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Based on observation and interview, the facility failed to ensure 100 percent of corridor doors positively latched into the door frame. This deficient practice could affect all hospital patients, staff and visitors.

Findings include:

Based on observation on 10/15/14 with the Director of Operations and Facilities Administration during the tour from 9:00 a.m. to 12:00 p.m., the corridor door to the patient soiled utility pass through area for the patient rooms on the 2nd, 3rd, 4th and 5th floors failed to latch into the frames. Based on interview at the time of observations, the Director of Operations and Facilities Administration acknowledged the corridor doors for the patient room soiled pass through were not latching into the door frames.

Based on observation and interview, the facility failed to ensure 100 percent of battery operated emergency lighting was tested in accordance with LSC 7.9. LSC 7.9.3, Periodic Testing of Emergency Lighting Equipment requires a functional test to be conducted at 30-day intervals and an annual test to be conducted on every required battery-powered emergency lighting system for not less than 1 ½ -hr duration. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect all Cancer Center patients, staff and visitors.

Findings include:

Based on observations with the Director of Operations and Facilities Administration during the tour of the Cancer Center on 10/15/14 at 3:30 p.m., the facility has at least twenty emergency lights with battery back-up spread out throughout the Cancer Center. Based on interview with the Outpatient Lead Facilities Maintenance person during record review on 10/16/14 at 9:00 a.m., there was no written record of a monthly function test or an annual test regarding the battery-operated emergency lights available for review.

Based on observation and interview, the facility failed to ensure 100 percent of battery operated emergency lighting was tested in accordance with LSC 7.9. LSC 7.9.3, Periodic Testing of Emergency Lighting Equipment requires a functional test to be conducted at 30-day intervals and an annual test to be conducted on every required battery-powered emergency lighting system for not less than 1 ½ -hr duration. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect all hospital patients, staff and visitors.

Findings include:

Based on observations with the Inpatient Lead Facilities Maintenance person during the tour on 10/15/14 from 9:00 a.m. to 12:00 p.m., the facility has at least fifteen emergency lights with battery back-up located in the the power house generator room, five operating rooms and in various electrical rooms spread out throughout the hospital. Based on interview with the Inpatient Lead Facilities Maintenance person during record review on 10/14/14 at 3:00 p.m., there was no written record of a monthly function test or an annual test regarding the battery-operated emergency lights in the hospital available for review.

Based on record review and interview, the facility failed to document a fire drill for the day shift for 1 of 4 calendar quarters. This deficient practice could affect all Ambulatory Surgery Center patients, staff and visitors.

Findings include:

Based on review of "Code Red Drill Evaluation Reports" documentation with the Director of Nursing during record review at 2:30 p.m. on 10/15/14, documentation of a fire drill conducted for the day shift in the third quarter (July, August, September) of 2014 was not available for review. Based on interview on 10/15/14 at 2:30 p.m., the Director of Nursing acknowledged the facility held an Inservice instead of a fire drill for the day shift in the third quarter of 2014.

Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was installed in accordance with NFPA 13, 1999 Standard for the Installation of Sprinkler Systems, to provide complete coverage for 5 of 5 elevator machine rooms. NFPA 13, Section 5-1.1 states sprinklers shall be installed throughout the premises. LSC Section 9.7.3.1 allows alternative automatic extinguishing systems other than an automatic sprinkler system such as a water mist, carbon dioxide, dry chemical foam or a standard extinguishing system of another type in lieu of an automatic sprinkler system. Such systems shall be installed, inspected and maintained in accordance with NFPA standards and shall activate the building fire alarm system. This deficient practice could affect all patients, staff and/or visitors in the facility.

Findings include:

Based on observation and interview, the Director of Operations and Facilities Administration on 10/15/14 at 8:45 a.m., acknowledged all five of the hospital elevator equipment rooms lack sprinkler coverage or protection from an automatic extinguishing system.

Based on observation and interview, the facility failed to electronically supervise 1 of 1 Post Indicator Valves (PIV). LSC Section 9.7.2.1 requires supervisory attachments to be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code and a distinctive supervisory signal to be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. This deficient practice could affect all ambulatory surgical center patients, staff and visitors, if the water to the sprinkler system was shut off and not detected due to lack of supervision.

Findings include:

Based on observation with the Inpatient Lead Facilities Maintenance person and Director of Operations and Facilities Administration on 10/15/14 at 1:10 p.m., the Post Indicator Valve (PIV) outside the Ambulatory Surgical Center was padlocked but lacked electronic supervision. Based on interview at the time of observation, the Inpatient Lead Facilities Maintenance person and Director of Operations and Facilities Administration acknowledged the sprinkler PIV lacked electronic supervision.

