HospitalInspections.org

Based on observation the facility failed to provide fire doors of such a character as to form an adequate two hour separation between the hospital and a non-conforming building.

Failure on the part of the facility to provide required fire barriers puts patients, staff and visitors of the facility at risk in the event of fire.

Findings include:

1. On 9/13/2011 the surveyor noted that double fire doors having a 90 minute rating provided separation between the 1949 building (old administration) and the hospital. The doors lacked latching hardware needed to maintain the required 2 hour separation between buildings.

Based on observation the facility failed to provide continuity of smoke barriers in the facility and to maintain the building's interior fire resistance rating . Failure to provide smoke barrier continuity and maintaining the interior fire resistance rating puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.


Findings include:

1. On 8/30/2011 the surveyor noted penetrations in the walls or ceilings of the following locations:
a) Generator room (sprinkler hanger); and
b) Emergency department furnace room (1 high and 2 low).

Based on observation the facility failed to provide doors that would resist the passage of smoke. Failure on the part of the facility to provide doors that have the ability to resist the passage of smoke puts patients, staff and visitors of the facility at risk of injury in the event of a fire.

Reference: NFPA 101 Life Safety Code, 2000 Edition, Chapter 8.3.4.1 and related Appendix.

Findings include:

1. On 9/13/2011 the surveyor noted doors with roller latches in the following locations/areas:
a) Ambulance janitors closet by exam 1;
b) West wing stairwell door;
c) Kitchen double doors; and
d) Surgery employee lounge/storage.

2. On 9/13/2011 the survey noted that doors to corridor in the following areas lacked latching mechanisms or would not properly latch:
a) Doors to laundry department (dirty linen, clean linen and main laundry);
b) Pharmacy waiting; and
c) Lobby double doors.

Based on observation the facility failed to provide self-closing doors for the purpose of smoke control.

Failure on the part of the facility to provide components necessary for the control of smoke puts patients, staff and visitors of the facility at risk in the event of fire.

Findings include:

1. On 9/13/2011 the surveyor noted that the following smoke control doors lacked self-closing devices:
a) Linen storage room; and
b) Casting room.

Based on observation the facility failed to provide and maintain an effective fire alarm system in certain areas of the facility.

Failure on the part of the facility to provide and maintain its fire alarm system where required puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Background:

NFPA 101 Life Safe Code 2000 Edition, Chapter 6.6.14.2 requires the most restrictive life safety requirement be applied when a lodging occupancy exists within a health care occupancy. And, Chapter 26.3.3.5 requires that smoke alarms be installed in accordance with 9.6.2.1 in staff sleeping rooms.

Findings include:

1. On 9/13/2011 the surveyor noted that the doctor's sleep room (sleeping compartment) lacked a smoke detector. It was further noted that a smoke detector had been located outside the sleeping compartment but that location failed to meet the requirements for proper location.

Based on observation, the hospital failed to install and maintain the automatic sprinkler system in accordance with NFPA 13 and NFPA 25 and Chapter 19.3.5 NFPA 101 Life Safety Code 2000 edition.

Failure to maintain the automatic sprinkler system as required puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 9/13/2011 the surveyor noted that ductwork for the air handling system located in the kitchen was suspended from sprinkler piping.

2. On 9/13/2011 the surveyor noted that the IT server room located in the basement lacked sprinkler coverage.

Based on observation and document review the hospital failed to implement a plan to maintain a fire-safe environment of care. More specifically, the facility failed to provide portable fire extinguishers that were being inspected as required.

Failure to maintain a fire-safe environment puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 8/302011 the surveyor noted that portable fire extinguishers in the following locations had not been inspected monthly as required:
a) Basement (last serviced in 2009); and
b) Mechanical room (2nd floor, last serviced in 2003).

Based on observation the facility failed to keep unacceptable portable space heating devices out of non-patient care areas of the facility.

Failure on the part of the facility to assure that unacceptable portable heating devices are kept out of the facility puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 9/13/2011 the surveyor noted a portable space heater in the cardiac-rehab unit that was of such a type that the heating elements would heat to a temperature exceeding 212 degrees F.

Based on observation the facility failed to maintain designated means of egress free of impediments to full instant use in the case of fire or other emergency.

Failure on the part of the facility to keep the means of egress free of impediments puts patients, staff and visitors of the facility at risk in the event of fire or other emergency.

Findings include:

1. On 9/13/201 the surveyor noted that the East Wing corridor had various types of equipment located on both sides of the corridor (carts, lift equipment, scale, etc). Said equipment was not temporarily parked for immediate use and staff were not observed using any of the equipment during the period of the survey.

2. On 9/13/2011 the surveyor noted that the main door of the kitchen was outfitted with a pad lock. Said log was not being used at the time of the inspection.

3. On 9/13/2011 the surveyor noted that the stairs leading from the basement to the public way was partially blocked by a refrigerator, tires and wooden pallets.

Based on observations the facility failed to maintain a safe environment by not properly securing compressed gas cylinders as is required by 4-3.1.1.2(a)3 NFPA 99.

Failure on the part of the facility to properly secure oxygen cylinders could allow them to topple and become missiles should their valves brake while toppling over. This puts patients, staff and visitors at risk of serious injury and death.

Findings include:

1. On 9/13/2011 the surveyor noted two K cylinders (oxygen and nitrous oxide) in the operating room anesthesia closet that were not secured in a manner that would prevent them from toppling over.

Based on observation the facility failed to provide a medical gas system in compliance with NFPA 99, Chapter 4. More specifically the requirements of Chapter 4-3.1.2.7 Piping Materials.

Failure to provide a medical gas system in compliance with NFPA 99 requirements puts patients at risk of harm from the inhalation of impure medical gases.

Findings include:

1. On 9/13/2011 the surveyor noted that copper piping identified as that serving the medical air system (located near the west wing exit) had soldered joints that were not brazed as is required.

Based on observation and interview the facility failed to provide an essential electrical system (EES) in accordance with NFPA 99. More specifically those sections dealing with alarms and containment.

Failure on the part of the facility to meet the requirements of NFPA 99 puts patients, staff and visitors of the facility at risk from power outages.

Findings include:

1. On 9/13/2011 the surveyor noted that the 70 Kw generator was not secured/locked so as to minimize the potential of vandalism. (see Chapter 5-2.4 NFPA 110, 1999 edition)

2. On 9/13/2011 during a tour of the facility the surveyor was informed by Staff Member #7 that the remote annunciator for the 70 Kw generator was located in the old ICU unit (cardiac rehab) which is not staffed after hours. Code requires the annunciator to be continuously monitored. (see Chapter 3-4.1.1.15 NFPA 99, 1999 edition)

3. On 9/13/2011 the surveyor noted that the main generator room was being used to store various combustible materials. Code prohibits storage in the generator room. (see Chapter 5-11.1 NFPA 110, 1999 edition)

Based on observation and interview the facility failed to provide a medical gas system that has master alarm panels located in two separate locations as is required.

Failure on the part of the facility to provide master alarms in two separated locations puts patients at risk of not having an uninterrupted supply of oxygen.

Findings include:

1. On 9/13/2011 the surveyor noted that a master alarm for the medical gas system was located in a continuously occupied location (nurses station). On the same date the surveyor was informed that the system lacked a second master alarm, more specifically a second master alarm located in the principle working area of the individual responsible for the maintenance of the medical gas system; i.e. physical plant office.

2. On 9/13/2011 the surveyor was informed by Staff Member #7 that the medical air system was not provide with alarms in a 24 hour manned station or the shop (principle working area of the individual responsible for system maintenance).

3. On 9/13/2011 the surveyor noted that the medical air alarm monitoring system for carbon monoxide and dew point detection was not plugged into a power supply making it non-functional. It was further noted that logs kept for the alarm had not been maintained since March of 2011.

Based on observation the facility failed provide wiring solutions in accordance with NFPA 70, National Electrical Code.

Failure on the part of the facility to provide wiring as required puts patients, staff and visitors of the facility at risk of electrical shock or fire.

Findings include:

1. On 9/13/2011 the surveyor noted the following violations:
a) Two control boxes serving the kitchen pantry walk-ins were open;
b) An extension cord was being used as a permanent source of power for a grinder and light unit;
c)Two electrical receptacles in the shop lacked covers;
d) An extension cord was connected to a power strip in the film storage room;
e) Electrical receptacles in patient care areas such as cardiac rehab and imaging were not hospital grade;
f) 70 KW generator not fully secured;
g) Breaker box serving generator was not secured or labeled;
h) Breakers labels in 3 of 4 panels located in the ICU electrical room did not have current information; and
i) A power strip supplying power to a printer was connected to an extension cord.

