HospitalInspections.org

Based on documentation review and interview, the facility failed to provide a mathematical formula to verify if the generator was run at 30 percent and did conduct a load bank test. This deficient practice would increase the probability that the generator would fail to run during an emergency loss of power and the emergency systems in the facility. The facility has the capacity for 25 beds with a census of 18 on the day of survey.

Findings are:
Documentation review on 3-21-24 at 12:08 pm revealed, the facility did not conduct an annual load bank for the generator. The facility failed to provide a mathematical formula to determine the required information for the 30 percent requirement for the generator.

During an interview on 3-21-24 at 12:08 pm, Staff A confirmed the findings.

Based on observation and interview, the facility failed to provide egress illumination that would provide illumination along the paths of egress. The lack of egress illumination along the path to safety would cause confusion and delay egress from the facility during an emergency. The facility has the capacity for 25 beds with a census of 18 on the day of survey.

Findings are:
Observation on 3-21-24 at 11:15 am revealed, the sidewalk from the new cafeteria addition failed to provide lighting to a public way.

During an interview on 3-21-24 at 11:15 am, Staff A confirmed the lack of egress lighting along the egress path.

NFPA Standard:
NFPA 101, 2012, 7.8.1.1*
Illumination of means of egress shall be provided in accordance with Section 7.8 for every building and structure where required in Chapters 11 through 43. For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, aisles, corridors, ramps, escalators, walkways, and exit passageways leading to a public way.

Based on observation and interview, the facility failed to assure that hazardous areas were separated from the rest of the building. These deficient practices would not assure that fire smoke and gasses would remain within the hazardous area and not spread. The facility has the capacity for 25 beds with a census of 18 on the day of survey.

Findings are:
Observation on 3-21-24 between 12:08 pm and 2:12 pm revealed:
1. Vinyl base cove was used as a fire rated sweep to cover the large undercut on the 1 ½ hour rated door in the maintenance area leading into the unsprinkled crawl space.
2. The wall between the laundry linen storage and the maintenance shop failed to provide 1 hour fire rating. The wall consisted of glass and wood.
3. The OR supply room in Materials Management failed to provide a self-closing device on the door.
4. Accounting storage room in the Therapy Services area was over 50 square feet and the door failed to provide a self-closing device.

During an interview on 3-21-24 between 12:08 pm and 2:12 pm, Staff A confirmed the observations.

Based on observation, documentation review and interview, the facility failed to assure that heat detectors were maintained and failed to assure that an audible and visual device was provided in sleeping areas. This deficient practice would not notify occupants in the areas of an emergency and that the heat detectors were operational. The facility has the capacity for 25 beds with a census of 18 on the day of survey.

Findings are:
Observation on 3-21-24 at 1:28 pm and 1:40 pm revealed:
1. The "Future MRI room" was used as a sleeping room and no audible visual device was provided.
2. No documentation of testing of the heat detector in the Assisted Living linen, housekeeping and electrical rooms.

During an interview on 3-21-24 at 1:28 pm and 1:40 pm, Staff A confirmed the findings.

Documentation review on 3-21-24 at 11:16 am revealed that no heat detectors had been tested.

During an interview on 3-21-24 at 11:16 am, Staff A stated that all smoke detectors were removed.

Based on record review and interview, the facility failed to provide a complete policy regarding the procedures to be taken in the event the fire sprinkler system was out of service for more than 10 hours in any 24-hour period. The lack of a complete written policy and procedure would result in staff failing to implement interim safety measures in the event of an emergency. The facility has the capacity for 25 beds with a census of 18 on the day of survey.

Findings are:
Record review on 3-21-24 at 11:12 am of the fire watch procedures revealed:
1. The policy lacked the required persons to contact including insurance carrier, the alarm company, property owner or designated representative, and supervisors.

During an interview on 3-21-24 at 11:12 am, Staff A confirmed the lack of information in the fire watch policy.

NFPA Standard:
2011, NFPA 25 15.5*
Preplanned Impairment Programs. 15.5.1
All preplanned impairments shall be authorized by the impairment coordinator. 15.5.2
Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented:
(1) The extent and expected duration of the impairment have been determined.
(2) The areas or buildings involved have been inspected and the increased risks determined.
(3) Recommendations have been submitted to management or the property owner or designated representative.
(4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following:
(a) Evacuation of the building or portion of the building affected by the system out of service
(b)*An approved fire watch
(c)*Establishment of a temporary water supply
(d)*Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire
(5) The fire department has been notified.
(6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified.
(7) The supervisors in the areas to be affected have been notified.
(8) A tag impairment system has been implemented. (See Section 15.3.)
(9) All necessary tools and materials have been assembled on the impairment site.
15.6 Emergency Impairments.
15.6.1 Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure.
15.6.2 When emergency impairments occur, emergency action shall be taken to minimize potential injury and damage.
15.6.3 The coordinator shall implement the steps outlined in Section 15.5.

