HospitalInspections.org

Based on observation the facility failed to provide an adequate corridor door.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 9:30 am to 1:30 pm on 1/30/2014 that the Break Room did not have a latch on the corridor door.

Based on observation the facility failed to provide adequate smoke barriers.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 9:30 am to 1:30 pm on 1/30/2014 that there were penetrations in the smoke barriers at the following locations: the public entry to the ER, at Health Information Services, at Exam and Treatment, and Room 119. Also, at the Store Room the surfacing material was completely missing on one side of the smoke barrier wall, and at Room 119 the wall did not continue to the deck.

Based on observation the facility failed to provide adequate hazardous area separation.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 9:30 am to 1:30 pm on 1/30/2014 that the Pantry did not have a closer.

Based on observation the facility failed to provide adequate fire sprinklers.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 9:30 am to 1:30 pm on 1/30/2014 that there was:

1) A missing head in the Water Heater Closet.
2) Light fixtures interfering with the spray pattern of the heads in the Receiving Room.

Based on observation the facility failed to provide adequate fire extinguishers.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 9:30 am to 1:30 pm on 1/30/2014 that the fire extinguisher did not have an inspection tag at the Utility for Housekeeping.

Based on observation the facility failed to provide adequate medical gas storage.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 9:30 am to 1:30 pm on 1/30/2014 that the bulk oxygen tank did not have a " No Parking " sign.

Based on observation the facility failed to provide adequate Essential Electrical System, EES.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 9:30 am to 1:30 pm on 1/30/2014 that the generator location did not have a light with a 90 minute battery backup and a receptacle on emergency power.

Receptacle Testing in Patient Care Areas - NFFA 99, 1999, 3-3.3.3

(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

NFPA 99, 1999, 3-3.4.2.3(a) states that testing shall be performed after initial installation, replacement or servicing of a device, and that additional testing shall be performed at intervals defined by documented performance data. Since data is not typically available from the manufacturer, the facility may document the failure rates of the receptacles and provide a testing schedule that will safeguard their patients. This shall be done by the Safety Committee, approved by the Governing Board, and written into the safety policies and procedures. H.L.R. 2007, ?133.142. Until this assessment has been done, receptacle testing shall be performed in all general care areas every 12 months and in critical care areas every 6 months. (NFPA 99, 1984).

Based on observation the facility failed to provide a complete record for receptacle testing per NFPA 99: 3-3.3.3. in patient care areas.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 9:30 am to 1:30 pm on 1/30/2014 that the records did not have all of the tests listed, and that the Critical Areas (OR, ER, and PACU) were not being tested twice a year.


Fuel and Water Preferred Customer Status

" Continuity of Essential Building Systems. When designated by the emergency preparedness management plan to provide continuous service in a disaster or emergency, health care facilities shall establish contingency plans for the continuity of essential building systems, as applicable: (a) Electricity, (b) Water, (c) Ventilation, (d) Fire protection systems, (e) Fuel sources, (f) Medical gas and vacuum systems (if applicable), (g) Communications systems. " - NFPA 99, 1999, 11-5.3.2

Based on observation the facility failed to provide letters from vendors for emergency fuel and water.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 9:30 am to 1:30 pm on 1/30/2014 that the facility did not have preferred customer status letters from suppliers/vendors for fuel and water.

Based on observation the facility failed to provide an adequate electrical system.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 9:30 am to 1:30 pm on 1/30/2014 that there were the following issues.

1) Panel F, breaker 11 had the power for the FACP. This panel was not identified as an " EMERGENCY " panel and the panel name, " F " , was not printed at the top of the panel.

2) The critical outlets in the OR and ER must have permanent labels identifying the panel/breaker that supplies power to the outlet.

Based on observation the facility failed to provide an adequate corridor door.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 9:30 am to 1:30 pm on 1/30/2014 that the Break Room did not have a latch on the corridor door.

Based on observation the facility failed to provide adequate smoke barriers.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 9:30 am to 1:30 pm on 1/30/2014 that there were penetrations in the smoke barriers at the following locations: the public entry to the ER, at Health Information Services, at Exam and Treatment, and Room 119. Also, at the Store Room the surfacing material was completely missing on one side of the smoke barrier wall, and at Room 119 the wall did not continue to the deck.

Based on observation the facility failed to provide adequate hazardous area separation.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 9:30 am to 1:30 pm on 1/30/2014 that the Pantry did not have a closer.

Based on observation the facility failed to provide adequate fire sprinklers.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 9:30 am to 1:30 pm on 1/30/2014 that there was:

1) A missing head in the Water Heater Closet.
2) Light fixtures interfering with the spray pattern of the heads in the Receiving Room.

Based on observation the facility failed to provide adequate fire extinguishers.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 9:30 am to 1:30 pm on 1/30/2014 that the fire extinguisher did not have an inspection tag at the Utility for Housekeeping.

Based on observation the facility failed to provide adequate medical gas storage.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 9:30 am to 1:30 pm on 1/30/2014 that the bulk oxygen tank did not have a " No Parking " sign.

Based on observation the facility failed to provide adequate Essential Electrical System, EES.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 9:30 am to 1:30 pm on 1/30/2014 that the generator location did not have a light with a 90 minute battery backup and a receptacle on emergency power.

Receptacle Testing in Patient Care Areas - NFFA 99, 1999, 3-3.3.3

(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

NFPA 99, 1999, 3-3.4.2.3(a) states that testing shall be performed after initial installation, replacement or servicing of a device, and that additional testing shall be performed at intervals defined by documented performance data. Since data is not typically available from the manufacturer, the facility may document the failure rates of the receptacles and provide a testing schedule that will safeguard their patients. This shall be done by the Safety Committee, approved by the Governing Board, and written into the safety policies and procedures. H.L.R. 2007, ?133.142. Until this assessment has been done, receptacle testing shall be performed in all general care areas every 12 months and in critical care areas every 6 months. (NFPA 99, 1984).

Based on observation the facility failed to provide a complete record for receptacle testing per NFPA 99: 3-3.3.3. in patient care areas.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 9:30 am to 1:30 pm on 1/30/2014 that the records did not have all of the tests listed, and that the Critical Areas (OR, ER, and PACU) were not being tested twice a year.


Fuel and Water Preferred Customer Status

" Continuity of Essential Building Systems. When designated by the emergency preparedness management plan to provide continuous service in a disaster or emergency, health care facilities shall establish contingency plans for the continuity of essential building systems, as applicable: (a) Electricity, (b) Water, (c) Ventilation, (d) Fire protection systems, (e) Fuel sources, (f) Medical gas and vacuum systems (if applicable), (g) Communications systems. " - NFPA 99, 1999, 11-5.3.2

Based on observation the facility failed to provide letters from vendors for emergency fuel and water.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 9:30 am to 1:30 pm on 1/30/2014 that the facility did not have preferred customer status letters from suppliers/vendors for fuel and water.

Based on observation the facility failed to provide an adequate electrical system.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 9:30 am to 1:30 pm on 1/30/2014 that there were the following issues.

1) Panel F, breaker 11 had the power for the FACP. This panel was not identified as an " EMERGENCY " panel and the panel name, " F " , was not printed at the top of the panel.

2) The critical outlets in the OR and ER must have permanent labels identifying the panel/breaker that supplies power to the outlet.