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Based on observation the facility failed to ensure a hazardous area was in accord with the approved Standard in the Surgery storage room. This condition would allow smoke and/or fire from a fire to enter the exit corridor, and make it untenable.

Findings include:

During tour on June 8, 2011 at 2:30 p.m., the 1 and 1/2 hour fire rated door was wedged open by metal shelving.
Reference: NFPA 80--Standard for Fire Doors and Windows (1999 Edition)
5.2.13.3 Blocking or wedging of doors in the open position shall be prohibited.

Based on a random selection of employee interviews and interview of administration personnel, the facility failed to ensure all facility staff had minimal knowledge regarding procedures in the event of a fire. These conditions may cause delay and confusion, when in need of evacuation processes.

Findings include:

1. During tour on June 7, 2011 at 2:45 p.m. in the Behavior Unit, a staff member (who normally works in the area) was asked to go to the nearest locked fire extinguisher cabinet and attempt to open the door. The person stated that they could not do that, as they did not have a key. A second member (also employed to work the area) was asked to do the same. This person went to the nurses' station, searched through a drawer and located a key, then proceeded to an extinguisher cabinet and was successful in opening the door. In a secure area such as the above described location, employees are required to have an extinguisher cabinet key on their person. This was confirmed by administrative staff interview.

2. On June 8, 2011 between 12 noon and 3:00 p.m., an employee in the MRI unit was interviewed to describe what the acronym "RACE" and "PASS" means, which effectively are the procedures to perform in the discovery of a fire. The answer given was "Rescue, Alarm, Confine, and Extinguish" and for a fire extinguisher "Pull, Aim, Squeeze, and Sweep". The employee was then given a hypothetical fire scenario, and instructed to explain step by step what action was required to be taken. The employee stated "A code would be called to the PBX operator, then attempt to confine the fire area, and if possible, extinguishment." The Life Safety Surveyor then questioned about the "A" in "RACE", but the employee was unsure of what it implied. The employee was told that the alarm shall be activated. During the time of the interview, a manual fire alarm pull station was within eight feet of the employee, it being located within five feet of an exit door.

A second random interview occurred within the Sterile Processing Department. An employee was asked the same questions regarding "RACE" and "PASS", and provided the correct answers. The employee was then told that they had discovered a fire, and asked to go to the nearest manual fire alarm pull station. The employee was unable to perform the task, and stated they did not know where one was. The Life Safety Surveyor then explained that at a minimum, there is always one within five feet of an exit door.
Reference: NFPA 101--19.7.1.1

Based on observations, the facility failed to ensure the automatic sprinkler system was completely maintained in the 3rd floor Standpipe pressure gauge in Stair "G", a dressing room in Radiology, Inspectors Test valve location in Emergency Department (E.D.), 3 Operating rooms in Surgery, and the main Telephone Equipment room. These conditions may affect operating capabilities of the suppression system in the event of a fire.

Findings include:

1. During tour on June 7, 2011 at 11:45 a.m., the stair "G" pressure gauge was dated 2004. Gauges are required to be replaced or re-calibrated every 5 years.

2. During tour on June 8, 2011 between 9:45 a.m. and 3:30 p.m., the Inspectors Test valve location (in E.D.) did not have an indicating sign, at the dressing room in Radiology two sprinklers were too close together. For the type of devices installed they must be a minimum of 5 feet apart. At the 3 Operating rooms in Surgery (being rooms #1, #4, and #5), recessed sprinkler ceiling cover plates had been painted over, which is prohibited. In the main Telephone Equipment room, sprinkler spacing exceeds allowable limitations.
Reference: NFPA 25--Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (1998 Edition)

Based on observation the facility failed to ensure compressed gas cylinders were stored by approved Standards within the equipment room of the MRI building. This condition may cause a cylinder upset endangering occupants.

Findings include:

During tour on June 8, 2011 at 11:45 a.m., one Helium and one Nitrogen cylinder were not secured from falling.
Reference: NFPA 99--Health Care Facilities (1999 Edition)
4-3.1.1.1 Cylinder and Container Management. Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

Based on observation, the facility failed to ensure medical gas systems were installed in accord with the approved Standard at the gases compound manifold relief valves. This condition may cause obstructions to occur preventing excess pressure discharge.

Findings include:

During tour on June 8, 2011 at 11:00 a.m., 2 of 2 pressure relief vent openings for the Nitrous Oxide and Nitrogen gas manifolds were not screened to prevent entry of foreign matter.
Reference: NFPA 99 Health Care Facilities (1999 Edition)
Figure 4-3.1.1.7 and Text 4-3.1.1.8 (e) Pressure Relief Valves. They shall have the discharge terminal turned down and screened to prevent the entry of rain, snow, or vermin.

Based on observation, the facility failed to ensure flammable and combustible product were stored by approved Standards within the Materials Management department. This condition would cause an incipient fire to accelerate rapidly, endangering occupants.

Findings include:

During tour on June 8, 2011 at 3:00 p.m., cartons of "Epi-Clenz" alcohol based hand cleaner exceeded allowable quantities for the storage method in use. The product was packaged in 8 ounce pressurized aerosol dispensers. There were 24 dispensers per carton. A total of 8 cartons were stored on open metal shelving, constituting a quantity of 12 gallons of product. A maximum of 10 gallons is the limit, unless stored within a one-hour enclosure, such as an approved flammable and combustible liquids storage cabinet.
Reference: NFPA 101--Life Safety Code (2000 Edition)
8.4.3 Flammable Liquids and Gases
8.4.3.1 The storage and handling of flammable liquids or gases shall be in accordance with the following applicable standards:
(1) NFPA 30-Flammable and Combustible Liquids Code (1996 Edition)
(2) NFPA 54-National Fuel Gas Code (1999 Edition)
(3) NFPA 58-Liquefied Petroleum Gas Code (1999 Edition)

Based on record review, observation and staff interview, the facility failed to maintain requirements for electrical safety as required by NFPA 70, National Electrical Code; NFPA 99, Health Care facilities 3-3.3.4.2; NFPA 101 Life Safety Code 9.1.2, and 4.6.12. Affected locations are at the Surgery area Line Isolation Monitor (LIM) panels and the Endoscopy area Line Isolation Monitor (LIM) panel.

Findings include:

1. Record review on June 7, 2011 at 3:00 p.m. revealed no recent documentation of Line Isolation Monitoring (LIM) devices testing. The devices are located in the Surgery Operating rooms corridor access area. Inspection labels in each of the panels were dated 2010 and had not been inspected since March of 2010.

2. On June 8, 2011 at 8:45 a.m. direct observation revealed 1 LIM panel in the Endoscopy area without any inspection label provided.
Reference: NFPA 99--Health Care Facilities (1999 Edition)
3-3.3.4.2(b) "The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators."