HospitalInspections.org

Based on document review and interview, the facility failed to maintain the Emergency Preparedness (EP) plan. This was evidenced by the failure to review and update the plan annually by current Administration. This affected 114 of 114 patients at the Main Hospital, and could result in an ineffective EP plan.

Finding:

During document review and interview with the AS, the EP plan review documentation was requested.

Main Hospital:

On 7/18/19 at 2:28 p.m., the facility provided the document titled, "Emergency Preparedness Plan." The last annual plan review was dated 5/31/16. Upon interview, AS1 and AS3 confirmed the finding, and stated that Administration was in the process of reviewing the current accepted plan.

Based on document review and interview, the facility failed to maintain the Emergency Preparedness (EP) plan. This was evidenced by the failure to ensure that evacuation transfer agreements with other facilities were current and updated. This affected 114 of 114 patients at the Main Hospital, and could result in ineffective evacuation and EP planning.

Finding:

During document review and interview with the AS, the EP Policies and Procedures were requested and reviewed.

Main Hospital:

On 7/18/19 at 3:20 p.m., the current facility evacuation-transfer agreements submitted, included one acute hospital, and two skilled nursing facilities that were no longer existing or providing care. Upon interview, AS1 and AS3 confirmed the finding.

Based on document review and interview, the facility failed to maintain the Emergency Preparedness (EP) plan. This was evidenced by the failure to provide a communication plan that included current contact information for all required Federal and State emergency officials. This affected 114 of 114 patients at the Main Hospital, and could result in an ineffective (EP) communication plan.

Finding:

During document review and interview with the AS, the EP Policies and Procedures were requested and reviewed.

Main Hospital:

On 7/18/19 at 3:45 p.m., the communication plan did not include Federal emergency officials and State Ombudsman contact information. Upon interview, AS1 confirmed the finding that EP Policy and Procedure did not include all required emergency contacts in the communication plan.

Based on document review and interview, the facility failed to maintain the emergency preparedness (EP) plan training. This was evidenced by the failure to provide initial and annual training and competency evaluation in EP plan Policies and Procedures to all new and existing on-site service providers under arrangement, consistent with their expected roles. This affected 114 of 114 patients at the Main Hospital, and could result in ineffective EP planning.

Finding:

During record review and interview with the AS, the EP plan training, was reviewed.

Main Hospital:

On 7/19/19 at 9:50 a.m., the facility's initial and annual training in EP Policies and Procedures, along with staff training files for completion and competency evaluation, were reviewed.
The training provided failed to show that initial and annual training for 83 of 83 Active Physicians providing on-site services, had been completed.

Upon interview, AS3 confirmed the finding stating that the facility had not completed and/or documented initial and annual training with staff competency evaluation for physicians providing on-site services.

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by a ceiling penetration. This affected one of two floors at the Main Hospital, and could result in the passage of smoke to other areas in the event of a fire.

Finding:

During a tour of the facility with the PO, the walls and ceiling were observed.

Main Hospital: 2nd Floor

On 7/15/19 at 2:40 p.m., the walls and ceiling in Radiology were observed. There was an approximately one-half inch penetration located in the ceiling inside the Cat-Scan Room, beside the Internet device.

Based on observation and interview, the facility failed to maintain the means of egress free from obstructions and impediments. This was evidenced by storage of equipment on both side of the corridors. This affected one of two floors at the Main Hospital, and could result in delayed evacuation in the event of an emergency.

NFPA 101, Life Safety Code, 2012 Edition

19.2 Means of Egress Requirements.
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11.

19.2.3.4 Any required aisle, corridor, or ramp shall be not less than 48 in. (1220 mm) in clear width where serving as
means of egress from patient sleeping rooms, unless otherwise permitted by one of the following:

(1) Aisles, corridors, and ramps in adjunct areas not intended for the housing, treatment, or use of inpatients shall be not less than 44 in. (1120 mm) in clear and unobstructed width.

Chapter 7 Means of Egress
7.1.10 Means of Egress Reliability.
7.1.10.1 General. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Findings:

During a facility tour and interview with the PO, the access corridors were observed.

Main Hospital:

1. On 7/15/19 at 11:15 a.m., the sleeping room corridor by Room 220 was observed. A chair and work station on wheels (WOW) that were not in use, and a crash-cart that was stored directly on the opposite side of the corridor, reduced the egress path clear width to approximately 36 inches. Upon interview, PO1 confirmed the finding.

2. On 7/15/19 at 11:25 a.m., the sleeping room corridor by Room 209 was observed. A laundry cart, and a WOW that were stored on the direct opposite side of the corridor, reduced the egress path clear width to approximately 36 inches. Upon interview, PO1 confirmed the finding.

Based on observation and interview, the facility failed to maintain the self-closing doors in the exit stairways. This was evidenced by a door that failed to self-close. This affected two of two floors at the Main Hospital, and could allow the spread of smoke and/or fire to adjoining compartments.

Finding:

During a facility tour and interview with the PO, the self-closing doors were observed.

Main Hospital: 2nd Floor

On 7/15/19 at 11:30 a.m., the 2nd Floor door to the Operating Room (OR) Exit Stair failed to self-close and latch. Upon interview, PO1 confirmed that the door arm on the self-closing mechanism was not working.

Based on observation and interview, the facility failed to maintain the emergency lighting. This was evidenced by a lighting unit that did not illuminate when tested. This affected one of two floors at the Main Hospital, and could result in limited visibility during an emergency.

NFPA 101 Life Safety Code, 2012 edition
19.2.9 Emergency Lighting.
19.2.9.1 Emergency lighting shall be provided in accordance
with Section 7.9

7.9.2 Performance of System.
7.9.2.3* The emergency lighting system shall be arranged to provide
the required illumination automatically in the event of any
interruption of normal lighting due to any of the following:
(1) Failure of a public utility or other outside electrical power
supply
(2) Opening of a circuit breaker or fuse
(3) Manual act(s), including accidental opening of a switch
controlling normal lighting facilities

7.9.2.6* Existing battery-operated emergency lights shall use
only reliable types of rechargeable batteries provided with suitable
facilities for maintaining them in properly charged condition.
Batteries used in such lights or units shall be approved
for their intended use and shall comply with NFPA 70, National
Electrical Code.

Finding:

During a facility tour and interview with the PO, the emergency lighting, was observed.

Main Hospital: 2nd Floor

On 7/15/19 at 3:10 p.m., the dual lighting unit located in the Post Anesthesia Care Unit (PACU), was equipped with battery back-up and a test button. The lights failed to illuminate when tested. Upon interview, PO1 confirmed the finding.

Based on observation and interview, the facility failed to maintain laboratory equipment. This was evidenced by not having a current fume hood inspection. This affected one of two floors at the Main Hospital, and could result in the increased risk of a hazardous condition.

NFPA 99 Health Care Facilities Code, 2012 Edition.
15.4 Laboratories. Laboratories using chemicals shall comply
with NFPA 45, Standard on Fire Protection for Laboratories Using
Chemicals, unless otherwise modified by other provisions of this
code.

NFPA 45, Standard on Fire Protection for Laboratories Using Chemicals, 2011 edition
8.12 Identification of Chemical Fume Hood Systems.
8.12.1* Special-use chemical fume hoods and special-use local
exhaust systems shall be identified to indicate their intended use.
8.12.2 Asign containing the following information from the last
inspection shall be affixed to each hood, or a properly maintained
log of all hoods providing the following information shall
be maintained:
(1) Inspection interval
(2) Last inspection date
(3) Average face velocity
(4) Location of fan that serves hood
(5) Inspector's name

8.13 Inspection, Testing, and Maintenance.
8.13.1* When installed or modified and at least annually thereafter,
chemical fume hoods, chemical fume hood exhaust systems,
and laboratory special exhaust systems shall be inspected
and tested as applicable, as follows:
(1) Visual inspection of the physical condition of the hood
interior, sash, and ductwork (see 7.5.3)
(2) Measuring device for hood airflow
(3) Low airflow and loss-of-airflow alarms at each alarm location
(4) Face velocity
(5) Verification of inward airflow over the entire hood face
(6) Changes in work area conditions that might affect hood
performance
8.13.2 Deficiencies in hood performance shall be corrected,
or one of the following shall apply:
(1) The activity within the hood shall be restricted to the capability
of the hood.
(2) The hood shall not be used.
8.13.3 Chemical fume hood face velocity profile or hood exhaust
air quantity shall be checked after any adjustment to the
ventilation system balance.

Finding:

During a facility tour and interview with the PO, the laboratory and equipment were observed.

Main Hospital: 2nd Floor

On 7/15/19 at 2:26 p.m., the Micro-Lab fume hood had an outdated annual inspection tag dated 3/19/18, with a retest due date for 3/2019. No current inspection was available for review. Upon interview, PO1 confirmed the finding.

Based on observation and interview, the facility failed to maintain the Fire Alarm Control Panel (FACP). This was evidenced by the failure to install an initiation device at a non-continuously occupied panel location. This affected two of two floors at the Main Hospital, and could result in an undetected fire at the panel.

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* General.
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.
10.14.3 Initiating Devices.
10.14.3.1 Initiating devices of the manual or automatic type
shall be selected and installed so as to minimize nuisance
alarms.
10.15* Protection of Fire Alarm System. In areas that are not
continuously occupied, automatic smoke detection shall be
provided at the location of each fire alarm control unit(s),
notification appliance circuit power extenders, and supervising
station transmitting equipment to provide notification of
fire at that location.
Exception: Where ambient conditions prohibit installation of automatic
smoke detection, automatic heat detection shall be permitted.

Finding:

During a tour of the facility and interview with the PO, the FACP, was observed.

Main Hospital:

On 7/15/19 at 10:45 a.m., the Main FACP was located in a non-continuously occupied Electrical Room, behind a closed door. A smoke or heat detection device was not installed at the panel location. Upon interview, PO1 confirmed the finding.

Based on observation and interview, the facility failed to maintain fire alarm system (FAS). This was evidenced by the failure to install notification devices at one sleeping area location. This affected one of two floors at the Main Hospital, and could delay in notifying occupants of an imminent fire danger.

NFPA 101, Life Safety Code, 2012 Edition
19.3.4.3.1 Occupant Notification. Occupant notification shall be accomplished automatically in accordance with 9.6.3, unless otherwise modified by the following:
(1)*In lieu of audible alarm signals, visible alarm-indicating appliances shall be permitted to be used in critical care areas.
(2) Where visual devices have been installed in patient sleeping areas in place of an audible alarm, they shall be permitted where approved by the authority having jurisdiction.

9.6.3 Occupant Notification.
9.6.3.1 Occupant notification shall be provided to alert occupants of a fire or other emergency where required by other sections of this Code.
9.6.3.4 Where permitted by Chapters 11 through 43, a positive alarm sequence shall be permitted, provided that it is in accordance with NFPA 72, National Fire Alarm and Signaling Code.
9.6.3.7 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level that exists under normal conditions of occupancy.
9.6.3.8 Audible alarm notification appliances shall produce signals that are distinctive from audible signals used for other purposes in a given building.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition
18.2 Purpose. Notification appliances shall provide stimuli for initiating emergency action and provide information to users, emergency response personnel, and occupants.
18.4.1.4 Audible notification appliances for alert and evacuation signal tones shall meet the requirements of 18.4.3 (Public Mode Audible Requirements), 18.4.4 (Private Mode Audible Requirements), 18.4.5 (Sleeping Area Requirements), or 18.4.6 (Narrow Band Tone Signaling for Exceeding Masked Thresholds), as applicable.

Finding:

During fire alarm testing and interview with the PO, fire alarm system notification devices were observed.

Main Hospital: 2nd Floor

On 7/16/19 at 11:20 a.m., the FAS was activated. No audible or visual notification appliances were observed installed on Overflow-unit 3 to alert occupants, and initiate emergency action by unit staff. Upon interview, PO1 confirmed the finding.

Based on observation, document review, and interview, the facility failed to maintain the fire alarm system (FAS). This was evidenced by the failure to perform a semi-annual inspection. This affected two of two floors at the Main Hospital, and three of three floors at the MOB Clinic, and could result in a non-detected system malfunction 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

Chapter 39 Existing Business Occupancies
39.3.4 Detection, Alarm, and Communications Systems.
39.3.4.1 General. A fire alarm system in accordance with Section
9.6 shall be provided in all business occupancies where
any one of the following conditions exists:
(1) The building is three or more stories in height.
(2) The occupancy is subject to 100 or more occupants above
or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.

