HospitalInspections.org

Based upon staff interviews and observations made during survey tour, the facility has failed to maintain the construction requirements for the classification of construction. This could potentially allow smoke, heat, and fire to spread from one area to the another and place patients, visitors, and staff at risk of smoke, heat, and fire.

The findings include, but are not limited to:

1. At 11:20am, I observed that the 1st floor ladies restroom by Admit did not have its escutcheon in place.
2. At 1:55pm, I observed that the OR patient changing room in bathroom has escutcheon missing.
3. At 2:21pm, I observed that the West End Nurses store room has ceiling tile missing and escutcheon missing.

Interview with Maintenance Director revealed that a system has not been implemented to check for these items on a regular basis. Maintenance Director had not been made aware of these items by staff or other maintenance staff.

These findings were acknowledged and discussed with the Maintenance Director.

The facility has failed to maintain doors with the required fire rating. This could result in a fire not being contained for the 20 minutes in a fire event, and thus expose other areas of the building to the threat of smoke, heat and fire. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the patients, staff and/or visitors within the smoke compartment.
The findings include, but are not limited to:
Based upon observations and staff interviews during the survey tour on May 12, 2015 between the hours of 8:00am and 5:00pm, I observed that the doors leading into corridors were hindered from automatically closing in the following locations:
1. At 11:05am, I observed that the Admin storage in the basement would not close and latch properly when tested.
2. At 11:46, I observed that the Family Counseling room has door propped open with a wooden wedge.
Interview with Maintenance Director revealed that he was not aware of the conditions of these fire rated doors. A system to check these items periodically has not been implemented.
The above was discussed and acknowledged by the Maintenance Director. .

The facility has failed to maintain doors with the required fire rating. This could result in a fire not being contained for the 20 minutes in a fire event, and thus expose other areas of the building to the threat of smoke, heat and fire. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the patients, staff and/or visitors within the smoke compartment.
The findings include, but are not limited to:
Based upon observations and staff interviews during the survey tour on May 12, 2015 between the hours of 8:00am and 5:00pm, I observed that the doors leading into corridors were hindered from automatically closing in the following locations:
1. At 11:40am, I observed that the dirty utility in ER has had the automatic door closure disabled and will not function to keep the door automatically in the closed position.
Interview with Maintenance Director revealed that he was not aware of the conditions of these fire rated doors. A system to check these items periodically has not been implemented.
The above was discussed and acknowledged by the Maintenance Director. .

The facility has failed to provide the required number of fire drills of one fire drill per quarter per shift. This could allow for staff to not be fully trained and thereby delay emergency response and evacuation of the building.

The findings include, but are not limited to:

Record review of the facility's fire drill records on May 12, 2015 between the hours of 9:00am and 11:00am, revealed the following deficiencies:

1. No record of a night shift drill in 4th quarter of 2014.
2. No record of night shift drill in 1st quarter of 2015.
3. Fire drill documentation revealed that the facility conducted 14 drills during the day shift in the year prior to the date of survey. Only 2 night drills were documented for the entire year prior to the date of survey. Records reveal that a night shift fire drill had not been conducted since September 2014.

Interview with Maintenance Director revealed that this facility has only 2 shifts, night and day. Some of the day shift fire drills were suppose to have been night shift, but that they were just shy of the time cut off to be considered night shift. Interview with Maintenance Director also revealed that there is no double check system in place to ensure that he is reminded of drills or to ensure that drills do not get missed.

This finding was observed and discussed with Maintenance Director.

The facility has failed to conduct testing of the hood and duct fire suppression equipment protecting the commercial cooking equipment in the kitchen. This could result in the failure of the system to operate properly which would endanger the patients, staff and/or visitors within the facility.
The findings include, but are not limited to:
Based upon record review and staff interviews on May 12, 2015 between approximately 9:00am and 11:00am, the facility has failed to provide documentation that the kitchen suppression system has received its 6 month servicing as required. Records indicate that the last time the system was serviced was on 10/09/2014 by Oxarc. The kitchen suppression system should have been serviced in April of 2015.
Interview with the Maintenance Director revealed that he was unaware that the date had been missed. He thought that they were under a contract to automatically get serviced every 6 months. Maintenance Director indicated that there was not a double check system in place to ensure these dates do not get missed.
The above was discussed and acknowledged by the Maintenance Director.

