HospitalInspections.org

Based on observation the facility failed to ensure that all roller latches were removed from patient doors and that the doors had positive latching devices which would keep the doors closed. This affects all patients in a census of 13. Findings included:
During tour of the hospital on 8/3/10 it was noted that 15 out of 15 patient room doors had roller latches on the doors. The roller latch to room 105 was observed to be broken.
A roller latch does not positively latch and when the door closes a plastic roller rests in a shallow channel on the door frame and when closed the door can be pushed open. A positive latching device would keep the door closed and require a knob or handle to be opened again. A roller latch would not keep the door in the closed position securely.

Based on observation the facility failed to ensure that all doors in a fire or smoke rated enclosure fully closed and that the areas above rated enclosure doors were properly protected to prevent the spread of fire or smoke in the facility. This was observed in five sections of the facility.
Observation during tour of the facility on 8/3/10 revealed a set of double doors at the end of the patient hall way leading to the clinic area. These doors were held open by electromagnetic closers designed to release the doors upon activation of the fire alarm system. When released the doors the doors did not fully close. The doors were shut again and did not close fully.
During building tour on 8/4/10 a set of double doors was observed leading to the emergency department and were held open by an electromagnetic closer designed to release upon activation of the fire alarm system. When released, one of the doors remained in the open position. When tried again the door remained open and needed to be pulled shut manually. It was noted that the door had left marks on the floor and contacted the floor when fully open which held it in the open position.
It was observed on 8/4/10 that the main supply/storage area for the facility (considered a hazardous area due to amount of storage) had a door to the maintenance offices. The door which led to the maintenance offices did not have an automatic closer on the door and was observed in the open position. It remained in the open position on two different visits to the area that day. The door is in place to provide separation for the storage area and to prevent spread of fire or smoke in event of fire. Without an automatic closer or hold open on the door it did not provide this protection.
Observation above the ceiling and over rated fire doors near room 113 revealed that there was an opening approximately two foot by two foot which had been made around the sprinkler pipes and other wires passing through the area. This area above the doors should be properly sealed or free from penetrations which would allow the passage of smoke or fire above the ceiling.
Observation on 8/3/10 of the ceiling area above the doorway which led from the patient care area to the dietary hallway was observed to be open on both sides. The area was not sealed or otherwise constructed to prevent the spread of smoke or fire above this fire rated enclosure.
Due to the doors not closing fully they would not prevent the spread of fire or smoke from one area to another and are required doors in this type of enclosure. The areas above the ceiling due to lack of appropriate construction or repair after penetrations had been made would not prevent the spread of smoke or fire.

Based on interview the facility failed to ensure that fire drills were conducted for the education of staff persons at least quarterly. This affects all persons in a census of 13 at time of admission. Findings included:
During an interview on 8/4/10 at 11:22 AM Staff CC stated that he has been employed at the facility for about one and a half years and is responsible for fire drills. Fire drills have not been conducted since he has been employed at the facility.
No drills have been done for other emergency type drills such as tornado or earthquake preparedness. There have been no community disaster drills in which the facility includes other community entities also involved in disaster preparedness.

Based on observation and record review the facility failed to ensure that the sprinkler system was tested quarterly as required by the 2000 Life Safety Code and sprinkler components were maintained to provide sprinkler protection for those areas of the facility that had sprinkler protection. This affects all persons in a census of 13. Findings included:
1. Review of the document for the most recent sprinkler inspection revealed that it occurred on 3/17/10.
2. During an interview on 8/4/10 at 1:35 PM Staff CC stated that the previous inspection had occurred on 4/2009. No other inspections had occurred than the two that had been done annually.
3. Observation on 8/4/10 of the business office revealed that one of six sprinkler heads in the area had lost the escutcheon (metal cup to aid sprinkler in position and function) and was positioned above the ceiling tile. This sprinkler would not provide coverage to the area as designed.
4. The room in which the computerized tomography (CT) radiological machine was had two sprinkler heads in the area and both of the sprinkler heads had missing escutcheons which would help the sprinkler heads maintain position within the ceiling and assure proper function of the sprinkler head.
The National Fire Protection Association under Code 25 for testing and maintenance of sprinkler systems requires:
Chapter 9-2.7 states that all water flow alarms shall be tested quarterly in accordance with the manufacturer's instructions.
Chapter 9-2.3 states that all system valves shall be protected from physical damage and shall be accessible.
Chapter 9-2.8 states that gauges shall be inspected monthly to verify that they are in good condition and that normal pressure is being maintained.
Chapter 9-2.8.2 states that gauges shall be replaced every five years or tested every five years by comparison with a calibrated gauge.
9-3.2.3 states that all valves shall be inspected weekly.
Chapter 9-3.4.1 states that each control valve shall be operated annually through its full range and returned to its normal position.
Chapter 9-3.4.3 states that valve supervisory switches shall be tested semiannually.

