HospitalInspections.org

Based on record review and interview, the facility failed to ensure that a hazard vulnerability analysis (HVA) included a community based component in the risk assessment. Failure to consider community risks in the development of the plan, has the potential to hinder planning, training and response during an emergency. This deficient practice affected all patients, staff and visitors on the date(s) of the survey.

Findings include:

During review of the provided Emergency Operations Plan (EP) conducted on 5/7/19 from 8:30 AM - 12:30 PM, records failed to demonstrate community relevant events as associated with the county all-hazards risk assessment, had been evaluated during development of the HVA. Interview of the facility Compliance Officer at approximately 9:30 AM, substantiated the HVA risks had been developed from internal facility discussions and county or state EMS agency data had not been evaluated in development of the plan. (See additionally E-0013)

Reference:
42 CFR 485.625(a) 1-2

Based on record review and interview, it was determined the facility failed to document their role under an 1135 waiver as declared by the Secretary and the provisions of care as required under this action if identified by emergency management officials. Failure to plan for alternate means of care and the role under an 1135 waiver has the potential to limit facility options during an emergency. This deficient practice potentially affects reimbursement and continuity of care for the 8 patients, staff and visitors housed on the date(s) of the survey.

Findings include:

On 5/7/19 from 8:30 AM - 12:30 PM, review of the provided EP, did not demonstrate the role of the facility under the declaration of an 1135 waiver, should that condition be enacted by the Secretary.

Interview of the Compliance Officer at approximately 10:00 AM, revealed she was not aware of the requirement to include facility defined roles under an 1135 waiver.

Reference:
42 CFR 485.625 (b) (8)

Based on record review, the facility failed to ensure current contact information for emergency management officials was provided in the emergency communication plan. Failure to provide contact information for Federal, State and other sources of assistance has the potential to hinder facility response and continuity of care for the 8 patients, staff and visitors in the facility on the date(s) of the survey.

Findings include:

On 5/7/19 from 8:30 AM - 12:30 PM, review of the EP established the plans listed for contacts in the event of an emergency, did not include numbers for Federal, State, tribal or other local emergency management agency contacts.

Reference:
42 CFR 483.73 (c) (2)

Based on observation, the facility failed to ensure the fire resistive properties of the structure were maintained. Failure to maintain required fire coatings on steel support structures has the potential to decrease the rated assembly load bearing capabilities and cause premature structural failure. This deficient practice affected all patients, staff and visitors on the date(s) of the survey.

Findings include:

During the facility tour conducted on 5/7/19 from 1:30 - 3:00 PM, observation of the steel support structures separating multiple levels of the east tower, revealed the load-bearing steel I-beams were missing protective coating(s) in the following areas:

Second floor electrical room abutting the elevators approximately two (2) feet by six (6) inches of protective coating missing.
Mechanical room HVAC 2A in the basement approximately one (1) foot by two (2) inches of protective coating missing.
Southside room B4 in the basement approximately six (6) inches by one (1) inch of protective coating missing.
Electrical room in the Lower basement approximately six (6) inches by six (6) inches of protective coating missing.

Actual NFPA standard:

19.1.6 Minimum Construction Requirements.
19.1.6.1 Health care occupancies shall be limited to the building construction types specified in Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7. (See 8.2.1.)
19.1.6.2% Any building of Type I(442), Type I(332), Type II(222), or Type II(111) construction shall be permitted to include roofing systems involving combustible supports,
decking, or roofing, provided that all of the following criteria are met:
(1) The roof covering shall meet Class C requirements in accordance with ASTM E 108, Standard Test Methods for Fire Tests of Roof Coverings, or

Based on observation and interview, the facility failed to ensure that door locking arrangements were in accordance with NFPA 101. Failure to ensure locks on doors did not require keys or special knowledge to release from the egress side, has the potential to hinder evacuation and trap patients during a fire or other emergency requiring evacuation. This deficient practice affected all patients using the sleep lab and staff on the date(s) of the survey.

Findings include:
During the facility tour conducted on 5/7/19 from 1:00 - 3:00 PM, observation of the following rooms revealed the doors were equipped with dual-keyed deadbolts in addition to the paddle activated door latch, requiring a key to unlock from the egress side:

Sleep Lab 1
Sleep Lab 2
Control Room for sleep lab
Overflow doctor sleep room abutting respiratory.

Asked about the locking arrangement during this tour at approximately 1:45 PM, the Maintenance Manager stated the locks were installed one month prior and the dual-keyed operation was to prevent patients from locking themselves in and thereby preventing staff access.

Actual NFPA standard:

19.2.2.2 Doors.
19.2.2.2.1 Doors complying with 7.2.1 shall be permitted.
19.2.2.2.2 Locks shall not be permitted on patient sleeping room doors, unless otherwise permitted by one of the following:
(1) Key-locking devices that restrict access to the room from the corridor and that are operable only by staff from the corridor side shall be permitted, provided that such devices do not restrict egress from the room.
(2) Locks complying with 19.2.2.2.5 shall be permitted.

7.2.1.5 Locks, Latches, and Alarm Devices.
7.2.1.5.3 Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from t

Based on observation and operational testing, the facility failed to ensure hazardous areas were protected in accordance with NFPA 101. Failure to ensure hazardous area doors opening into the corridor self-close as designed, has the potential to allow smoke, fire and dangerous gases to pass between compartments, hindering egress during a fire. This deficient practice affected staff on the date(s) of the survey.

Findings include:

During the facility tour conducted on 5/7/19 from 1:00 - 3:00 PM and 5/8/19 from 8:00 - 10:00 AM, observation and operational testing of the door entering the Maintenance office and shop located in the basement level, revealed the door was designed and equipped to self-close, but was held open with a piece of wire secured to a file cabinet.

Actual NFPA standard:

19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in
accordance with 8.7.1.
19.3.2.1.1 An automatic extinguishing system, where used in hazardous areas, shall be permitted to be in accordance with 19.3.5.9.
19.3.2.1.2% Where the sprinkler option of 19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4.
19.3.2.1.3 The doors shall be self-closing or automatic-closing.

Based on observation and operational testing, the facility failed to ensure Laboratories were protected in accordance with NFPA 101. Failure to ensure doors entering the corridor from the lab are equipped to self-close and latch, has the potential to expose patients, staff and visitors to the increased risks of fires from an hazardous area, hindering the safe evacuation through the egress corridor. This deficient practice affected all patients, staff and visitors on the date(s) of the survey.

Findings include:

During the facility tour conducted on 5/7/19 from 1:00 - 3:00 PM, observation and operational testing of the door entering the Laboratory from the corridor, revealed the door would not self-close and latch as designed. Further observation of the Lab revealed a high level of stored combustibles and chemicals, creating a severe hazard risk to the facility.

Actual NFPA standard:

19.3.2.2% Laboratories. Laboratories employing quantities of flammable, combustible, or hazardous materials that are considered as a severe hazard shall be in accordance with Section
8.7 and the provisions of NFPA 99, Health Care Facilities Code, applicable to administration, maintenance, and testing.
8.7 Special Hazard Protection.
8.7.1 General.
8.7.1.1% Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following
means:
(1) Enclosing the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.3
(2) Protecting the area with automatic extinguishing systems in accordance with Section 9.7
(3) Applying both 8.7.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 11 through 43

Based on record review, observation and interview, the facility failed to ensure alcohol-based hand rub (ABHR) dispensers were maintained in accordance with NFPA 101. Failure to ensure ABHR dispensers are clear of ignition sources and tested during refilling procedures, has the potential of increasing the risk of fires from flammable liquids. This deficient practice affected all patients and staff on the date(s) of the survey.

Findings include:

1) During review of provided refill documentation conducted on 5/8/19 from 8:00 - 10:00 AM, records did not provide documentation of the procedures of testing conducted during each occasion an ABHR refill was replaced.
2) During the facility tour conducted on 5/7/19 from 1:00 - 3:00 PM, both automatic and manual ABHR dispensers were identified stored throughout the facility. Further observation revealed an ABHR dispenser installed over an electric door switch at OR 2 and one above a double light switch at room E-339.

Interview of the Compliance Officer and the Maintenance Manager on 5/7/19 at approximately 2:45 PM, established neither was aware of the requirement for testing dispensers each time a refill was installed.

Actual NFPA standard:

NFPA 101

19.3.2.6% Alcohol-Based Hand-Rub Dispensers. Alcohol-based hand-rub dispensers shall be protected in accordance with 8.7.3.1, unless all of the following conditions are met:
(1) Where dispensers are installed in a corridor, the corridor shall have a minimum width of 6 ft (1830 mm).
(2) The maximum individual dispenser fluid capacity shall be as follows: (a) 0.32 gal (1.2 L) for dispensers in rooms, corridors, and areas open to corridors
(b) 0.53 gal (2.0 L) for dispensers in suites of rooms
(3) Where aerosol containers are used, the maximum capacity of the aerosol

Based on record review, observation and interview, the facility failed to ensure that fire suppression systems were maintained in accordance with NFPA 25. Failure to conduct internal piping inspections to evaluate piping condition, has the potential to hinder system response during a fire event. This deficient practice affected all patients, staff and visitors on the date(s) of the survey.

Findings include:

1) During review of maintenance inspection and testing records conducted on 5/7/19 from 9:30 AM - 12:30 PM, records did not indicate the date of the last internal piping inspection of the fire suppression system.
2) During the facility tour conducted on 5/7/19 from 1:00 - 3:00 PM, observation of the main fire riser and the dry system riser did not reveal any tags or identifying inspection labels indicating a five-year internal piping inspection had been conducted.