Based on observation the facility failed to provide fire doors of such a character as to form an adequate two hour separation between the hospital and a non-conforming building.

Failure on the part of the facility to provide required fire barriers puts patients, staff and visitors of the facility at risk in the event of fire.

Findings include:

1. On 9/13/2011 the surveyor noted that double fire doors having a 90 minute rating provided separation between the 1949 building (old administration) and the hospital. The doors lacked latching hardware needed to maintain the required 2 hour separation between buildings.

Based on observation the facility failed to provide continuity of smoke barriers in the facility and to maintain the building's interior fire resistance rating . Failure to provide smoke barrier continuity and maintaining the interior fire resistance rating puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.


Findings include:

1. On 8/30/2011 the surveyor noted penetrations in the walls or ceilings of the following locations:
a) Generator room (sprinkler hanger); and
b) Emergency department furnace room (1 high and 2 low).

Based on observation the facility failed to provide doors that would resist the passage of smoke. Failure on the part of the facility to provide doors that have the ability to resist the passage of smoke puts patients, staff and visitors of the facility at risk of injury in the event of a fire.

Reference: NFPA 101 Life Safety Code, 2000 Edition, Chapter 8.3.4.1 and related Appendix.

Findings include:

1. On 9/13/2011 the surveyor noted doors with roller latches in the following locations/areas:
a) Ambulance janitors closet by exam 1;
b) West wing stairwell door;
c) Kitchen double doors; and
d) Surgery employee lounge/storage.

2. On 9/13/2011 the survey noted that doors to corridor in the following areas lacked latching mechanisms or would not properly latch:
a) Doors to laundry department (dirty linen, clean linen and main laundry);
b) Pharmacy waiting; and
c) Lobby double doors.

Based on observation the facility failed to provide self-closing doors for the purpose of smoke control.

Failure on the part of the facility to provide components necessary for the control of smoke puts patients, staff and visitors of the facility at risk in the event of fire.

Findings include:

1. On 9/13/2011 the surveyor noted that the following smoke control doors lacked self-closing devices:
a) Linen storage room; and
b) Casting room.

Based on observation the facility failed to provide and maintain an effective fire alarm system in certain areas of the facility.

Failure on the part of the facility to provide and maintain its fire alarm system where required puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Background:

NFPA 101 Life Safe Code 2000 Edition, Chapter 6.6.14.2 requires the most restrictive life safety requirement be applied when a lodging occupancy exists within a health care occupancy. And, Chapter 26.3.3.5 requires that smoke alarms be installed in accordance with 9.6.2.1 in staff sleeping rooms.

Findings include:

1. On 9/13/2011 the surveyor noted that the doctor's sleep room (sleeping compartment) lacked a smoke detector. It was further noted that a smoke detector had been located outside the sleeping compartment but that location failed to meet the requirements for proper location.

Based on observation, the hospital failed to install and maintain the automatic sprinkler system in accordance with NFPA 13 and NFPA 25 and Chapter 19.3.5 NFPA 101 Life Safety Code 2000 edition.

Failure to maintain the automatic sprinkler system as required puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 9/13/2011 the surveyor noted that ductwork for the air handling system located in the kitchen was suspended from sprinkler piping.

2. On 9/13/2011 the surveyor noted that the IT server room located in the basement lacked sprinkler coverage.

Based on observation and document review the hospital failed to implement a plan to maintain a fire-safe environment of care. More specifically, the facility failed to provide portable fire extinguishers that were being inspected as required.

Failure to maintain a fire-safe environment puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 8/302011 the surveyor noted that portable fire extinguishers in the following locations had not been inspected monthly as required:
a) Basement (last serviced in 2009); and
b) Mechanical room (2nd floor, last serviced in 2003).

Based on observation the facility failed to keep unacceptable portable space heating devices out of non-patient care areas of the facility.

Failure on the part of the facility to assure that unacceptable portable heating devices are kept out of the facility puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 9/13/2011 the surveyor noted a portable space heater in the cardiac-rehab unit that was of such a type that the heating elements would heat to a temperature exceeding 212 degrees F.

Based on observation the facility failed to maintain designated means of egress free of impediments to full instant use in the case of fire or other emergency.

Failure on the part of the facility to keep the means of egress free of impediments puts patients, staff and visitors of the facility at risk in the event of fire or other emergency.