Based on observation and interview, the facility failed to ensure 1 of 1 sprinkler systems was continuously maintained in reliable operating condition and inspected and tested periodically. NFPA 25, 2-3.2 requires gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced. This deficient practice affects all hospital patients, staff and visitors.

Findings include:

Based on observation with the Inpatient Lead Facilities Maintenance person from 9:00 a.m. to 9:45 a.m. on 10/15/14, the sprinkler system located in the fire pump room had at least nine pressure gauges with years of manufacture ranging from 2006 to 2008. Sprinkler risers in the south mechanical room (AG230) and north mechanical room (AG104) had at least twelve pressure gauges with years of manufacture also ranging from 2006 to 2008. Based on interview during the time of observation, the Inpatient Lead Facilities Maintenance person was unaware of the requirement for gauges to be replaced or tested every 5 years and acknowledged sprinkler pressure gauges throughout the hospital had not been tested or replaced since installation of the sprinkler system.

Based on observation and interview, the facility failed to regulate the use of portable space heaters in employee areas. This deficient practice could affect staff within the Ambulatory Surgery Center (ASC) Central Supply room.

Findings include:

Based on observation with the Inpatient Lead Facilities Maintenance person and Director of Operations and Facilities Administration on 10/15/10 at 1:30 p.m., a portable space heater was located in the ASC Central Supply room office. Based on interview at the time of observation, the Director of Operations and Facilities Administration acknowledged space heaters were not allowed anywhere within the health facility locations.

Based on record review and interview, the facility failed to exercise 1 of 1 generators to meet the requirements of NFPA 110, the Standard for Emergency and Standby Powers Systems, chapter 6-4.2. Chapter 3-4.4.1.1 of NFPA 99, the Standard for Health Care Facilities requires monthly testing of the generator serving the emergency electrical system to be in accordance with NFPA 110. Chapter 6-4.2 of NFPA 110 requires generator sets in Level 1 and Level 2 service to be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
a. Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating.
b. Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.

NFPA 110, 6-4.2.2 requires diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

This deficient practice could affect all ambulatory surgical center patients, staff and visitors.

Findings include:

Based on review of the "Planned Maintenance Checklist-Monthly" for the ambulatory emergency generator with the Inpatient Lead Facilities Maintenance person on 10/14/14 at 3:30 p.m., it could not be determined if the generator met the requirements of Chapter 6-4.2 of NFPA 110. Line J(2)j of the generator checklist which was intended to show the load percentage in kilowatts was consistently recorded with amperage/voltage or left blank. Based on interview at the time of review, the Inpatient Lead Facilities Maintenance person indicated the ambulatory surgical center generator does not operate at more than 30 percent of the EPS nameplate rating when tested and indicated the most recent load bank test was conducted more than a year ago on 06/29/13.

1) Based on record review and interview, the facility failed to exercise 2 of 2 generators to meet the requirements of NFPA 110, the Standard for Emergency and Standby Powers Systems, chapter 6-4.2. Chapter 3-4.4.1.1 of NFPA 99, the Standard for Health Care Facilities requires monthly testing of the generator serving the emergency electrical system to be in accordance with NFPA 110. Chapter 6-4.2 of NFPA 110 requires generator sets in Level 1 and Level 2 service to be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
a. Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating.
b. Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
The date and time of day for required testing shall be decided by the owner, based on facility operations. This deficient practice could affect all hospital patients, staff and visitors.

Findings include:

Based on review of the "Planned Maintenance Checklist-Monthly" for the two hospital emergency generators with the Inpatient Lead Facilities Maintenance person on 10/14/14 at 3:30 p.m., it could not be determined if the two generators met the requirements of Chapter 6-4.2 of NFPA 110. Line J(2)j of the generator checklist which was intended to show the load percentage in kilowatts was consistently recorded with amperage/voltage or left blank. Based on interview at the time of review, the Inpatient Lead Facilities Maintenance person indicated the two generators operate at more than 30 percent of the EPS nameplate rating when tested but acknowledged the documentation was lacking to demonstrate compliance.

2) Based on observation and interview, the facility failed to ensure 2 of 2 emergency generators were equipped with remote manual stops. LSC 7.9.2.3 requires emergency generators providing power to emergency lighting systems shall be installed, tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110, 1999 edition, 3-5.5.6 requires Level I installations shall have a remote manual stop station of a type similar to a break-glass station located elsewhere on the premises where the prime mover is located outside the building. This deficient practice could affect hospital residents, staff and visitors.

Findings include:

Based on observation of the power house generator room on 10/15/14 at 9:05 a.m. during a tour of the facility with the Inpatient Lead Facilities Maintenance person, emergency stop buttons were provided on the generators but the generators were not equipped with remote manual stop stations. Based on interview at the time of observation, the Inpatient Lead Facilities Maintenance person acknowledged remote shut off devices for either generator were not provided.

