HospitalInspections.org

Based on record review and interview staff it was determined the facility failed to provide documentation of a local fire inspection. An annual local fire inspection ensures the building remains within the building codes and fire safety codes. Failure to have an annual fire inspection could bring harm to patients and staff during an emergency.

CMS State Operations Manuel Appendix A- Interpretive Guidelines §482.11 The hospital must ensure that all applicable Federal, State and local law requirements are met.. The facility and its staff must operate and furnish services in compliance with applicable Federal, State, and local laws and regulations pertaining to licensure and any other relevant health and safety requirements. NFPA 101 2012 Life Safety Code Section 4.6.12. Maintenance, Inspection, and Testing. 4.6.12 Maintenance, inspection and testing shall be performed under supervision of a responsible person who shall ensure that testing, inspection, and maintenance are made at specified intervals in accordance with applicable NFPA standards or as directed by the authority having jurisdiction.

485.625 42 CFR Ch. IV (10-1-16 Edition) adversely affect the health and safety of patients.
(4) The CAH maintains written evidence of regular inspection and approval by State or local fire control
agencies.

Findings include:

Records review on Sep 22, 2021 revealed the facility failed to provide required documentation of an annual local fire inspection since before 2015.

Employee # 1, #3 and #4 confirmed during the exit conference that the facility failed to provide required documentation of an annual local fire inspection.

Based on observation and staff interview, it was determined the facility failed to maintain doors to be self or automatic closing due to door wedges or the door door failed fully close and latch. Failing to keep self-closing or automatic closing doors closed will allow smoke and heat, during a fire, to spread throughout the facility, which has potential to harm patients.

NFPA 101 Life Safety Code, 2012, Chapter 21 Existing, Section 21.3.2 1 "Doors to hazardous areas shall be self-closing or automatic closing in accordance with 21.2.2.4." Section 21.2.2.4 "Any door required to be self-closing shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2." Section 7.2.1.8.2 "The required manual fire alarm system and the systems required by 7.2.1.8.2. shall be arranged to initiate the closing action of all such doors throughout the entire facility." Section 7.2.1.8 "Self-Closing Devices." Section 7.2.1.8.1* "A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic closing in accordance with 7.2.1.8.2."

"Protection from Hazards" Chapter 39 Section 39.2.2.2 "Doors" Section 39.2.2.2.1 "Doors complying with 7.2.1 shall be permitted." Chapter 39, Section 39.3.2.1, General "Hazardous areas including, but not limited to, areas used for general storage... shall be protected in accordance with Section 8.7." Chapter 8, Section 8.7.1.3 "Doors in barriers required to have a fire resistance rating shall have a minimum 3/4-hour fire protecting rating and shall be self or automatic closing in accordance with 7.2.1.8." Section 7.2.1.8.1 "A door leaf normally required to be kept closed shall not be secured in the open position at any time and shall be self or automatic closing in accordance with 7.2.1.8.2."

Observations while on tour September 20-23 2021, revealed the fire door separating the hospital and the administrative section was not able to latch during testing. In addition the following doors propped open;
1. Two doors held open with equipment in endoscopy
2. One door held open with a door wedge in the X-Ray area
3. One door held open by dropped down door wedge in the ER area

Employee # 1, #3 and #4 confirmed during the exit conference that the facility had doors that were not closing as designed.

Based on observation it was determined the facility failed to protect the entire facility with an automatic sprinkler system. This would result in the sprinkler system not being able to extinguish the fire and could result in injury or death to the building occupants.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.1, "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Chapter 9, Section 9.7.1.1, " Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems." NFPA 13, Chapter 8 Obstructions to Sprinkler Discharge Pattern Development. Section 8.6.5.2.1.1 Continuous or noncontiguous obstructions less than or equal to 18 in. below the sprinkler deflector that prevent the pattern from fully developing shall comply with 8.6.5.2.

NFPA 13: Standard for the Installation of Sprinkler Systems, 2010 Edition - Chapter 4 General Requirements 4.1 Level of Protection.
A building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas except where specific sections of this standard permit the omission of sprinklers. 4.2 Limited Area Systems. 4.2.1 When partial sprinkler systems are installed, the requirements of this standard shall be used insofar as they are applicable. 4.2.2 The authority having jurisdiction shall be consulted in each case.

NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition. Chapter 8
8.15.7 * Exterior Roofs, Canopies, Porte-Cocheres, Balconies, Decks, or Similar Projections.
8.15.7.1 Unless the requirements of 8.15.7.2, 8.15.7.3, or 8.15.7.4 are met, sprinklers shall be installed under exterior roofs, canopies, porte-cocheres, balconies, decks, or similar projections exceeding 4 ft (1.2 m) in width.

8.15.7.2 * Sprinklers shall be permitted to be omitted where the canopies, roofs, porte-cocheres, balconies, decks, or similar projections are constructed with materials that are noncombustible, limited-combustible, or fire retardant-treated wood as defined in NFPA 703, Standard for Fire Retardant-Treated Wood and Fire-Retardant Coatings for Building Materials.


Findings include:

During a facility tour conducted on September 20-23, 2021 revealed the facility was not protected by the sprinkler system under the over hang on the back of the hospital. The sprinkler system was not installed during initial construction since the over hang was constructed with non combustible materials that have degraded over time. This over hang has holes in the material allowing the over grown vegetation to grow into the overhang area. The issue is the lack of sprinklers or lack of non-combustible materials at this point.

Employees # 1, #3 and #4 confirmed during the exit conference on September 23, 2021 rear canopy was not protected by the sprinkler system or non-combustible materials.

Based on observation it was determined that the facility failed to keep the sprinkler heads clean. Failing to maintain the sprinkler heads which are part of the entire sprinkler assembly could cause harm to the residents by allowing a fire to spread before the temperature is reached to set off the sprinkler head.

NFPA 101 Life Safety Code, 2012 edition, Chapter 19, Section 19.3.5.3
Where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. Chapter 9, Section 9.7.1 "Each automatic sprinkler system required by another section of this Code shall be in accordance with on of the following." " NFPA 13, Standard for the Installation of Sprinkler Systems." Chapter 26, Section 26.1 "General." "A sprinkler system installed in accordance with standard shall be properly inspected, tested, and maintained by the property owner or their authorized representative in accordance with NFPA 25. NFPA 25, Section 5.2.1 "Sprinklers, Section 5.2.1.1.1 "Sprinklers shall not show signs of leakage, shall be free of corrosion, foreign materials, paint and physical damage." Section 5.2.1.1.2 Any sprinkler that shows the signs of any of the following shall be replaced. 1. leakage
2. Corrosion 3. Physical damage 4. Loss of fluid in the glass bulb heat responsive element
5. * Loading See A.5.2.1.1.2 (5) In lieu of replacing sprinklers that are loaded with a coating of dust , it is permitted to clean sprinklers with compressed air or by a vacuum provided that the equipment does not touch the sprinkler. 6. Painting unless painted by the manufacturer. Section 5.2.1.1.4 Any sprinkler shall be replaced that has signs of leakage, is painted other than by the manufacturer, corroded, damaged, or loaded, is in the improper orientation. Annex E Examples of Classification of needed repairs Sprinklers and Escutcheon plates that are missing, painted or rusted.

Findings Include:

Observations while on tour September 21, 2021 revealed that six (6) out of six (6) heads were dirty in the kitchen area.

During the exit conference on September 23, 2021 employee #1 and #3 and #4 confirmed that the sprinkler heads were dirty in the kitchen area.

Based on observation it was determined the the facility failed to prevent a fire extinguishers from being blocked and readily accessible in areas of the facility. Failing to have clear access to a fire extinguisher during an emergency could result in harm to the patients and/or staff.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.12 "Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1" Section 9.7.4.1 "Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for portable Fire Extinguishers." NFPA 10, Chapter 7, Section 7.2.2 Periodic inspections or electronic monitoring of fire extinguishers shall include a check of at least the following items: No obstruction to access or visibility.