Findings include:

1. On 9/13/201 the surveyor noted that the East Wing corridor had various types of equipment located on both sides of the corridor (carts, lift equipment, scale, etc). Said equipment was not temporarily parked for immediate use and staff were not observed using any of the equipment during the period of the survey.

2. On 9/13/2011 the surveyor noted that the main door of the kitchen was outfitted with a pad lock. Said log was not being used at the time of the inspection.

3. On 9/13/2011 the surveyor noted that the stairs leading from the basement to the public way was partially blocked by a refrigerator, tires and wooden pallets.

Based on observations the facility failed to maintain a safe environment by not properly securing compressed gas cylinders as is required by 4-3.1.1.2(a)3 NFPA 99.

Failure on the part of the facility to properly secure oxygen cylinders could allow them to topple and become missiles should their valves brake while toppling over. This puts patients, staff and visitors at risk of serious injury and death.

Findings include:

1. On 9/13/2011 the surveyor noted two K cylinders (oxygen and nitrous oxide) in the operating room anesthesia closet that were not secured in a manner that would prevent them from toppling over.

Based on observation the facility failed to provide a medical gas system in compliance with NFPA 99, Chapter 4. More specifically the requirements of Chapter 4-3.1.2.7 Piping Materials.

Failure to provide a medical gas system in compliance with NFPA 99 requirements puts patients at risk of harm from the inhalation of impure medical gases.

Findings include:

1. On 9/13/2011 the surveyor noted that copper piping identified as that serving the medical air system (located near the west wing exit) had soldered joints that were not brazed as is required.

Based on observation and interview the facility failed to provide an essential electrical system (EES) in accordance with NFPA 99. More specifically those sections dealing with alarms and containment.

Failure on the part of the facility to meet the requirements of NFPA 99 puts patients, staff and visitors of the facility at risk from power outages.

Findings include:

1. On 9/13/2011 the surveyor noted that the 70 Kw generator was not secured/locked so as to minimize the potential of vandalism. (see Chapter 5-2.4 NFPA 110, 1999 edition)

2. On 9/13/2011 during a tour of the facility the surveyor was informed by Staff Member #7 that the remote annunciator for the 70 Kw generator was located in the old ICU unit (cardiac rehab) which is not staffed after hours. Code requires the annunciator to be continuously monitored. (see Chapter 3-4.1.1.15 NFPA 99, 1999 edition)

3. On 9/13/2011 the surveyor noted that the main generator room was being used to store various combustible materials. Code prohibits storage in the generator room. (see Chapter 5-11.1 NFPA 110, 1999 edition)

Based on observation and interview the facility failed to provide a medical gas system that has master alarm panels located in two separate locations as is required.

Failure on the part of the facility to provide master alarms in two separated locations puts patients at risk of not having an uninterrupted supply of oxygen.

Findings include:

1. On 9/13/2011 the surveyor noted that a master alarm for the medical gas system was located in a continuously occupied location (nurses station). On the same date the surveyor was informed that the system lacked a second master alarm, more specifically a second master alarm located in the principle working area of the individual responsible for the maintenance of the medical gas system; i.e. physical plant office.

2. On 9/13/2011 the surveyor was informed by Staff Member #7 that the medical air system was not provide with alarms in a 24 hour manned station or the shop (principle working area of the individual responsible for system maintenance).

3. On 9/13/2011 the surveyor noted that the medical air alarm monitoring system for carbon monoxide and dew point detection was not plugged into a power supply making it non-functional. It was further noted that logs kept for the alarm had not been maintained since March of 2011.

Based on observation the facility failed provide wiring solutions in accordance with NFPA 70, National Electrical Code.

Failure on the part of the facility to provide wiring as required puts patients, staff and visitors of the facility at risk of electrical shock or fire.

Findings include:

1. On 9/13/2011 the surveyor noted the following violations:
a) Two control boxes serving the kitchen pantry walk-ins were open;
b) An extension cord was being used as a permanent source of power for a grinder and light unit;
c)Two electrical receptacles in the shop lacked covers;
d) An extension cord was connected to a power strip in the film storage room;
e) Electrical receptacles in patient care areas such as cardiac rehab and imaging were not hospital grade;
f) 70 KW generator not fully secured;
g) Breaker box serving generator was not secured or labeled;
h) Breakers labels in 3 of 4 panels located in the ICU electrical room did not have current information; and
i) A power strip supplying power to a printer was connected to an extension cord.