprinkler assembly." Section 6.7.3 "Cover plates used with concealed sprinklers shall be protected with listed guards."

Findings include:

Observation on tour of the facility on August 12, 2019, revealed a missing escutcheon plate in the copier room located in Administration.

The Resource CEO and the Director of Plant Ops acknowledged during the exit conference on August 13, 2019, that there was a missing escutcheon plate in the copier room located in Administration.

Based on observation and staff interview, it was determined the facility failed to identify one electrical conduit box did not have an approved cover on it. Failure to cover open junction boxes could cause potential harm to staff and could cause a fire which may result in harm to both staff and patients.

NFPA 101 Life Safety Code, 2012 Edition, Chapter 19, Section 19.5.1.1 "Utilities shall comply with the provisions of Section 9.1." Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70 'National Electrical Code" NEC, 2011. NFPA 70, Article 314, Section 314.28 "Boxes and conduit bodies used as pull or junction boxes shall comply with 314.28(A) through (E). Subsection (C) Covers. "All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where used, metal covers shall comply with the grounding requirements of 250.110."

Findings include:

Observation on tour of the facility on August 12, 2019, revealed an open junction box in the ceiling above the employee entrance corridor doors. The exposed junction box had multiple capped wires protruding out of it.

The Resource CEO and the Director of Plant Ops acknowledged during the exit conference on August 13, 2019, that there was an open junction box in the ceiling above the employee entrance corridor doors. The exposed junction box had multiple capped wires protruding out of it.

Based on record review and staff interview, it was determined the facility failed to perform the required fire drills. Failing to conduct the fire drills in accordance with the life safety code to familiarize staff with conditions under an actual fire, has potential harm to patients and staff during an actual fire or emergency situation.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.7.1.6 "Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers and administrative staff) with the signals and emergency action required under varied conditions." NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.7.2.2 "written health care occupancy fire safety plan shall provide for the following:

1. Use of alarms
2. Transmission to the fire department
3. Emergency phone call to the fire department
4. Response to alarms
5. Isolation of fire
6. Evacuation of immediate area
7. Evacuation of smoke compartment
8. Preparation of floors and building for evacuation
9. Extinguishment of fire."

Findings include:

The fire drill documentation was requested on August 12, 2019. There was no drill conducted for the first and second shift in the first quarter of 2019.

The Resource CEO and the Director of Plant Ops acknowledged during the exit conference on August 13, 2019, there was no drill conducted for the first and second shift in the first quarter of 2019.

Based on record review and interview with staff, it was determined the facility failed to have written documentation of the Annual Inspection and Testing of Door openings in accordance with NFPA 80, 2010 Edition, "Standard for Fire doors and Other Opening Protective's." Failing to inspect and test fire rated door assemblies in accordance with NFPA 80 annually could potentially cause risk of harm to the patients.

NFPA 101 2012 Life Safety Code Section 8.3.3. Fire door and Windows Section 8.3.3.1 "Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed labeled fire door assemblies and fire window assemblies and their accompanying hardware,including all frames, closing devices, anchorage and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening protective, except as otherwise specified in this code."

NFPA 80 Section 5.2* Inspections Section 5.2.1* "Fire door assemblies shall be inspected and tested not less than annually , and a written record of the inspection shall be signed and kept for the AHJ. Section 5.2.3 Functional Testing. Section 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing."

NFPA 80 Section 13.4 Automatic closing Section 5.2.5 "Horizontal sliding , Vertically Sliding, and Rolling Doors."
Section 5.2.14.3 "All horizontal or vertical sliding or rolling fire doors shall be inspected and tested annually to check for proper operation at frequent intervals to ensure operation."

Findings include:

The annual fire rated door assembly records were requested on August 12, 2019. The facility did not have written records of the Annual Inspection and Testing of Door Openings in accordance with NFPA 80 Standard for Fire Doors and Other Opening Protective's for 2019. The last annual inspection was dated 03/12/2018.