The facility has failed to provide a required emergency stop button for the existing generator in an approved location. This could allow for a problem to exist at the generator and staff must go inside the generator enclosure housing the generator to shut off the generator. Failure to have an emergency shut off switch could potentially create a greater hazard during a power outage and thus expose patients, visitors, and staff to a power outage without generator power coverage.

The findings include but are not limited to:

Observations made during the survey tour on May 12, 2015 at 2:40pm, revealed that emergency shut off button is inside the weatherproof cabinet of the generator.

Interviews with the Maintenance Director revealed that the hospital was not aware that the generators required remote shut-down switches.

This finding was observed and discussed with the Maintenance Director.

Based upon staff interviews, observations and record reviews the facility was unable to verify that the type one essential electrical system (EES) is divided into the critical branch, life safety branch and the emergency system in accordance with NFPA 99.

The findings include but are not limited to:

The facility has failed to ensure that the life safety branch of the the hospital furnished electrical drawings detailing the various branches of the Essential Electrical System (EES). The drawing showed that the EES is not in compliance with the National Fire Protection Association Standard 99 (NFPA 99).

The findings include but are not limited to:

Observations made during document review of the generator branches revealed that the Life Safety Branch (LSB) of the EES has the following circuits that are not permitted on the LSC branch:

> Cable Television Power
> Nurse Call System
> Power for the Steam Boiler and Autoclave
>Security Camera
>Computers for designated Offices
>Electrical and lights for designated Offices

2. The following permitted Circuits were also observed:

> Exit Egress Lighting
> Door hold open devices
> Fire alarm System
> Smoke / Fire Damper power

Interview with the Maintenance Director revealed that the not permitted items were color coded to move to the equipment branch, but had not been done yet. The hospital is aware of the deficiency in the Life Safety Branch and has a waiver in place. I asked the facility Administrator to produce the waiver. The waiver could not be produced at the time of survey.

This finding was observed and discussed with the Maintenance Director and the Administrator.

The facility has failed to ensure that the facility was free of electrical hazards. The facility failed to ensure that when power strips and multi-plug adaptors were used that they were being used correctly. This could allow for an electrical fire to start and thus expose patients, visitors, and staff to the threat of fire.

The findings include, but are not limited to:

Based upon observations and staff interviews on May 12, 2015 between approximately 11:00am and 4:30pm, I observed improper use of power strips in the following locations:

1. At 11:00am, I observed an unapproved adaptor in use in the Administrator's Office/Conference room. This adaptor did not have an over-current feature and did not have a reset button.
2. At 11:05am, I observed that the desk next to Accounts Receivable in the basement has a power strip into an unapproved adaptor.
3. At 11:05am, I observed a white extension cord onto a power strip for stapler and calculator in the Business Office.
4. At 11:06am, I observed that Patient Account Rep has power strip into a power strip.
5. At 11:06am, I observed the Business office to have a refrigerator into a power strip.
6. At 11:15am, I observed a white extension cord for Acct, Rep Desk.
All the above are in the basement.
7. At 11:30am, I observed Respitory Therapy Office to have a white extension cord for battery charger.
8. At 11:30am, I observed Respitory Therapy Office to have an extension cord feeding a power strip.
9. At 11:47am, I observed Doctor's ER office has microwave and refrigerator plugged into a power strip.
10. At 2:33pm, I observed Dr's dictation/Acute Area has beige extension cord for fridge and coffee maker.
11. At 3:05pm, I observed Info Systems to have power strip into power strip.

None of the above items are in patient care areas. All must be corrected. Use of a waiver in these instances are not allowed.

Interview with the Maintenance Director revealed that he was not aware of all these incorrect electrical items. Interview revealed that there is not system in place for periodic checks for these items so that they do not reoccur.

These findings were observed and discussed with the Maintenance Director.

Based upon staff interviews and observations made during survey tour, the facility has failed to maintain the construction requirements for the classification of construction. This could potentially allow smoke, heat, and fire to spread from one area to the another and place patients, visitors, and staff at risk of smoke, heat, and fire.

The findings include, but are not limited to:

1. At 11:20am, I observed that the 1st floor ladies restroom by Admit did not have its escutcheon in place.
2. At 1:55pm, I observed that the OR patient changing room in bathroom has escutcheon missing.
3. At 2:21pm, I observed that the West End Nurses store room has ceiling tile missing and escutcheon missing.

Interview with Maintenance Director revealed that a system has not been implemented to check for these items on a regular basis. Maintenance Director had not been made aware of these items by staff or other maintenance staff.

These findings were acknowledged and discussed with the Maintenance Director.

The facility has failed to maintain doors with the required fire rating. This could result in a fire not being contained for the 20 minutes in a fire event, and thus expose other areas of the building to the threat of smoke, heat and fire. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the patients, staff and/or visitors within the smoke compartment.
The findings include, but are not limited to:
Based upon observations and staff interviews during the survey tour on May 12, 2015 between the hours of 8:00am and 5:00pm, I observed that the doors leading into corridors were hindered from automatically closing in the following locations:
1. At 11:05am, I observed that the Admin storage in the basement would not close and latch properly when tested.
2. At 11:46, I observed that the Family Counseling room has door propped open with a wooden wedge.
Interview with Maintenance Director revealed that he was not aware of the conditions of these fire rated doors. A system to check these items periodically has not been implemented.
The above was discussed and acknowledged by the Maintenance Director. .

The facility has failed to maintain doors with the required fire rating. This could result in a fire not being contained for the 20 minutes in a fire event, and thus expose other areas of the building to the threat of smoke, heat and fire. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the patients, staff and/or visitors within the smoke compartment.
The findings include, but are not limited to:
Based upon observations and staff interviews during the survey tour on May 12, 2015 between the hours of 8:00am and 5:00pm, I observed that the doors leading into corridors were hindered from automatically closing in the following locations:
1. At 11:40am, I observed that the dirty utility in ER has had the automatic door closure disabled and will not function to keep the door automatically in the closed position.
Interview with Maintenance Director revealed that he was not aware of the conditions of these fire rated doors. A system to check these items periodically has not been implemented.
The above was discussed and acknowledged by the Maintenance Director. .

The facility has failed to provide the required number of fire drills of one fire drill per quarter per shift. This could allow for staff to not be fully trained and thereby delay emergency response and evacuation of the building.

The findings include, but are not limited to:

Record review of the facility's fire drill records on May 12, 2015 between the hours of 9:00am and 11:00am, revealed the following deficiencies:

1. No record of a night shift drill in 4th quarter of 2014.
2. No record of night shift drill in 1st quarter of 2015.
3. Fire drill documentation revealed that the facility conducted 14 drills during the day shift in the year prior to the date of survey. Only 2 night drills were documented for the entire year prior to the date of survey. Records reveal that a night shift fire drill had not been conducted since September 2014.

Interview with Maintenance Director revealed that this facility has only 2 shifts, night and day. Some of the day shift fire drills were suppose to have been night shift, but that they were just shy of the time cut off to be considered night shift. Interview with Maintenance Director also revealed that there is no double check system in place to ensure that he is reminded of drills or to ensure that drills do not get missed.

This finding was observed and discussed with Maintenance Director.

The facility has failed to conduct testing of the hood and duct fire suppression equipment protecting the commercial cooking equipment in the kitchen. This could result in the failure of the system to operate properly which would endanger the patients, staff and/or visitors within the facility.
The findings include, but are not limited to:
Based upon record review and staff interviews on May 12, 2015 between approximately 9:00am and 11:00am, the facility has failed to provide documentation that the kitchen suppression system has received its 6 month servicing as required. Records indicate that the last time the system was serviced was on 10/09/2014 by Oxarc. The kitchen suppression system should have been serviced in April of 2015.
Interview with the Maintenance Director revealed that he was unaware that the date had been missed. He thought that they were under a contract to automatically get serviced every 6 months. Maintenance Director indicated that there was not a double check system in place to ensure these dates do not get missed.
The above was discussed and acknowledged by the Maintenance Director.

