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Based on document review and interview, the facility failed to maintain emergency preparedness policies and procedures for providing subsistence needs. This was evidenced by the absence of a policy and procedure for waste disposal. This affected all patients and could result in unsafe conditions due to waste in the event of an emergency.

Findings:

During document review and interview with staff on 3/2/20, the emergency preparedness policies and procedures were requested.

At 1:05 p.m., there were no documents indicating how the facility would manage waste disposal during a disaster. Upon interview, Staff 1 and Staff 5 confirmed the finding and stated that they only had a policy for sewage disposal during an emergency situation.

Based on document review and interview, the facility failed to provide policies and procedures to provide care and treatment at an alternate site. This was evidenced by the absence of a policy and procedure indicating the facility's role in providing treatment and care under an 1135 waiver at an alternate care site in the event of an emergency. This affected all patients and could result in the facility being inadequately prepared to provide care at an alternate location.

Findings:

During document review and interview with staff on 3/2/20, the emergency preparedness policies and procedures were requested.

At 1:19 p.m., there was no policy and procedure provided outlining the facility's plan in providing care and treatment at an alternate location under an 1135 waiver, in the event of an emergency. Upon interview, Staff 1 and Staff 5 confirmed the finding and stated that they would be creating a policy.

Based on document review, observation, and interview, the facility failed to maintain the fire alarm system. This was evidenced by the absence of an annual charger test, and an annual 30 minute discharge, and two of two semi-annual load voltage test for four of four lead-acid back-up batteries on the fire alarm control unit (FACU). This affected four of four smoke compartments and a basement and could result in system impairment during an emergency situation.

NFPA 101, Life Safety Code, 2012 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with section 9.6
9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition
14.4.5* Testing Frequency. Unless otherwise permitted by other sections of this Code, testing shall be performed in accordance with the schedules in Table 14.4.5, or more often if required by the authority having jurisdiction.
Table 14.4.5 Testing Frequencies.

6. Batteries - fire alarm systems
(d) Sealed lead-acid type
(1) Charger test: Initial/Reacceptance and Annually
(2) Discharge test (30 minutes): Initial/Reacceptance and Annually
(3) Load voltage test: Initial/Reacceptance and Semiannually

Findings:

During document review, observation, and interview with staff on 3/2/20, the FACU back-up batteries were observed and records were requested.

At 9:00 a.m., the FACU was observed with four lead-acid back-up batteries that were marked with the installation date of 2/18/18.

At 9:43 a.m., there were no documents provided indicating the batteries had an annual charger test, an annual 30 minutes discharge test, and two semi-annual load voltage tests completed in the past 12 months. Upon interview, the Staff 5 confirmed the finding and stated that they were not aware of this requirement.

Based on document review and interview, the facility failed to maintain the smoke detection devices. This was evidenced by 46 of 46 system smoke detectors that were not tested for smoke sensitivity. This affected four of four smoke compartments and a basement and could result in the malfunction of the smoke detector in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.2.10.1.1 Where required by another section of this Code, single-station and multiple-station smoke alarms shall be in accordance with NFPA 72, National Fire Alarm and Signaling Code, unless otherwise provided in 9.6.2.10.1.2, 9.6.2.10.1.3, or 9.6.2.10.1.4.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition.
29.10 Maintenance and Tests. Fire-warning equipment shall be maintained and tested in accordance with the manufacturer ' s published instructions and per the requirements of Chapter 14.

14.4.5.3* In other than one- and two-family dwellings, sensitivity of smoke detectors and single- and multiple-station smoke alarms shall be tested in accordance with 14.4.5.3.1 through 14.4.5.3.7.
14.4.5.3.1 Sensitivity shall be checked within 1 year after installation.
14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3.
14.4.5.3.3 After the second required calibration test, if sensitivity tests indicate that the device has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years.
14.4.5.3.3.1 If the frequency is extended, records of nuisance alarms and subsequent trends of these alarms shall be maintained.
14.4.5.3.3.2 In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
14.4.5.3.4 To ensure that each smoke detector or smoke alarm is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/fire alarm control unit arrangement whereby the detector causes a signal at the fire alarm control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction

Findings:

During document review and interview with staff on 3/2/20, the smoke detection device records were requested.