Based on observation the facility failed to ensure that all compressed medical gas cylinders were individually secured and protected from falling. Findings included:
Observation during tour on 8/4/10 revealed that a metal cage contained 12 "H" size (larger cylinders) of compressed medical gasses. The tanks were separated by a metal partition in the middle of the cage with six tanks on each side. Each group of six tanks was secured by one chain across the front of the tanks. One smaller compressed gas cylinder was labeled "acetylene" and was on the floor of the enclosure with no method to secure it from falling.
Observation of the tanks in the enclosure of the main oxygen supply (liquid oxygen tank) revealed 12 "H" size tanks secured by one chain in a fenced enclosure.
Chapter 5.1.3.3.2 of the National Fire Protection Association's code 99 for health care facilities states that locations for central supply systems and the storage of medical gases shall meet the following requirements: (7) be provided with racks, chains, or other fastenings to individually secure all cylinder, whether connected, unconnected, full, or empty from falling.

Based on observation the facility failed to ensure that all inoperable fire alarm devices are removed from use. Findings included:
During tour of the facility the following items were noted to have a sticker placed on the item with the phrase "abandoned fire alarm device, do not use". All items were still in place.
Two smoke detectors and two fire alarm bells in the hall near the therapy area. A manual pull station near room 113. In the patient care area two lighted indicators for the sprinkler system and one alarm bell.
Chapter 4.6.12.2 of the 2000 Life Safety code states that existing life safety features obvious to the public, if not required by the Code (Life Safety Code), shall be either maintained or removed.
Appendix A for this requirement states that the presence of a life safety feature, such as sprinklers or fire alarm devices, creates a reasonable expectation by the public that these safety features are functional. When systems are inoperable or taken out of service both devices remain, they present a false sense of safety. Also before taking any life safety features out of service, extreme care needs to be exercised to ensure that the feature is not required, was not originally provided as an alternative or equivalency, or is no longer required due to other new requirements in the current code. It is not intended that the entire system or protection feature be removed. Instead, components such as sprinklers, initiating devices, notification appliances, standpipe hose, and exit systems should be removed to reduce the likelihood of relying on inoperable systems or features.

Based on record review and interview the facility failed to ensure that the generator was tested under load at least monthly. This affects all persons in a census of 13. Findings included:
Record review of the generator records revealed that the generator ran weekly and was started automatically. No portion of the record indicated that the generator had been run at least monthly under a load (supplied power to facility), only that it had run as indicated by hour meter readings.
During an interview on 8/4/10 at 1:47 PMStaff CC stated that the generator was last put under a load and tested about one year ago. It was last year about this same time of year that a contracted company had performed this test.
Chapter 8.3.2 of the 2002 edition of the National Fire Protection Association code 110 for emergency power systems states that a routine maintenance and operational testing program shall be initiated immediately after the generator has passed acceptance tests.
8.3.4 states that a written record of the generator inspections, tests, exercising, operation, and repairs shall be maintained on the premises.
8.4.1 states that generators shall be inspected weekly and exercised under load at least monthly.

Based on interview the facility failed to ensure that a policy or procedure was in place for alternative provisions to be utilized when the fire alarm system was out of service as required by the 2000 Life Safety Code. This affects all persons in a census of 13. Findings included:
During an interview on 8/4/10 at 11:22 AM Staff CC stated that maintenance staff persons thought there was a policy for alternative provisions for when the fire alarm system was out of service but that this policy/procedure could not be located. At the conclusion of the survey there still had been no policy found concerning the impairment of the fire alarm system when it occurred for a total of more than four hours in 24 hour period.
The facility had no policy or procedure to evacuate the facility or implement a fire watch when the alarm system was out of service.

Based on interview the facility failed to ensure that a policy or procedure was in place for alternative provisions to be utilized when the fire alarm system was out of service as required by the 2000 Life Safety Code. This affects all persons in a census of 13. Findings included:
During an interview on 8/4/10 at 11:22 AM Staff CC stated that maintenance staff persons thought there was a policy for alternative provisions for when the fire alarm system was out of service but that this policy/procedure could not be located. At the conclusion of the survey there still had been no policy found concerning the impairment of the fire alarm system when it occurred for a total of more than four hours in 24 hour period.
The facility had no policy or procedure to evacuate the facility or implement a fire watch when the alarm system was out of service.