9.6.1* General.
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.
Chapter 14 Inspection, Testing, and Maintenance
14.1 Application.
14.1.1 The inspection, testing, and maintenance of systems, their initiating devices, and notification appliances shall comply with the requirements of this chapter.
14.3 Inspection.
14.3.1* Unless otherwise permitted by 14.3.2 visual inspections shall be performed in accordance with the schedules in Table 14.3.1 or more often if required by the authority having jurisdiction.
14.3.2 Devices or equipment that is inaccessible for safety considerations (e.g., continuous process operations, energized electrical equipment, radiation, and excessive height) shall be permitted to be inspected during scheduled shutdowns if approved by the authority having jurisdiction.
14.3.4 The visual inspection shall be made to ensure that there are no changes that affect equipment performance.

Table 14.3.1 Visual Inspection Frequencies-semiannually
3. Batteries
4. Transient suppressors
5. Fire alarm control unit trouble signals
7. In- building fire emergency voice/alarm communications equipment
8. Remote annunciators
9. Initiating devices
10. Guard's tour equipment
11. Combination systems (a) Fire extinguisher electronic monitoring device/systems
(b) Carbon monoxide detectors/systems
12. Interface equipment
13. Alarm notification appliances
14. Exit marking audible notification appliances
15. Supervising station alarm systems-transmitters
16. Special procedures
17. Supervising station alarm systems-receivers
18. Public emergency alarm reporting system transmission equipment
20. Mass notification system, non-supervised systems installed prior to adoption of this edition

14.6.2 Maintenance, Inspection, and Testing Records.
14.6.2.1 Records shall be retained until the next test and for 1 year thereafter.
14.6.2.4* A record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 14.6.2.4:
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(S) tested
(8) Functional test of detectors
(9)*Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Functional test of mass notification system control units
(13) Functional test of signal transmission to mass notification systems
(14) Functional test of ability of mass notification system to silence fire alarm notification appliances
(15) Tests of intelligibility of mass notification system speakers
(16) Other tests as required by the equipment manufacturer ' S published instructions
(17) Other tests as required by the authority having jurisdiction
(18) Signatures of tester and approved authority representative
(19) Disposition of problems identified during test (e.g., system owner notified, problem corrected/successfully retested, device abandoned in place)

Finding:

During a facility tour, document review, and interview with the PO, the FAS were observed and records were requested.

Main Hospital:

1. On 7/16/19 at 3:10 p.m., the Main Hospital was observed with an automatic FAS. The current Annual Fire Alarm Inspection/Testing Report was dated 10/26/18. No post-semi-annual visual inspection with battery testing was available for review. Upon interview, PO1 confirmed that the FAS was inspected and tested on an annual basis.

MOB Clinic:

2. On 7/16/19 at 3:11 p.m., the MOB Clinc was observed with an automatic FAS. The current Annual Fire Alarm Inspection/Testing Report was dated 10/26/18. No post-semi-annual visual inspection with battery testing was available for review. Upon interview, PO1 confirmed that the FAS was inspected and tested on an annual basis.

Based on observation and interview, the facility failed to maintain the integrity of the automatic fire sprinkler system. This was evidenced by sprinkler heads that were obstructed and had foreign material-debris. This affected one of two floors at the Main Hospital, and could result in the ineffective operation of the automatic fire sprinkler system in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.5 Extinguishment Requirements.
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.
9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following:
(1) NFPA 13, Standard for the Installation of Sprinkler Systems
(2) NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two Family Dwellings and Manufactured Homes
(3) NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height

9.7.5 Maintenance and Testing. All automatic sprinkler and
standpipe systems required by this 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 13, Standard for the Installation of Sprinkler System. 2010 Edition
8.6.6* Clearance to Storage (Standard Pendent and Upright Spray Sprinklers).
8.6.6.1 The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

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 for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request.

Chapter 5 Sprinkler Systems.
5.1.1 Minimum Requirements.
5.1.1.1 This chapter shall provide the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems.
5.2.1 Sprinklers.
5.2.1.1.1 Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).
5.2.1.1.2 Any sprinkler that shows 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
(6) Painting unless painted by the sprinkler manufacturer

Findings:

During a facility tour and interview with the PO, the automatic fire sprinkler system was observed.

