HospitalInspections.org

Based on observation and interview with staff, the facility failed to provide corridors separated from use areas by walls constructed to resist the passage of smoke. Findings:

1) The sliding glass window in the reception area does not have latching hardware, resulting in the space behind the window being open to the corridor. NFPA 101, Section 19.3.6.1 Exception No. 1 (c) permits spaces to be open to the corridor provided that "the open space is protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4". .

Based on observation and interview with staff, the facility failed to provide doors with a means suitable for keeping the door closed. Roller latches are prohibited by CMS regulations in all health care facilities. Findings,

(1) Roller latches have been replaced in patient rooms. However doors to other rooms through out the building still have roller latches.

Based on observation and interview with the interim CEO, the facility failed to provide smoke barriers that are constructed to provide at least a one half hour fire resistance rating in accordance with 8.3. Findings:

Smoke walls through out the building have penetrations around piping, duct work, electrical conduit etc. that are not sealed with fire caulking. Penetrations above the cross-corridor doors and the walls that extended across from the corridor to outside walls have not been sealed.

Based on review of the Fire Drill Report form and interview with the Interim CEO, the facility failed to ensure the staff is familiar with procedures and is aware that drills are part of established routine. Findings:

The report form for the drill conducted on 7-6-2011 documented that policy had not been followed. There was no evidence that corrective action had been taken.

Based on interview with the Interim Director of Maintenance and Interim CEO, the facility failed to provide a fire alarm system maintained in accordance with NFPA 72 and to keep records of maintenance readily available. Finding:

The facility could not provide records of the last two years of annual inspections of the fire alarm system.

Based on observation and review of the annual fire suppression test report of the sprinkler system conducted on January 12, 2011, the facility failed to maintain the sprinkler system in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Findings:

The fire suppression system was inspected on January 12, 2011 by MAC Systems, the system was yellow tagged with a list of deficiencies. The Interim Director of Maintenance and Interim CEO stated they were unaware that the system was yellow tagged. There was no evidence the deficiencies had been corrected or were scheduled to be corrected.

Based on observation and interview with Interim CEO, Interim Director of Maintenance, the facility failed to provide heating, ventilating, and air conditioning that comply with the provisions of NFPA 90A; Appendix B, Maintenance, Paragraph B-1 "Owners...should establish a planned maintenance program". Findings:

The HVAC equipment filters were not maintained with proper filters. The filters were extremely dirty and impeded the proper air flow as evidences by the doors to the HVAC Air Handlers located through out the facility were blocked open in an attempt to gain greater air flow. This creates a non-compliant return plenum.

The HVAC unit to the Operating Rooms was pulling unfiltered air into the OR Suite, by-passing the filter section, the room housing the air-handler was functioning as a return air plenum..

Based on observation and interview with staff, the facility failed to provide a piped in medical gas system that complies with NFPA 99, Chapter 4. Finding:

The main gas shut off valve located in the fenced bulk tank area was not labeled as "main gas shut off".

Based on observation and interview with staff, the facility failed to provide anesthetizing locations protected in accordance with NFPA 99 and maintained with relative humidity equal to or greater than 35%. The facility failed to provide ventilating systems for anesthetizing locations as required by NFPA 5-4.1.3. Findings:

The OR Rooms humidity controls and humidifier are not functional; thus, the humidity levels cannot be measured and adjusted per NFPA 5-4.1.1..

Based upon observation and interview with staff, the facility failed to provide proper protection of the Operating Rooms ventilation system per 19.3.2.3, NFPA 99. Findings:

There is not an automatic smoke evacuation system for the Operating Rooms as required by NFPA 5-4.1.3..

Based on interview with the electrician, Interim CEO, and review of the Generator Exercise Log provided by the facility, the facility failed to exercise the generator under load for 30 minutes per month in accordance with NFPA 99. Findings:

There was no documentation that the generators are exercised under load monthly.

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

1) Patient rooms other than ICU Rooms did not have emergency power in accordance with NFPA 70 517.18 (A), which states that "each patient bed location shall be supplied by at least two branch circuits, one from the emergency system and one from the normal system."

2) Replacement receptacles were not hospital grade outlets per NFPA 70, 517.18 (D).

3) Replacement outlets have not been tested for impedance in accordance with NFPA 99 1999 edition Chapter 3-3.3.2.1. The hospital electrician has not performed impedance testing in any Patient Care area.

4) Line Isolation Monitors located in the operating rooms have not been tested in accordance with NFPA 99 3-3.3.4.2.