Based on observation and interview, the facility failed to ensure 100 percent of corridor doors positively latched into the door frame. This deficient practice could affect all hospital patients, staff and visitors.

Findings include:

Based on observation on 10/15/14 with the Director of Operations and Facilities Administration during the tour from 9:00 a.m. to 12:00 p.m., the corridor door to the patient soiled utility pass through area for the patient rooms on the 2nd, 3rd, 4th and 5th floors failed to latch into the frames. Based on interview at the time of observations, the Director of Operations and Facilities Administration acknowledged the corridor doors for the patient room soiled pass through were not latching into the door frames.

Based on observation and interview, the facility failed to ensure 100 percent of battery operated emergency lighting was tested in accordance with LSC 7.9. LSC 7.9.3, Periodic Testing of Emergency Lighting Equipment requires a functional test to be conducted at 30-day intervals and an annual test to be conducted on every required battery-powered emergency lighting system for not less than 1 ½ -hr duration. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect all Cancer Center patients, staff and visitors.

Findings include:

Based on observations with the Director of Operations and Facilities Administration during the tour of the Cancer Center on 10/15/14 at 3:30 p.m., the facility has at least twenty emergency lights with battery back-up spread out throughout the Cancer Center. Based on interview with the Outpatient Lead Facilities Maintenance person during record review on 10/16/14 at 9:00 a.m., there was no written record of a monthly function test or an annual test regarding the battery-operated emergency lights available for review.

Based on observation and interview, the facility failed to ensure 100 percent of battery operated emergency lighting was tested in accordance with LSC 7.9. LSC 7.9.3, Periodic Testing of Emergency Lighting Equipment requires a functional test to be conducted at 30-day intervals and an annual test to be conducted on every required battery-powered emergency lighting system for not less than 1 ½ -hr duration. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect all hospital patients, staff and visitors.

Findings include:

Based on observations with the Inpatient Lead Facilities Maintenance person during the tour on 10/15/14 from 9:00 a.m. to 12:00 p.m., the facility has at least fifteen emergency lights with battery back-up located in the the power house generator room, five operating rooms and in various electrical rooms spread out throughout the hospital. Based on interview with the Inpatient Lead Facilities Maintenance person during record review on 10/14/14 at 3:00 p.m., there was no written record of a monthly function test or an annual test regarding the battery-operated emergency lights in the hospital available for review.

Based on record review and interview, the facility failed to document a fire drill for the day shift for 1 of 4 calendar quarters. This deficient practice could affect all Ambulatory Surgery Center patients, staff and visitors.

Findings include:

Based on review of "Code Red Drill Evaluation Reports" documentation with the Director of Nursing during record review at 2:30 p.m. on 10/15/14, documentation of a fire drill conducted for the day shift in the third quarter (July, August, September) of 2014 was not available for review. Based on interview on 10/15/14 at 2:30 p.m., the Director of Nursing acknowledged the facility held an Inservice instead of a fire drill for the day shift in the third quarter of 2014.

Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was installed in accordance with NFPA 13, 1999 Standard for the Installation of Sprinkler Systems, to provide complete coverage for 5 of 5 elevator machine rooms. NFPA 13, Section 5-1.1 states sprinklers shall be installed throughout the premises. LSC Section 9.7.3.1 allows alternative automatic extinguishing systems other than an automatic sprinkler system such as a water mist, carbon dioxide, dry chemical foam or a standard extinguishing system of another type in lieu of an automatic sprinkler system. Such systems shall be installed, inspected and maintained in accordance with NFPA standards and shall activate the building fire alarm system. This deficient practice could affect all patients, staff and/or visitors in the facility.

Findings include:

Based on observation and interview, the Director of Operations and Facilities Administration on 10/15/14 at 8:45 a.m., acknowledged all five of the hospital elevator equipment rooms lack sprinkler coverage or protection from an automatic extinguishing system.

Based on observation and interview, the facility failed to electronically supervise 1 of 1 Post Indicator Valves (PIV). LSC Section 9.7.2.1 requires supervisory attachments to be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code and a distinctive supervisory signal to be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. This deficient practice could affect all ambulatory surgical center patients, staff and visitors, if the water to the sprinkler system was shut off and not detected due to lack of supervision.

Findings include:

Based on observation with the Inpatient Lead Facilities Maintenance person and Director of Operations and Facilities Administration on 10/15/14 at 1:10 p.m., the Post Indicator Valve (PIV) outside the Ambulatory Surgical Center was padlocked but lacked electronic supervision. Based on interview at the time of observation, the Inpatient Lead Facilities Maintenance person and Director of Operations and Facilities Administration acknowledged the sprinkler PIV lacked electronic supervision.