Main Hospital: 2nd Floor

1. On 7/15/19 at 2:00 p.m., the pendant style sprinkler head located in the Kitchen, above the bread storage cart was observed. Bread was stored on the top shelf at approximately two inches below the sprinkler defector. Upon interview, PO1 confirmed the finding.

2. On 7/15/19 at 2:06 p.m., the pendant style sprinkler head located inside the Kitchen walk-in freezer was observed. The sprinkler had ice build-up on the deflector. Upon interview, PO1 confirmed the finding.

Based on document review and interview, the facility failed to maintain interim fire measures. This was evidenced by the failure to provide written protocol to ensure that if the automatic sprinkler system was out of service for more than 10 hours in a 24 hour period, the authority having jurisdiction (AHJ) would be notified. This affected two of two floors at the Main Hospital, and could result in the AHJ not having the ability to exercise oversight in a timely manner if the fire sprinkler system should become inoperable.

Finding:

During document review and interview with the PO, the interim fire measures and policy were reviewed.

Main Hospital: 1st and 2nd Floors

On 7/16/19 at 2:10 p.m., the approved Fire Watch policy was reviewed. The policy did not include time parameters for notification to the Department of Public Health if the fire sprinkler system was out of service for more than 10 hours in a 24 hour period. Upon interview, PO1 confirmed the finding.

Based on observation and interview, the facility failed to maintain the portable fire extinguishers. This was evidenced by an extinguisher that was obstructed. This affected one of two floors at the Main Hospital, and could result in the inability of staff to readily access the fire 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.

9.7.4.1* 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.
6.1.3.3.1 Fire extinguishers shall not be obstructed or obscured from view.

Finding:

During a facility tour and interview with the PO, the portable fire extinguishers were observed.

Main Hospital: 2nd floor

On 7/15/19 at 3:55 p.m., the ABC-Type portable fire extinguisher located in the corridor by the Unit 3-East End, was obstructed from view and access by a wheel chair stationed directly in front of the extinguisher. Upon interview, PO1 confirmed the finding.

Based on observation and interview, the facility failed to maintain the integrity of the corridor construction. This was evidenced by unsealed wall and ceiling penetrations. This affected one of two floors at the Main Hospital, and could result in the passage of smoke to other areas in the event of a fire.

Findings:

During a facility tour and interview with the PO, the corridor walls and ceiling were observed.

Main Hospital: 2nd Floor

1. On 7/15/19 at 11:05 a.m., there were two approximately one quarter inch diameter wall penetrations located at the Unit Two Hams Nursing Station, below the monitors. Upon interview, PO1 Confirmed the finding.

2. On 7/15/19 at 11:20 a.m., there was an approximately one inch diameter ceiling penetration located in the access corridor by Room 215. Upon interview, PO1 Confirmed the finding.

3. On 7/15/19 at 1:30 p.m., two ceiling penetrations approximately one inch by four inches in size, were located in the Unit Three Corridor by Room 316. Upon interview, PO1 Confirmed the finding.

Based on observation and interview, the facility failed to maintain the corridor doors. This was evidenced by obstructed access corridor doors. This affected two of two floors at the Main Hospital, and could result in the inability to contain smoke and/or fire to a room.

Findings:

During a facility tour and interview with the PO, the corridor doors were observed.

Main Hospital: 2nd Floor

1. On 7/15/19 at 11:28 a.m., the door to Patient Room 206 was observed. A portable chair stationed at the foot of A-Bed and in the swing path of the door, prevented the door from closing and latching. Upon interview, PO1 confirmed the finding.

2. On 7/15/19 at 1:50 p.m., the door to Unit 3-Patient Room 605 was observed. The door was obstructed from closing and latching by a cubicle curtain and a bed stationed directly against the door, and a wooden wedge lodged under the base of the door. Upon interview, PO2 confirmed the finding.

Main Hospital: 1st Floor

3. On 7/16/19 at 9:45 a.m., the door to the OB Delivery Room was observed. A fetal monitor was stationed in the swing path of the door, preventing the door from fully closing and latching. Upon interview, PO2 confirmed the finding.

Based on observation, document review, and interview, the facility failed to maintain the elevators. This was evidenced by three of three elevators with expired permits. This affected two of two floors at the Main Hospital. This could result in an elevator failure and delay in egress.