Findings include:

During a facility tour conducted on September 21-22 ,2021 three (3) portable fire extinguishers were obstructed that were located in the following areas;
1. In the med surg hallway that were blocked by wheel chairs
2. In the riser room there were stacked boxes blocking access to the extinguisher.
3. The exit hallway between the kitchen and laundry had cleaning equipment in from of the extinguisher.

Employee #1, #3 and #4 confirmed during the exit conference that the extinguishers were obstructed.

Based on observation, interview and record review it was determined the facility failed to inspect and maintain the facilities fire /smoke dampers or fusible links. Failing to inspect and maintain the facility smoke dampers may cause harm to the patients and staff.

NFPA 101 Life Safety Code, 2012 Edition Chapter 19, Section 19.5.2, "Heating Ventilating and Air Conditioning." Section 19.5.2.1 "Heating, ventilating and air conditioning shall comply with the provisions of section 9.2 and shall be installed in accordance with the manufacture's specifications" Section 9.2.1 " Air Conditioning, Heating, Ventilating, Ductwork, and Related Equipment." Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90 A." "Standard for Installation of Air Conditioning and Ventilating Systems, NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protective's.

NFPA 90 A 2012 Edition Section 5.4.8 Maintenance Section 5.4.8.1 Fire dampers and ceiling dampers shall be maintained in accordance with NFPA 80 Standard for Fire Doors and Other opening Protective's. Section 5.4.8.2 Smoke dampers shall be maintained in accordance with NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protective's.

NFPA 80 Standard for Fire Doors and Other opening Protective's Chapter 19 Installation, Testing, and Maintenance of Fire Dampers, Section 19.4* Periodic Inspection and Testing The test and inspection frequency shall be every 4 years, except in hospitals, where the frequency shall be every six years.

Section 19.4.4 if the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in place if so equipped. Section 19.4.5 The operational test of the fire damper shall verify that there is no damper interference due to rusted, bent, misaligned, or damaged frame or blades, or defective hinges or other moving parts. Section 19.4.6 The damper frame shall not b penetrated by any foreign objects that would effect fire damper operations. Section 19.4.7 The fusible link shall be reinstalled after testing is complete. Section 19.4.8.1 if the link is damaged or painted, it shall be replaced with a link of the same size, temperature and rating. Section 19.4.9 All inspections and testing shall be documented, indicating the location of the fire damper or combination fire/smoke damper, date of inspection, name of inspector, and deficiencies discovered. Section 19.4.9.1 The documentation shall have a space to indicate when and how the deficiencies were corrected. Section 19.4.11 Periodic inspections and testing of a combination fire/smoke damper shall also meet the inspection and testing requirements contained in Chapter 6 of NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protective's.

NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protective's Chapter 6 Installation, Testing and Maintenance smoke dampers. Section 6.5.2 Each damper shall be tested and inspected one year after installation. The test and inspection frequency shall then be every 4 years, except hospitals, where the frequency shall be every 6 years.

Section 6.5 Periodic Inspection and Testing. Section 6.5.11 All inspections and testing shall be documented, indicating the location of the fire damper or combination fire/smoke damper, date of inspection, name of inspector, and deficiencies discovered. Section 19.4.9.1 The documentation shall have a space to indicate when and how the deficiencies were corrected. Section 6.5.11

Section 6.6 Maintenance.

Section 6.6.1 Any reports of abrupt changes in airflow or noise from the duct system shall be investigated to verify that it is not related to damper operation. Section 6.6.2* All exposed moving parts of the damper shall be dry lubricated as required by the manufacturer. Section 6.6.3 if the damper is not operable, repairs shall begin as soon a s possible. Section 6.6.4 Following any repairs, the damper shall be tested for proper operation in accordance with Section 6.6.5 Smoke damper actuation shall be initiated at a time interval recommended by the actuator manufacturer. Section 6.6.6 All maintenance shall be maintained and records shall be retained in accordance with 6..5.11 and 6.5.12.

Findings Include:

During review of the facility documentation conducted on September 20-22, 2021 revealed the facility had fire or smoke dampers, they were not aware that the building needed to fire or smoke dampers tested. No documentation was found the document review indicating that the smoke dampers were inspected in the past six years.