The Resource CEO and the Director of Plant Ops acknowledged during the exit conference on August 13, 2019, that there was no documentation to review of the annual fire rated door assemblies for 2019. The last annual inspection was dated 03/12/2018.

Based on record review and interview with staff, it was determined the facility failed to have the required maintenance and inspection for the medical gas and vacuum piped systems. Failure to have annual inspections of the gas and vacuum piped systems has potential harm to patients during system failures.

NFPA 99 2012 Edition, Chapter 5, Section 5.2.13 "Category 2 Operation and Management. Category 2 systems shall comply with 5.1.14." Section 5.1.14.4.3 "An annual review of bulk system capacity shall be conducted to ensure the source system has sufficient capacity." Section 5.1.14.2.4 "Central supply systems for nonflammable gases shall conform to the following: (1) They shall be inspected annually; (2) They shall be maintained by a qualified representative of the equipment owner; (3) A record of the annual inspection shall be available for review by the authority having jurisdiction."

Findings Include:

The medical gas and vacuum piped systems inspection and maintenance records were requested on August 12, 2019. There was no documentation to review that the facility had their medical gas and vacuum piped system inspected and maintained for 2018.

The Resource CEO and the Director of Plant Ops acknowledged during the exit conference on August 13, 2019, that there was no documentation to review that the facility had their medical gas and vacuum piped system inspected and maintained for 2018.

Based on record review and interview with staff, it was determined that the facility failed to conduct, maintain and document electrical receptacle testing in all patient care areas annually throughout the facility. Failing to test and document annually the receptacle testing of all patient care areas of the facility could lead to an ignition hazard in a patient care area, and potentially cause a fire and or injury to the patients.

NFPA 101 Life Safety Code, 2012, Chapter 4, Section 4.6.12.4 "Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected or operated as specified elsewhere in the Code or as directed by the authority having jurisdiction." NFPA 99, Health Care Facilities Code, 2012, Chapter 6, Section 6.3.4.1.1 "Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device." 6.3.4.1.2 "Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data." 6.3.4.1.3 "Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months."

Findings include:

The receptacle testing documentation was requested on August 12, 2019. There was no documentation available for review provided for receptacle testing in patient care areas for 2019. The last documented testing of receptacles was dated 05/04/2018.

The Resource CEO and the Director of Plant Ops acknowledged during the exit conference on August 13, 2019, that there was no documentation to review for receptacle testing in patient care areas for 2019. The last documented testing of receptacles was dated 05/04/2018.

Based on record review and interview with staff, it was determined the facility failed to document the required annual testing of the emergency generator. Failure to test the emergency generator under load and document the annual load test has potential to harm patients during emergency system failures.

NFPA 101 Life Safety Code, 2012, Chapter19, Section 19.7.6 "Maintenance and Testing (See 4.6.12) Section 4.6.12.2 " Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 99 "HEALTH CARE FACILITIES". 2012, Chapter 6, Section 6.4.4.1.1.4 (A) "Test Criteria. Generator sets shall be tested 12 times a year with testing intervals of not less than 20 days nor more thant 40 days. Generator sets serving essential electrical systmes shall be tested in accordance with NFPA 110, Standards for Emergency and Standby Power Systems, Chapter 8." NFPA 110, Standard for Emergency and Standby Power Systems (2010), Chapter 8, Section 8.4.2.3 "Diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW ratin for 20 continuous minutes and at not less than 75 percent of the EPS nameplate kW ratinging for 1 continuous hour for a total test duration of not less than 1.5 continuous hours."

Findings Include:

The emergency generator documentation was requested on August 12, 2019. There was no documentation that the annual inspection and maintenance was completed for 2018.

The Resource CEO and the Director of Plant Ops acknowledged during the exit conference on August 13, 2019, that there was no documentation that the annual inspection and maintenance was completed for 2018.