NFPA 101, Life Safety Code, 2012 Edition
19.5.3 Elevators, Escalators, and Conveyors. Elevators, escalators, and conveyors shall comply with the provisions of Section 9.4.
9.4 Elevators, Escalators, and Conveyors.
9.4.1* General. An elevator, other than an elevator in accordance with 7.2.13, shall not be considered a component in a required means of egress but shall be permitted as a component in an accessible means of egress.
9.4.6 Elevator Testing.
9.4.6.1 Elevators shall be subject to periodic inspections and
tests as specified in ASME A17.1/CSA B44, Safety Code for Elevators
and Escalators.

7.2.12.2.4* Where an elevator provides access from an area of refuge to a public way that is in accordance with 7.2.12.2.2, all of the following criteria shall be met:
(1) The elevator shall be approved for fire fighters' emergency operations as provided in ASME A17.1/CSA B44, Safety Code for Elevators and Escalators.
(2) The power supply shall be protected against interruption from fire occurring within the building but outside the area of refuge.
(3) The elevator shall be located in a shaft system meeting the requirements for smoke-proof enclosures in accordance with 7.2.3, unless otherwise provided in 7.2.12.2.4.1 and 7.2.12.2.4.2.

Findings:

During a facility tour, document review, and interview with the PO, the elevators were observed, and permits were reviewed.

Main Hospital: 1st and 2nd Floors

1. On 7/16/19 at 9:25 a.m., the Dove elevator was observed. The posted permit inside the elevator had an expiration date of 2/8/19. Upon interview, PO1 confirmed the finding.

2. On 7/16/19 at 10:58 a.m., Elevator Right 2 was observed. The elevator was equipped with firefighters' emergency operations, and was observed out of service. The permit for the elevator had a posted expiration date of 2/8/19. Upon interview, PO1 stated that the hydraulic equipment had failed, and that a new pump was on order.

3. On 7/16/19 at 2:15 p.m., the facility was observed with three elevators: Left-1 and Right-2 (both equipped with fire fighters' emergency services), and a Dove elevator. Documentation titled, "Elevator Permits", was reviewed. The documentation indicated that three of three elevators had expired permits dated 2/8/19. No scheduled follow-up service and inspection date was available for review. Upon interview, PO1 confirmed the finding.

Based on observation and interview, the facility failed to maintain the fire rated door assemblies in corridors. This was evidenced by an obstructed rolling service counter fire door. This affected one of two floors at the Main Hospital, and could result in the inability to contain fire to a room.

NFPA 101. Life Safety Code, 2012 Edition
19.1.1.4.1.1 Communicating openings in dividing fire barriers
required by 19.1.1.4.1 shall be permitted only in corridors
and shall be protected by approved self-closing fire door assemblies.
(See also Section 8.3.)

8.3.3 Fire Doors and Windows.
8.3.3.1 Openings required to have a fire protection rating by
Table 8.3.4.2 shall be protected by approved, listed, labeled
fire door assemblies and fire window assemblies and their accompanying
hardware, including all frames, closing devices,
anchorage, and sills in accordance with the requirements of
NFPA 80, Standard for Fire Doors and Other Opening Protective's,
except as otherwise specified in this Code.

NFPA 80, Standard for Fire Doors and Other Opening Protective's, 2010 edition.
Chapter 5 Care and Maintenance
5.2.13 Prevention of Door Blockage.
5.2.13.1 Door openings and the surrounding areas shall be
kept clear of anything that could obstruct or interfere with the
free operation of the door.

Chapter 13 Service Counter Fire Doors
13.4 Automatic Closing.
13.4.1 All service counter fire doors shall be equipped to
close automatically in the event of fire.
13.4.2 A service counter fire door of the rolling type shall be
automatic closing so that, upon activation or release of a fusible
link or detector, the door shall close.

Finding:

During a facility tour and interview with the PO, the rolling fire doors were observed.

Main Hospital: 1st Floor

On 7/16/19 at 9:40 a.m., the facility was observed with a 60 minute fire-rated-rolling service counter door, located in the corridor at the Labor and Delivery Nursing Station. The door was obstructed by a printer stationed on the counter below the door. Upon interview, PO1 confirmed the finding.