Based on observation the facility failed to ensure that all roller latches were removed from patient doors and that the doors had positive latching devices which would keep the doors closed. This affects all patients in a census of 13. Findings included:
During tour of the hospital on 8/3/10 it was noted that 15 out of 15 patient room doors had roller latches on the doors. The roller latch to room 105 was observed to be broken.
A roller latch does not positively latch and when the door closes a plastic roller rests in a shallow channel on the door frame and when closed the door can be pushed open. A positive latching device would keep the door closed and require a knob or handle to be opened again. A roller latch would not keep the door in the closed position securely.

Based on observation the facility failed to ensure that all doors in a fire or smoke rated enclosure fully closed and that the areas above rated enclosure doors were properly protected to prevent the spread of fire or smoke in the facility. This was observed in five sections of the facility.
Observation during tour of the facility on 8/3/10 revealed a set of double doors at the end of the patient hall way leading to the clinic area. These doors were held open by electromagnetic closers designed to release the doors upon activation of the fire alarm system. When released the doors the doors did not fully close. The doors were shut again and did not close fully.
During building tour on 8/4/10 a set of double doors was observed leading to the emergency department and were held open by an electromagnetic closer designed to release upon activation of the fire alarm system. When released, one of the doors remained in the open position. When tried again the door remained open and needed to be pulled shut manually. It was noted that the door had left marks on the floor and contacted the floor when fully open which held it in the open position.
It was observed on 8/4/10 that the main supply/storage area for the facility (considered a hazardous area due to amount of storage) had a door to the maintenance offices. The door which led to the maintenance offices did not have an automatic closer on the door and was observed in the open position. It remained in the open position on two different visits to the area that day. The door is in place to provide separation for the storage area and to prevent spread of fire or smoke in event of fire. Without an automatic closer or hold open on the door it did not provide this protection.
Observation above the ceiling and over rated fire doors near room 113 revealed that there was an opening approximately two foot by two foot which had been made around the sprinkler pipes and other wires passing through the area. This area above the doors should be properly sealed or free from penetrations which would allow the passage of smoke or fire above the ceiling.
Observation on 8/3/10 of the ceiling area above the doorway which led from the patient care area to the dietary hallway was observed to be open on both sides. The area was not sealed or otherwise constructed to prevent the spread of smoke or fire above this fire rated enclosure.
Due to the doors not closing fully they would not prevent the spread of fire or smoke from one area to another and are required doors in this type of enclosure. The areas above the ceiling due to lack of appropriate construction or repair after penetrations had been made would not prevent the spread of smoke or fire.

Based on interview the facility failed to ensure that fire drills were conducted for the education of staff persons at least quarterly. This affects all persons in a census of 13 at time of admission. Findings included:
During an interview on 8/4/10 at 11:22 AM Staff CC stated that he has been employed at the facility for about one and a half years and is responsible for fire drills. Fire drills have not been conducted since he has been employed at the facility.
No drills have been done for other emergency type drills such as tornado or earthquake preparedness. There have been no community disaster drills in which the facility includes other community entities also involved in disaster preparedness.

Based on observation and record review the facility failed to ensure that the sprinkler system was tested quarterly as required by the 2000 Life Safety Code and sprinkler components were maintained to provide sprinkler protection for those areas of the facility that had sprinkler protection. This affects all persons in a census of 13. Findings included:
1. Review of the document for the most recent sprinkler inspection revealed that it occurred on 3/17/10.
2. During an interview on 8/4/10 at 1:35 PM Staff CC stated that the previous inspection had occurred on 4/2009. No other inspections had occurred than the two that had been done annually.
3. Observation on 8/4/10 of the business office revealed that one of six sprinkler heads in the area had lost the escutcheon (metal cup to aid sprinkler in position and function) and was positioned above the ceiling tile. This sprinkler would not provide coverage to the area as designed.
4. The room in which the computerized tomography (CT) radiological machine was had two sprinkler heads in the area and both of the sprinkler heads had missing escutcheons which would help the sprinkler heads maintain position within the ceiling and assure proper function of the sprinkler head.
The National Fire Protection Association under Code 25 for testing and maintenance of sprinkler systems requires:
Chapter 9-2.7 states that all water flow alarms shall be tested quarterly in accordance with the manufacturer's instructions.
Chapter 9-2.3 states that all system valves shall be protected from physical damage and shall be accessible.
Chapter 9-2.8 states that gauges shall be inspected monthly to verify that they are in good condition and that normal pressure is being maintained.
Chapter 9-2.8.2 states that gauges shall be replaced every five years or tested every five years by comparison with a calibrated gauge.
9-3.2.3 states that all valves shall be inspected weekly.
Chapter 9-3.4.1 states that each control valve shall be operated annually through its full range and returned to its normal position.
Chapter 9-3.4.3 states that valve supervisory switches shall be tested semiannually.