Employee #1, #3 and #4 acknowledged during the exit conference conducted that the facility failed to test the HVAC dampers every six years.

Based on observation the facility failed to protect staff and patients from live electrical energy. Failing to protect personnel from energized electrical energy can result in death or serious injury from contact with electricity.

NFPA 101: Life Safety Code, 2012 Edition Chapter 9 Building Service and Fire Protection Equipment
9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NEC 70: National Electrical Code, 2011 Edition Chapter 1 General
110.27 Guarding of Live Parts.
110.27(A) Live Parts Guarded Against Accidental Contact.
Except as elsewhere required or permitted by this Code, live parts of electrical equipment operating at 50 volts or more shall be guarded against accidental contact by approved enclosures or by any of the following means:
(1) By location in a room, vault, or similar enclosure that is accessible only to qualified persons.
(2) By suitable permanent, substantial partitions or screens arranged so that only qualified persons have access to the space within reach of the live parts. Any openings in such partitions or screens shall be sized and located so that persons are not likely to come into accidental contact with the live parts or to bring conducting objects into contact with them.
(3) By location on a suitable balcony, gallery, or platform elevated and arranged so as to exclude unqualified persons.
(4) By elevation of 2.5 m (8 ft) or more above the floor or other working surface.

Observations while on tour September 20-22 2021, revealed the facility has about 70% of the electrical breakers panels were the door cover latch is missing or broken.

Employee # 1, #3 and #4 confirmed during the exit conference that the facility was missing latches on most of the electrical panels throughout the facility.

Based on Observation it was determined the facility allowed the use of a multiple outlet adapters, power strips and extension cords and did not use the wall outlet receptacles for appliances. Failure to properly use power cords and outlets could lead to electrical overload or fire which could cause harm to the patients and staff.

NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2 , "All Patient Care Areas," Sections 6.3.2.2..6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings include:

Observations while on tour September 22-23, 2020 revealed the following locations with power strips plugged into power strips (Daisy Chained). Heavy load drawing appliance (refrigerators, microwaves and large printers) plugged into power strips. In addition almost all power strips were hanging by the wires and not mounted.
1. The a power strip in the IT managers office were hanging.
2. The Lab break room had a refrigerator plugged into a power strip.
3. The Med surg office had a refrigerator plugged into a power strip.
4. The laundry room surge protection was hanging
Many other locations not documented.

A policy named Use of Power Strips was provided and stated " All location; Refrigerators and microwaves are not allowed to be plugged into power strips. Absolutely no exceptions theses devices."

Employee #1, #3 and #4 confirmed during the exit conference that the facility had many examples of the improper use of power strips

Based on observation and staff interview the facility failed to provide a record of electrical equipment tests, repairs, and modifications. Failing to conduct maintenance on patient care appliances could cause harm to the resident if the appliance malfunctions.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 10, Section 10.5.6 Record Keeping-Patient Appliances Electrical Equipment - Testing and Maintenance Requirements
"The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training."

Findings include:

Observation, record review and staff interview on September 20-23, 2021, revealed the facility had multiple pieces of equipment that displayed expiration dates for preventative maintaince that were expired. The electrical equipment were located through out the hospital most of these were located in the file rooms. One example was the the otoscope and ophthalmoscope in the emergency room.

A Policy was requested but not provided

Employee #1, #3 and #4 acknowledged during the exit conference that the facility failed to PM testing on all electrical equipment in the facility.

Based on Observation the facility failed to secure two medical gas Nitrous Oxide cylinders in a stand or cart. Failing to secure compressed medical gas cylinders could cause harm to the patients and staff.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 11 Section 11.6.2.3 (11) Free standing cylinders shall be properly chained or supported in a proper cylinder stand or cart."

Findings include:

Observations while on tour September 20-22, 2021 revealed six (6) unsecured Oxygen cylinders and 1 helium cylinders in the Medical Gas storage room and two (2) portable E cylinders in the Endoscopy area.

Employee #1, #3 and #4 confirmed during the exit conference the awareness of the unsecured oxygen tanks in the endoscopy area and the outside O2 medical gas room.