Based on observation, document review, and interview, the facility failed to maintain the bulk-supplied piped Gas and Vacuum Systems. This was evidenced by the failure to provide training and certification for staff maintaining the systems, and to establish a documented maintenance program established through risk assessment and manufacturer recommendations. This affected two of four floors at the Main Hospital, and could result in a system malfunction.

NFPA 99, Health Care Facilities Code, 2012 Edition.
Chapter 4 Fundamentals
4.1* Building System Categories. Building systems in health
care facilities shall be designed to meet system Category 1
through Category 4 requirements as detailed in this code.
4.1.1* Category 1. Facility systems in which failure of such equipment
or system is likely to cause major injury or death of patients
or caregivers shall be designed to meet system Category 1 requirements
as defined in this code.

5.1.14* Category 1 Operation and Management.
5.1.14.2 Maintenance of Medical Gas, Vacuum, WAGD, and
Medical Support Gas Systems.
5.1.14.2.1* General. Health care facilities with installed medical
gas, vacuum,WAGD, or medical support gas systems, or combinations
thereof, shall develop and document periodic maintenance
programs for these systems and their subcomponents as appropriate
to the equipment installed.

5.1.14.2.2 Maintenance Programs.
5.1.14.2.2.1 Inventories. Inventories of medical gas, vacuum,
WAGD, and medical support gas systems shall include at least
all source subsystems, control valves, alarms, manufactured assemblies
containing patient gases, and outlets.

5.1.14.2.2.2* Inspection Schedules. Scheduled inspections for
equipment and procedures shall be established through the
risk assessment of the facility and developed with consideration
of the original equipment manufacturer recommendations
and other recommendations as required by the authority
having jurisdiction.

5.1.14.2.2.4 Maintenance Schedules. Scheduled maintenance
for equipment and procedures shall be established through
the risk assessment of the facility and developed with consideration
of the original equipment manufacturer recommendations
and other recommendations as required by the authority
having jurisdiction.

5.1.14.2.2.5 Qualifications. Persons maintaining these systems
shall be qualified to perform these operations.Appropriate qualification
shall be demonstrated by any of the following:
(1) Training and certification through the health care facility
by which such persons are employed to work with specific
equipment as installed in that facility
(2) Credentialing to the requirements of ASSE 6040, Professional
Qualification Standard for Medical Gas Maintenance Personnel
(3) Credentialing to the requirements of ASSE 6030, Professional
Qualification Standard for Medical Gas Systems Verifiers

5.1.14.2.3 Inspection and Testing Operations.
5.1.14.2.3.1 General. The elements in 5.1.14.2.2.2 through
5.1.15 shall be inspected or tested as part of the maintenance
program as follows:
(1)*Medical air source, as follows:
(a) Room temperature
(b) Shaft seal condition
(c) Filter condition
(d) Presence of hydrocarbons
(e) Room ventilation
(f) Water quality, if so equipped
(g) Intake location
(h) Carbon monoxide monitor calibration
(i) Air purity
(j) Dew point
(2)*Medical vacuum source - exhaust location
(3) WAGD source - exhaust location
(4)*Instrument air source - filter condition
(5)*Manifold sources (including systems complying with
5.1.3.5.10, 5.1.3.5.11, 5.1.3.5.12, and 5.1.3.5.13), as follows:
(a) Ventilation
(b) Enclosure labeling
(6) Bulk cryogenic liquid source inspected in accordance
with NFPA 55, Compressed Gases and Cryogenic Fluids Code
(7) Final line regulation for all positive pressure systems -
delivery pressure
(8)*Valves - labeling
(9)*Alarms and warning systems-lamp and audio operation
(10) Alarms and warning systems, as follows:
(a) Master alarm signal operation
(b) Area alarm signal operation
(c) Local alarm signal operation
(11)*Station outlets/inlets, as follows:
(a) Flow
(b) Labeling
(c) Latching/delatching
(d) Leaks

5.1.15* Category 1 Maintenance. Facilities shall have a routine
maintenance program for their piped medical gas and vacuum
systems.

Findings:

During a facility tour, document review, and interview with the PO, the piped Gas and Vacuum Systems were observed, and maintenance records were requested.