At 9:45 a.m., records provided indicated the last smoke sensitivity test completed for 46 of 46 system smoke detectors were on 12/21/17. There were no records provided indicating the smoke sensitivity testing had been completed in the past 24 months. There were also no records provided for nuisance alarms and subsequent trends of the system smoke alarms. Upon interview, Staff 5 acknowledged confirmed the finding.

Based on document review and interview, the facility failed to maintain the automatic sprinkler system and its components. This was evidenced by the absence of seven of twelve monthly inspections. This affected four of four smoke compartments and a basement and could result in the malfunction of the automatic sprinkler system in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.5.1 Buildings containing nursing homes 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.

9.7 Automatic Sprinklers and Other Extinguishing Equipment
9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by the Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition.
4.3 Records
4.3.1* Records shall be made inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request.

5.2.4 Gauges
5.2.4.1* Gauges on a wet pipe sprinkler shall be inspected monthly to ensure that they are in good condition and the normal water supply pressure is being maintained.
13.3.2.1.1 Valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly.
13.3.2.2* The valve inspection shall verify that the valves are in the following condition:
(1) In the normal open or closed position
(2)*Sealed, locked, or supervised
(3) Accessible
(4) Provided with correct wrenches
(5) Free from external leaks
(6) Provided with applicable identification

13.4.1.1* Alarm valves and system riser check valves shall be externally inspected monthly and shall verify the following:
(1) The gauges indicate normal supply water pressure is being maintained.
(2) The valve is free of physical damage.
(3) All valves are in the appropriate open or closed position.
(4) The retarding chamber or alarm drains are not leaking.

13.6.1.1.1 Valves secured with locks or electrically supervised in accordance with applicable NFPA standards shall be inspected monthly.

Findings:

During document review and interview with staff on 3/2/20, the automatic sprinkler system records were requested.

At 10:33 a.m., records provided indicated the monthly visual inspections for the alarm and system riser check valves and pressure gauge for the following months were not completed: February, April, May, July, August, October, and November of 2019. Upon interview, Staff 5 confirmed the finding.

Based on document review and interview, the facility failed to maintain the sprinkler system out of service policy. This was evidenced by the absence of fire watch policy in the event the sprinkler system was impaired. This affected four of four smoke compartments and a basement and could result in delayed emergency assistance in the event of a fire during sprinkler system disruption.

Findings:

During document review and interview with staff on 3/2/20, the fire watch policy was requested.

At 10:28 a.m., the fire watch policy provided included a plan in the event the fire alarm system was impaired. There was no fire watch policy provided that include a plan in the event the sprinkler system was impaired. Upon interview, Staff 1 and Staff 5 acknowledged and confirmed the finding.

Based on observation and interview, the facility failed to maintain the portable fire extinguishers. This was evidenced by one extinguisher that was installed over 5 feet above the floor level. This affected one of four smoke compartments and could result in the inability to obtain the extinguisher in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.5.12 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.

9.7.4 Manual Extinguishing Equipment.
9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 2010 Edition.
6.1.3.8 Installation Height.
6.1.3.8.1 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor.

Findings:

During a tour of the facility and interview with staff on 3/2/20, the the portable fire extinguishers were observed.

At 1:32 p.m., the ABC type portable fire extinguisher located in the North Roof Access/Storage Room was observed. The extinguisher was mounted with the handle at approximately 69 inches from the floor. Upon interview, Staff 5 acknowledged and confirmed the finding.

Based on document review and interview, the facility failed to maintain the fire drills. This was evidenced by incomplete fire drills. This affected four of four smoke compartments and a basement and could result in staff being unprepared in the event of a fire.