The facility has failed to provide a required emergency stop button for the existing generator in an approved location. This could allow for a problem to exist at the generator and staff must go inside the generator enclosure housing the generator to shut off the generator. Failure to have an emergency shut off switch could potentially create a greater hazard during a power outage and thus expose patients, visitors, and staff to a power outage without generator power coverage.

The findings include but are not limited to:

Observations made during the survey tour on May 12, 2015 at 2:40pm, revealed that emergency shut off button is inside the weatherproof cabinet of the generator.

Interviews with the Maintenance Director revealed that the hospital was not aware that the generators required remote shut-down switches.

This finding was observed and discussed with the Maintenance Director.

Based upon staff interviews, observations and record reviews the facility was unable to verify that the type one essential electrical system (EES) is divided into the critical branch, life safety branch and the emergency system in accordance with NFPA 99.

The findings include but are not limited to:

The facility has failed to ensure that the life safety branch of the the hospital furnished electrical drawings detailing the various branches of the Essential Electrical System (EES). The drawing showed that the EES is not in compliance with the National Fire Protection Association Standard 99 (NFPA 99).

The findings include but are not limited to:

Observations made during document review of the generator branches revealed that the Life Safety Branch (LSB) of the EES has the following circuits that are not permitted on the LSC branch:

> Cable Television Power
> Nurse Call System
> Power for the Steam Boiler and Autoclave
>Security Camera
>Computers for designated Offices
>Electrical and lights for designated Offices

2. The following permitted Circuits were also observed:

> Exit Egress Lighting
> Door hold open devices
> Fire alarm System
> Smoke / Fire Damper power

Interview with the Maintenance Director revealed that the not permitted items were color coded to move to the equipment branch, but had not been done yet. The hospital is aware of the deficiency in the Life Safety Branch and has a waiver in place. I asked the facility Administrator to produce the waiver. The waiver could not be produced at the time of survey.

This finding was observed and discussed with the Maintenance Director and the Administrator.

The facility has failed to ensure that the facility was free of electrical hazards. The facility failed to ensure that when power strips and multi-plug adaptors were used that they were being used correctly. This could allow for an electrical fire to start and thus expose patients, visitors, and staff to the threat of fire.

The findings include, but are not limited to:

Based upon observations and staff interviews on May 12, 2015 between approximately 11:00am and 4:30pm, I observed improper use of power strips in the following locations:

1. At 11:00am, I observed an unapproved adaptor in use in the Administrator's Office/Conference room. This adaptor did not have an over-current feature and did not have a reset button.
2. At 11:05am, I observed that the desk next to Accounts Receivable in the basement has a power strip into an unapproved adaptor.
3. At 11:05am, I observed a white extension cord onto a power strip for stapler and calculator in the Business Office.
4. At 11:06am, I observed that Patient Account Rep has power strip into a power strip.
5. At 11:06am, I observed the Business office to have a refrigerator into a power strip.
6. At 11:15am, I observed a white extension cord for Acct, Rep Desk.
All the above are in the basement.
7. At 11:30am, I observed Respitory Therapy Office to have a white extension cord for battery charger.
8. At 11:30am, I observed Respitory Therapy Office to have an extension cord feeding a power strip.
9. At 11:47am, I observed Doctor's ER office has microwave and refrigerator plugged into a power strip.
10. At 2:33pm, I observed Dr's dictation/Acute Area has beige extension cord for fridge and coffee maker.
11. At 3:05pm, I observed Info Systems to have power strip into power strip.

None of the above items are in patient care areas. All must be corrected. Use of a waiver in these instances are not allowed.

Interview with the Maintenance Director revealed that he was not aware of all these incorrect electrical items. Interview revealed that there is not system in place for periodic checks for these items so that they do not reoccur.

These findings were observed and discussed with the Maintenance Director.