On 5/7/19 at approximately 11:45 AM, interview of the Maintenance Manager about the missing inspection revealed he was not aware the internal piping inspection had not been completed.

Actual NFPA standard:

NFPA 25

5.1.1 Minimum Requirements.
5.1.1.1 This chapter shall provide the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems.
5.1.3 Obstruction Investigations. The procedures outlined in Chapter 14 shall be followed where there is a need to conduct an obstruction investigation.
14.2 Internal Inspection of Piping.
14.2.1 Except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of
one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic

Based on observation and physical examination, the facility failed to ensure fire extinguishers were installed in accordance with NFPA 10. Failure to mount extinguishers at the correct height could hinder access during a fire event. This deficient practice affected all patients, staff and visitors on the date of the survey.

Findings include:

During the facility tour conducted on May 9, 2019 from approximately 10:30 AM - 2:00 PM, observation of extinguishers installed in corridors revealed the following fire extinguishers were mounted over 60 inches to the top when measured from the floor:

Respiratory Therapy office measured 67 inches to the top of the extinguisher
OR 1 measured 63 inches to the top of the extinguisher
OR Hopper Room measured 70 inches to the top of the extinguisher
Basement electrical room measured 73 inches to the top of the extinguisher
Basement mechanical space measured 65 inches to the top of the extinguisher

Actual NFPA standard:

NFPA 10
6.1.3.8 Installation Height.
6.1.3.8.1 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor.

6.1.3.8.2 Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be installed so that the top of the fire extinguisher is not more than 31.2 ft
(1.07 m) above the floor.

6.1.3.8.3 In no case shall the clearance between the bottom of the hand portable fire extinguisher and the floor be less than 4 in. (102 mm).

Based on observation, the facility failed to ensure safe electrical installations in accordance with NFPA 101 and NFPA 70. Failure to use relocatable power taps (RPTs) in accordance to the approved, listed assembly has the potential to expose patients, staff and visitors to electrical shock and/or arc fires. This deficient practice affected staff on the date(s) of the survey.

Findings include:

1) During the facility tour conducted on 5/7/19 from 1:00 - 3:00 PM, observation of the Environmental Services office in the basement revealed a RPT for supplying power to a full-size refrigerator and a coffee maker.

2) During the facility tour conducted on 5/7/19 from 1:00 - 3:00 PM, observation of the staff breakroom abutting the Emergency Room waiting area, revealed a RPT plugged in series (daisy-chained) into an extension cord, to supply power to a coffee maker.

Actual NFPA standard:

NFPA 70
`
110.2 Approval. The conductors and equipment required or permitted by this Code shall be acceptable only if approved.
Informational Note: See 90.7, Examination of Equipment for Safety, and 110.3, Examination, Identification, Installation, and Use of Equipment. See definitions of Approved,
Identified, Labeled, and Listed.
110.3 Examination, Identification, Installation, and Use of Equipment.
(A) Examination. In judging equipment, considerations such as the following shall be evaluated:
(1) Suitability for installation and use in conformity with the provisions of this Code
Informational Note: Suitability of equipment use may be identified by a description marked on or provided with a product to identify the suitability of the product for a specific purpose, environment, or application. Special conditions of use or other limitations and other pertinent information may

Based on record review, observation and interview, the facility failed to ensure electrical receptacles were inspected and tested in accordance with NFPA 99. Failure to test receptacles, whether fixed or portable, on a routine basis, has the potential to expose patients, staff and visitors to electrical shock and/or arc fires. This deficient practice affected all patients, staff and visitors on the date(s) of the survey.

Findings include:

1) During review of provided maintenance and inspection records conducted on 5/7/19 from 8:30 AM - 12:30 PM, records did not indicate inspection and testing had been conducted on any of the hospital-grade outlets or Patient-Care Related Electrical Equipment (PCREE) UL 1363A relocatable power tap (RPT) outlets, within the past twelve months.
On 5/7/19 at approximately 2:00 PM, interview of the Maintenance Manager revealed the facility had ended the routine inspection and testing of this equipment approximately one year prior to the survey date.

2) During the facility tour conducted on 5/7/19 from 1:00 - 3:00 PM, observation of fixed outlets and portable, multiple plug outlets installed in the facility revealed hospital-grade fixed outlets installed throughout and UL 1363A RPTs, with hospital grade outlets installed on PCREE equipment in both OR 1 and OR2.

Actual NFPA standard:

6.3.2.2.8 Wet Procedure Locations.
6.3.2.2.8.1% Wet procedure locations shall be provided with special protection against electric shock.
6.3.2.2.8.4% Operating rooms shall be considered to be a wet procedure location, unless a risk assessment conducted by the health care governing body determines otherwise.
6.3.2.2.8.5 In existing construction, the requirements of
6.3.2.2.8.1 shall not be required when a written inspection procedure, acceptable to the authority