Main Hospital

On 7/18/19 at 11:45 a.m., no documentation was available for a risk assessment or manufacturer's recommendations for the established in-house maintenance program. No documentation for system training and certification was submitted for the facility's maintenance staff that were maintaining the system.Upon interview, PO1 confirmed the above finding.

The facility was observed with a category 1 piped medical gas and vacuum system. Documentation titled, "Remodel Certification" dated 4/29/15, indicated that a routine maintenance and service was performed by a certified vendor for a system breach.
Upon interview, PO1 stated that the facility has been maintaining the system since that date due to no further breach in the system.

Documentation for Policy and Procedure titled, "Engineering Department Piped Medical Gas Systems," indicated that the Engineering Department checks the system on a per shift basis, and any system corrected deficiencies are inspected and certified by a qualified Medical Gas Systems Consultant. Repairs to the system were made by the facility on the following dates: 1/22/19, 2/20/19, 5/15/19, 5/22/19, 9/9/18, 9/10/18, and 12/17/18, for outlet leaks.
The facility was not able to provide documentation for a follow-up inspection after the repairs by a certified vendor.

Based on observation and interview, the facility failed to maintain the electrical equipment and wiring. This was evidenced by the non-compliant use of a power strips. This affected one of two floors at the Main Hospital, and could result in an electrical fire.

NFPA 101, Life Safety Code, 2012 Edition
19.5 Building Services.
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.

Chapter 9 Building Service and Fire Protection Equipment
9.1 Utilities.
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.

NFPA 70, National Electrical Code, 2011 Edition
400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(7) Where subject to physical damage

400.10 Pull at Joints and Terminals. Flexible cords and
cables shall be connected to devices and to fittings so that
tension is not transmitted to joints or terminals.
Exception: Listed portable single-pole devices that are intended
to accommodate such tension at their terminals
shall be permitted to be used with single-conductor flexible
cable.
Informational Note: Some methods of preventing pull on a
cord from being transmitted to joints or terminals are knotting
the cord, winding with tape, and fittings designed for
the purpose.

Findings:

During a facility tour and interview with the PO, the electrical equipment and wiring were observed.

Main Hospital: 2nd Floor

1. On 7/15/19 at 11:30 a.m., the electrical equipment in the Unit 2 Storage Room was observed. A power strip used to power a medical warmer machine, was hanging above the floor, suspended by the cord. Upon interview, PO1 confirmed the finding.

2. On 7/15/19 at 1:40 p.m., two power strips used outside the patient care vicinity inside Day Surgery-Patient Room 607 were observed. The two power strips were chain-plugged together, and were used to power a room light with a wall mounted switch, and medical computer equipment. The power strips were not UL 1363 or the listed equivalent. Upon interview, PO1 confirmed the finding.

Power strips being used for patient care related electrical equipment (PCREE) in the patient care vicinity are required to meet specific UL requirements. Power strip for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in patient care rooms (outside of vicinity) meet UL 1363.

Based on observation, document review, and interview, the facility failed to maintain medical gas safety. This was evidenced by the absence of an annual safety education program for risks associated with handling and use of a bulk cryogenic oxygen supply system. This affected two of two floors at the Main Hospital, 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.

Finding:

During observation, document review, and interview with the PO, the oxygen equipment was observed, and training records were requested.

Main Hospital:

On 7/16/19 at 2:55 p.m., the facility was observed with a bulk cryogenic oxygen supply system. No records were provided for the annual service by a supplier for training on the operation of the system and associated risks. Upon interview, PO1 confirmed the finding stating that the facility did not have a documented training by the oxygen supplier.

Based on document review and interview, the facility failed to maintain Fire Loss Prevention in the Operating Room (OR). This was evidenced by not providing documented training and continuing education in emergency procedures to surgeons. This affected one of two floors at the Main Hospital, and could result in the increased risk of a hazardous condition encountered during surgical procedures.

Finding:

During document review and interview with the OR, Fire Loss Prevention training was requested and reviewed.

Main Hospital: 1st Floor

On 7/17/19 at 11:50 a.m., annual training-review in OR Fire Loss Prevention Policies and Procedures, along with training files for completion were reviewed. The training provided failed to show that an annual training for 36 of 36 surgeons had been completed.
Upon interview, OR1 confirmed the finding stating that the facility had not completed initial and annual training for surgeons.