Based on observation and interview, the facility failed to ensure corridor doors would resist the passage of smoke. This deficient practice would not prevent the spread of fire, smoke and gasses within the exit corridors. The facility has the capacity for 25 beds with a census of 18 on the day of survey.

Findings are:
Observation on 3-21-24 at 1:34 pm revealed, Trauma Room 1 sliding door failed to latch within the doorframe.

During an interview on 3-21-24 at 1:34 pm, Staff A confirmed the door failed to latch within the frame and stated that the area was not a suite.

Based on interview and record review, the facility failed to provide a complete fire plan. This deficient practice would delay evacuation and affected all smoke compartments and all occupants. The facility has the capacity for 25 beds with a census of 18 on the day of survey.

Findings are:
Record review on 3-21-24 at 11:35 am revealed, the fire evacuation plan failed to include:
1. Removal of occupants in the immediate are of fire, those adjacent and across the hall and above or
below the fire.
2. Smoke compartment evacuation.
3. Evacuation policy failed to detail that the room of fire origin shall not be crossed, before continuing
to evacuate the remainder of the smoke compartment.
4. That items in the corridor shall be removed.
5. Staff required to call fire department/911.

During an interview on 3-21-24 at 11:35 am, Staff A confirmed the lack of the of information in the fire plan.

NFPA Standard:
NFPA 101, 2012, 19.7.2.2
Fire Safety Plan. A written health care occupancy fire
safety plan shall provide for all of the following:
(1) Use of alarms
(2) Transmission of alarms to fire department
(3) Emergency phone call to 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

18.7.2.3.1
All health care occupancy personnel shall be instructed in the use of and response to fire alarms.

18.7.2.3.2
All health care occupancy personnel shall be instructed in the use of the code phrase to ensure transmission of an alarm under any of the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system

18.7.2.3.3
Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.

Based on documentation review and interview, the facility failed to conduct fire drills at random times
and failed to activate the fire alarm 24 hours before or after the 3rd shift drills. This deficient practice failed to provide simulated training for staff to respond to a fire emergency during various activities and staffing levels. The facility has the capacity for 25 beds with a census of 18 on the day of survey.

Findings are:
Documentation review on 3-21-24 at 11:03 am revealed:
1. Numerous drills failed to be conducted more than 1 hour apart.
2. Fire alarm was not activated during 3rd shift, 24 hours before or after the drill was conducted.

During an interview on 3-21-24 at 11:03 am, Staff A confirmed the findings.

Based on documentation review and interview, the facility failed to provide a mathematical formula to verify if the generator was run at 30 percent and did conduct a load bank test. This deficient practice would increase the probability that the generator would fail to run during an emergency loss of power and the emergency systems in the facility. The facility has the capacity for 25 beds with a census of 18 on the day of survey.

Findings are:
Documentation review on 3-21-24 at 12:08 pm revealed, the facility did not conduct an annual load bank for the generator. The facility failed to provide a mathematical formula to determine the required information for the 30 percent requirement for the generator.

During an interview on 3-21-24 at 12:08 pm, Staff A confirmed the findings.

Based on observation and interview, the facility failed to prohibit the use of extension cords as a substitute for adequate wiring. This deficient practice would create an increased fire hazard. The facility has the capacity for 25 beds with a census of 18 on the day of survey.

Findings are:
Observation on 3-21-24 at 1:52 pm revealed, a refrigerator plugged into a power-strip in Respiratory Therapy office.

During an interview on 3-21-24 at 1:52 pm, Staff A confirmed the findings.

Based on observation and interview, the facility failed to assure that excessive oxygen was not stored within a resident sleeping room. This deficient practice would allow the escape of oxygen which would cause an oxygen enriched atmosphere and increase the potential for a fire. The facility has the capacity for 25 beds with a census of 18 on the day of survey.

Findings are:
Observation on 3-21-24 at 1:21 pm revealed:
1. Resident in room 27 using an oxygen concentrator and nine additional oxygen cylinders in the room.

During an interview on 3-21-24 at 1:21 pm, Staff A confirmed excessive oxygen within the resident room.