Findings:

During document review and interview with staff on 3/2/20, the quarterly fire drill records were requested.

At 9:30 a.m., the AM shift quarterly fire drills were reviewed. The AM shift fire drills completed for the third and the forth quarter of 2019 did not provide the time the fire drills were completed. Upon interview, Staff 5 acknowledged and confirmed the finding.

Based on document review and interview, the facility failed to maintain the medical gas and vacuum piped system. This was evidenced by discrepancy that was found noted and was not corrected. This affected four of four smoke compartment and a basement and could result in an increase risk of fire.

Findings:

During document review and interview with staff on 3/2/20, the gas and vacuum piped system records were requested.

At 9:59 a.m., 34 pages of medical gas and vacuum testing report dated 10/11/18 was reviewed. Page 1-4 of the document titled, "Performance Improvement Plan" indicated the following deficiency was found during the inspection/test and were not corrected: "Replace defective nitrogen control panel is OR 2, cannot adjust pressure."

Upon interview, Staff 5 confirmed the finding and stated that they were working on getting the repaired complete.

Based on document review, observation, and interview, the facility failed to maintain the emergency power system. This was evidenced by the absence of an annual fuel quality test and of 12 of 12 monthly conductance tests for two of two sealed lead acid batteries at the 125 kilowatt (KW) diesel fueled generator. This affected four of four smoke compartments and a basement and could result in the failure of the generator in the event of a power outage.

NFPA 99, Health Care Facilities Code, 2012 Edition.
6.4.4.1.1.3 Maintenance shall be preformed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 8.

NFPA 110, Standard for Emergency and Standby Power Systems, 2010 Edition.
8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted.

8.3.8 A fuel quality test shall be performed at least annually using tests approved by ASTM standards.

Findings:

During document review, a tour of the facility, and and interview with staff on 3/2/20, the records for the 125 KW diesel generator were requested.

The 125 KW diesel fueled generator was observed in an enclosed room. The generator was equipped with two sealed lead acid batteries.

1. At 10:13 a.m., records provided indicated the last annual fuel quality test was completed on 7/15/17. There were no records provided indicating a fuel quality test had been completed in the past 12 months. Upon interview, Staff 5 acknowledged and confirmed the finding.

2. At 10:16 a.m., there were no records provided indicating the two sealed lead-acid batteries on the generator were tested for conductance on a monthly basis. Upon interview, Staff 5 confirmed the finding and stated that they were not aware of this requirement.

Based on document review and interview, the facility failed to maintain medical gas safety. This was evidenced by the absence of a continuing education program for risks associated with handling and use of medical gases. This affected four of four smoke compartments and could result in the unsafe handling and use of oxygen and oxygen delivery equipment.

NFPA 99, Health Care Facilities Code, 2012 Edition.
11.5.2.1.2 Health care facilities shall provide programs of continuing education for their personnel.
11.5.2.1 Qualification and Training of Personnel.
11.5.2.1.1* Personnel concerned with the application and maintenance of medical gases and others who handle medical gases and the cylinders that contain the medical gases shall be trained on the risks associated with their handling and use.
11.5.2.1.2 Health care facilities shall provide programs of continuing education for their personnel.
11.5.2.1.3 Continuing education programs shall include periodic review of safety guidelines and usage requirements for medical gases and their cylinders.
11.5.2.1.4 Equipment shall be serviced only by personnel trained in the maintenance and operation of the equipment.
11.5.2.1.5 If a bulk cryogenic system is present, the supplier shall provide annual training on its operation.

Findings:

During document review and interview with staff on 3/2/20, the oxygen equipment records were requested.

At 10:50 a.m., there were no records provided indicating continued education for risks associated with the handling and the use of medical gases provided. Upon interview, Staff 5 confirmed the finding and stated that they needed to implement a training for it.