Based on observation and interview with staff, the facility failed to provide corridors separated from use areas by walls constructed to resist the passage of smoke. Findings:

1) The sliding glass window in the reception area does not have latching hardware, resulting in the space behind the window being open to the corridor. NFPA 101, Section 19.3.6.1 Exception No. 1 (c) permits spaces to be open to the corridor provided that "the open space is protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4". .

Based on observation and interview with staff, the facility failed to provide doors with a means suitable for keeping the door closed. Roller latches are prohibited by CMS regulations in all health care facilities. Findings,

(1) Roller latches have been replaced in patient rooms. However doors to other rooms through out the building still have roller latches.

Based on observation and interview with the interim CEO, the facility failed to provide smoke barriers that are constructed to provide at least a one half hour fire resistance rating in accordance with 8.3. Findings:

Smoke walls through out the building have penetrations around piping, duct work, electrical conduit etc. that are not sealed with fire caulking. Penetrations above the cross-corridor doors and the walls that extended across from the corridor to outside walls have not been sealed.

Based on review of the Fire Drill Report form and interview with the Interim CEO, the facility failed to ensure the staff is familiar with procedures and is aware that drills are part of established routine. Findings:

The report form for the drill conducted on 7-6-2011 documented that policy had not been followed. There was no evidence that corrective action had been taken.

Based on interview with the Interim Director of Maintenance and Interim CEO, the facility failed to provide a fire alarm system maintained in accordance with NFPA 72 and to keep records of maintenance readily available. Finding:

The facility could not provide records of the last two years of annual inspections of the fire alarm system.

Based on observation and review of the annual fire suppression test report of the sprinkler system conducted on January 12, 2011, the facility failed to maintain the sprinkler system in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Findings:

The fire suppression system was inspected on January 12, 2011 by MAC Systems, the system was yellow tagged with a list of deficiencies. The Interim Director of Maintenance and Interim CEO stated they were unaware that the system was yellow tagged. There was no evidence the deficiencies had been corrected or were scheduled to be corrected.

Based on observation and interview with Interim CEO, Interim Director of Maintenance, the facility failed to provide heating, ventilating, and air conditioning that comply with the provisions of NFPA 90A; Appendix B, Maintenance, Paragraph B-1 "Owners...should establish a planned maintenance program". Findings:

The HVAC equipment filters were not maintained with proper filters. The filters were extremely dirty and impeded the proper air flow as evidences by the doors to the HVAC Air Handlers located through out the facility were blocked open in an attempt to gain greater air flow. This creates a non-compliant return plenum.

The HVAC unit to the Operating Rooms was pulling unfiltered air into the OR Suite, by-passing the filter section, the room housing the air-handler was functioning as a return air plenum..

Based on observation and interview with staff, the facility failed to provide a piped in medical gas system that complies with NFPA 99, Chapter 4. Finding:

The main gas shut off valve located in the fenced bulk tank area was not labeled as "main gas shut off".

Based on observation and interview with staff, the facility failed to provide anesthetizing locations protected in accordance with NFPA 99 and maintained with relative humidity equal to or greater than 35%. The facility failed to provide ventilating systems for anesthetizing locations as required by NFPA 5-4.1.3. Findings:

The OR Rooms humidity controls and humidifier are not functional; thus, the humidity levels cannot be measured and adjusted per NFPA 5-4.1.1..

Based upon observation and interview with staff, the facility failed to provide proper protection of the Operating Rooms ventilation system per 19.3.2.3, NFPA 99. Findings:

There is not an automatic smoke evacuation system for the Operating Rooms as required by NFPA 5-4.1.3..

Based on interview with the electrician, Interim CEO, and review of the Generator Exercise Log provided by the facility, the facility failed to exercise the generator under load for 30 minutes per month in accordance with NFPA 99. Findings:

There was no documentation that the generators are exercised under load monthly.

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

1) Patient rooms other than ICU Rooms did not have emergency power in accordance with NFPA 70 517.18 (A), which states that "each patient bed location shall be supplied by at least two branch circuits, one from the emergency system and one from the normal system."

2) Replacement receptacles were not hospital grade outlets per NFPA 70, 517.18 (D).

3) Replacement outlets have not been tested for impedance in accordance with NFPA 99 1999 edition Chapter 3-3.3.2.1. The hospital electrician has not performed impedance testing in any Patient Care area.

4) Line Isolation Monitors located in the operating rooms have not been tested in accordance with NFPA 99 3-3.3.4.2.