Based on observation and interview, the facility failed to ensure 1 of 1 sprinkler systems was continuously maintained in reliable operating condition and inspected and tested periodically. NFPA 25, 2-3.2 requires gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced. This deficient practice affects all hospital patients, staff and visitors.

Findings include:

Based on observation with the Inpatient Lead Facilities Maintenance person from 9:00 a.m. to 9:45 a.m. on 10/15/14, the sprinkler system located in the fire pump room had at least nine pressure gauges with years of manufacture ranging from 2006 to 2008. Sprinkler risers in the south mechanical room (AG230) and north mechanical room (AG104) had at least twelve pressure gauges with years of manufacture also ranging from 2006 to 2008. Based on interview during the time of observation, the Inpatient Lead Facilities Maintenance person was unaware of the requirement for gauges to be replaced or tested every 5 years and acknowledged sprinkler pressure gauges throughout the hospital had not been tested or replaced since installation of the sprinkler system.

Based on observation and interview, the facility failed to regulate the use of portable space heaters in employee areas. This deficient practice could affect staff within the Ambulatory Surgery Center (ASC) Central Supply room.

Findings include:

Based on observation with the Inpatient Lead Facilities Maintenance person and Director of Operations and Facilities Administration on 10/15/10 at 1:30 p.m., a portable space heater was located in the ASC Central Supply room office. Based on interview at the time of observation, the Director of Operations and Facilities Administration acknowledged space heaters were not allowed anywhere within the health facility locations.

Based on record review and interview, the facility failed to exercise 1 of 1 generators to meet the requirements of NFPA 110, the Standard for Emergency and Standby Powers Systems, chapter 6-4.2. Chapter 3-4.4.1.1 of NFPA 99, the Standard for Health Care Facilities requires monthly testing of the generator serving the emergency electrical system to be in accordance with NFPA 110. Chapter 6-4.2 of NFPA 110 requires generator sets in Level 1 and Level 2 service to be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
a. Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating.
b. Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.

NFPA 110, 6-4.2.2 requires diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

This deficient practice could affect all ambulatory surgical center patients, staff and visitors.

Findings include:

Based on review of the "Planned Maintenance Checklist-Monthly" for the ambulatory emergency generator with the Inpatient Lead Facilities Maintenance person on 10/14/14 at 3:30 p.m., it could not be determined if the generator met the requirements of Chapter 6-4.2 of NFPA 110. Line J(2)j of the generator checklist which was intended to show the load percentage in kilowatts was consistently recorded with amperage/voltage or left blank. Based on interview at the time of review, the Inpatient Lead Facilities Maintenance person indicated the ambulatory surgical center generator does not operate at more than 30 percent of the EPS nameplate rating when tested and indicated the most recent load bank test was conducted more than a year ago on 06/29/13.

1) Based on record review and interview, the facility failed to exercise 2 of 2 generators to meet the requirements of NFPA 110, the Standard for Emergency and Standby Powers Systems, chapter 6-4.2. Chapter 3-4.4.1.1 of NFPA 99, the Standard for Health Care Facilities requires monthly testing of the generator serving the emergency electrical system to be in accordance with NFPA 110. Chapter 6-4.2 of NFPA 110 requires generator sets in Level 1 and Level 2 service to be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
a. Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating.
b. Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
The date and time of day for required testing shall be decided by the owner, based on facility operations. This deficient practice could affect all hospital patients, staff and visitors.

Findings include:

Based on review of the "Planned Maintenance Checklist-Monthly" for the two hospital emergency generators with the Inpatient Lead Facilities Maintenance person on 10/14/14 at 3:30 p.m., it could not be determined if the two generators met the requirements of Chapter 6-4.2 of NFPA 110. Line J(2)j of the generator checklist which was intended to show the load percentage in kilowatts was consistently recorded with amperage/voltage or left blank. Based on interview at the time of review, the Inpatient Lead Facilities Maintenance person indicated the two generators operate at more than 30 percent of the EPS nameplate rating when tested but acknowledged the documentation was lacking to demonstrate compliance.

2) Based on observation and interview, the facility failed to ensure 2 of 2 emergency generators were equipped with remote manual stops. LSC 7.9.2.3 requires emergency generators providing power to emergency lighting systems shall be installed, tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110, 1999 edition, 3-5.5.6 requires Level I installations shall have a remote manual stop station of a type similar to a break-glass station located elsewhere on the premises where the prime mover is located outside the building. This deficient practice could affect hospital residents, staff and visitors.

Findings include:

Based on observation of the power house generator room on 10/15/14 at 9:05 a.m. during a tour of the facility with the Inpatient Lead Facilities Maintenance person, emergency stop buttons were provided on the generators but the generators were not equipped with remote manual stop stations. Based on interview at the time of observation, the Inpatient Lead Facilities Maintenance person acknowledged remote shut off devices for either generator were not provided.