Based on observation the facility failed to ensure that all compressed medical gas cylinders were individually secured and protected from falling. Findings included:
Observation during tour on 8/4/10 revealed that a metal cage contained 12 "H" size (larger cylinders) of compressed medical gasses. The tanks were separated by a metal partition in the middle of the cage with six tanks on each side. Each group of six tanks was secured by one chain across the front of the tanks. One smaller compressed gas cylinder was labeled "acetylene" and was on the floor of the enclosure with no method to secure it from falling.
Observation of the tanks in the enclosure of the main oxygen supply (liquid oxygen tank) revealed 12 "H" size tanks secured by one chain in a fenced enclosure.
Chapter 5.1.3.3.2 of the National Fire Protection Association's code 99 for health care facilities states that locations for central supply systems and the storage of medical gases shall meet the following requirements: (7) be provided with racks, chains, or other fastenings to individually secure all cylinder, whether connected, unconnected, full, or empty from falling.

Based on observation the facility failed to ensure that all inoperable fire alarm devices are removed from use. Findings included:
During tour of the facility the following items were noted to have a sticker placed on the item with the phrase "abandoned fire alarm device, do not use". All items were still in place.
Two smoke detectors and two fire alarm bells in the hall near the therapy area. A manual pull station near room 113. In the patient care area two lighted indicators for the sprinkler system and one alarm bell.
Chapter 4.6.12.2 of the 2000 Life Safety code states that existing life safety features obvious to the public, if not required by the Code (Life Safety Code), shall be either maintained or removed.
Appendix A for this requirement states that the presence of a life safety feature, such as sprinklers or fire alarm devices, creates a reasonable expectation by the public that these safety features are functional. When systems are inoperable or taken out of service both devices remain, they present a false sense of safety. Also before taking any life safety features out of service, extreme care needs to be exercised to ensure that the feature is not required, was not originally provided as an alternative or equivalency, or is no longer required due to other new requirements in the current code. It is not intended that the entire system or protection feature be removed. Instead, components such as sprinklers, initiating devices, notification appliances, standpipe hose, and exit systems should be removed to reduce the likelihood of relying on inoperable systems or features.

Based on record review and interview the facility failed to ensure that the generator was tested under load at least monthly. This affects all persons in a census of 13. Findings included:
Record review of the generator records revealed that the generator ran weekly and was started automatically. No portion of the record indicated that the generator had been run at least monthly under a load (supplied power to facility), only that it had run as indicated by hour meter readings.
During an interview on 8/4/10 at 1:47 PMStaff CC stated that the generator was last put under a load and tested about one year ago. It was last year about this same time of year that a contracted company had performed this test.
Chapter 8.3.2 of the 2002 edition of the National Fire Protection Association code 110 for emergency power systems states that a routine maintenance and operational testing program shall be initiated immediately after the generator has passed acceptance tests.
8.3.4 states that a written record of the generator inspections, tests, exercising, operation, and repairs shall be maintained on the premises.
8.4.1 states that generators shall be inspected weekly and exercised under load at least monthly.

Based on interview the facility failed to ensure that a policy or procedure was in place for alternative provisions to be utilized when the fire alarm system was out of service as required by the 2000 Life Safety Code. This affects all persons in a census of 13. Findings included:
During an interview on 8/4/10 at 11:22 AM Staff CC stated that maintenance staff persons thought there was a policy for alternative provisions for when the fire alarm system was out of service but that this policy/procedure could not be located. At the conclusion of the survey there still had been no policy found concerning the impairment of the fire alarm system when it occurred for a total of more than four hours in 24 hour period.
The facility had no policy or procedure to evacuate the facility or implement a fire watch when the alarm system was out of service.

Based on interview the facility failed to ensure that a policy or procedure was in place for alternative provisions to be utilized when the fire alarm system was out of service as required by the 2000 Life Safety Code. This affects all persons in a census of 13. Findings included:
During an interview on 8/4/10 at 11:22 AM Staff CC stated that maintenance staff persons thought there was a policy for alternative provisions for when the fire alarm system was out of service but that this policy/procedure could not be located. At the conclusion of the survey there still had been no policy found concerning the impairment of the fire alarm system when it occurred for a total of more than four hours in 24 hour period.
The facility had no policy or procedure to evacuate the facility or implement a fire watch when the alarm system was out of service.