HospitalInspections.org

Based on observation and facility staff interview, the facility staff failed to ensure the building construction Type II (111) was maintained. Failure to maintain the construction type puts the patients, staff and visitors at risk in a fire by increasing the flammability of the structural frame of the building from fire. This facility had a capacity of 58. The facility census was 31.

Observations made 2/13/2019 at approximately 12:08 P.M., of the smoking building, showed a covered 10 feet by 12 feet enclosure. Observation showed the enclosure had a 2x4 wood frame construction Type V(000), did not contain sprinkler coverage, contained electrical service for a light fixture and an electrical receptacle. Observation showed a trash receptacle with an attached ash tray approximately half full of cigarette butts and a clay plant pot containing a large quantity of cigarette butts. Observation showed the wood structure measured approximately three feet from the hospital exterior wall.

Record review of NFPA 101, Life Safety Code, 2012 edition, showed Type V (000) construction standard required full sprinkler coverage.

During an interview on 2/13/2020 at approximately 4:54 P.M., the facility Maintenance Manager said entrance enclosure was built around 2005.

Based on observation, the facility failed to provide signage on one exit access door equipped with a delayed locking device. This deficient practice has the potential to affect patients, staff and visitors. Additionally, facility staff failed to ensure locks in a means of egress could be quickly unlocked to allow evacuation of the building in the event of a fire or other emergency. Failure to provide signage indicating a delayed lock door release procedure on an exit door has the potential to delay exiting the building in the event of an emergency. The census was 31.

1. Observation on 2/13/2020, during the facility tour, showed the designated exit door in the nursery unit equipped with a delayed egress locking mechanism. Observation did not show a sign adjacent to the locking device indicating the locking mechanism procedure.


7.2.1.6.1 Delayed-Egress Locking Systems.
7.2.1.6.1.1 Approved, listed, delayed-egress locking systems
shall be permitted to be installed on door assemblies serving
low and ordinary hazard contents in buildings protected
throughout by an approved, supervised automatic fire detection
system in accordance with Section 9.6 or an approved,
supervised automatic sprinkler system in accordance with Section
9.7, and where permitted in Chapters 11 through 43, provided
that all of the following criteria are met:
(1) The door leaves shall unlock in the direction of egress
upon actuation of one of the following:
(a) Approved, supervised automatic sprinkler system in
accordance with Section 9.7
(b) Not more than one heat detector of an approved,
supervised automatic fire detection system in accordance
with Section 9.6
(c) Not more than two smoke detectors of an approved,
supervised automatic fire detection system in accordance
with Section 9.6
(2) The door leaves shall unlock in the direction of egress upon
loss of power controlling the lock or locking mechanism.
(3)*An irreversible process shall release the lock in the direction
of egress within 15 seconds, or 30 seconds where approved
by the authority having jurisdiction, upon application
of a force to the release device required in 7.2.1.5.10
under all of the following conditions:
(a) The force shall not be required to exceed 15 lbf (67 N).
(b) The force shall not be required to be continuously
applied for more than 3 seconds.
(c) The initiation of the release process shall activate an
audible signal in the vicinity of the door opening.
(d) Once the lock has been released by the application of
force to the releasing device, relocking shall be by
manual means only.
(4)*A readily visible, durable sign in letters not less than 1 in.
(25 mm) high and not less than 1.8 in. (3.2 mm) in stroke
width on a contrasting background that reads as follows
shall be located on the door leaf adjacent to the release
device in the direction of egress:
PUSH UNTILALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS
(5) The egress side of doors equipped with delayed-egress
locks shall be provided with emergency lighting in accordance
with Section 7.9.


2. Observation on 2/12-13/2020, during the facility tour, showed the double doors on the Emergency Department/Outpatient #1 hallway designated exit double doors equipped with magnetic locking devices. Observation showed the locks had a release switch on the wall adjacent to the doors. Observation showed the corridor measured approximately 42 feet long, was a designated exit per the facility evacuation plan, did not contain an exit sign and was locked at night (blocks exit access).

3. Observations on 2/12-13/2020 showed the access/exit doors on 2 of 2 courtyards had the means to be locked from the interior of the building preventing exiting from the courtyards.

During an interview 2/13/2020 at 4:51 P.M., the facility Maintenance Manager said he/she did not know the code requirements for locking arrangements.

NFPA 101, 2012 edition, Section 19.2.2.2.6 states:

"19.2.2.2.6 Doors that are located in the means of egress and are
permitted to be locked under other provisions of 19.2.2.2.5 shall
comply with all of the following:
(1) Provisions shall be made for the rapid removal of occupants
by means of one of the following:
(a) Remote control of locks
(b) Keying of all locks to keys carried by staff at all times
(c) Other such reliable means available to the staff at all
times
(2) Only one locking device shall be permitted on each door.
(3) More than one lock shall be permitted on each door, subject
to approval of the authority having jurisdiction."

Based on observation, staff interview, and record review, the facility staff failed to provide continuously maintained exit ways free of all obstructions or impediments continuous to a public way such as a parking lot. This deficient practice has the potential to affect all patients, staff and visitors in the facility. Failure to ensure exterior exit ways comply with LSC requirements could delay evacuation out of the building in the event of a fire or other emergency. The facility census was 31.

1. Observation on 2/13/2020 at approximately 1:11 P.M., during the facility tour, showed the ICU hallway exit discharge area led to a grass covered yard that required residents, staff, and visitors to traverse approximately 100 feet of grass to reach the parking lot.


Record review of the facility layout showed the exit discharge area designated for patient, staff and visitors use.

During an interview on 2/13/2020 at 4:55 P.M., the facility Maintenance Manager said the building was constructed in 2002 and never had a sidewalk.


The National Fire Protection Association 101, Life Safety Code 2012 Edition, section 7.7 states:


7.7 Discharge from Exits.

7.7.1* Exit Termination. Exits shall terminate directly, at a
public way or at an exterior exit discharge, unless otherwise
provided in 7.7.1.2 through 7.7.1.4.

Based on observation and facility staff interview, facility staff failed to provide emergency lighting not controlled by light switches. This deficient practice has the potential to affect all patients, staff and visitors within the facility. Failure to provide emergency lighting could prevent proper illumination of required areas in the event of power loss. The facility census was 31.

1. Observations on 2/12-13/2020, during the Life Safety Code (LCS) tour, showed the following light fixtures in the facility controlled by light switches:

-Emergency department medication room,

-Med surge medication room,

-Operating rooms.


During an interview on 2/13/2020 at 4:52 P.M., the facility Maintenance Manager said he/she did not know the emergency light code requirements.

NFPA 99, 2012 edition, section 6.4.2.2.4.2 states:

"6.4.2.2.4.2 The critical branch shall supply power for task illumination,
fixed equipment, select receptacles, and select power
circuits serving the following areas and functions related to patient
care:
(1) Critical care areas that utilize anesthetizing gases, task illumination,
select receptacles, and fixed equipment
(2) Isolated power systems in special environments
(3) Task illumination and select receptacles in the following:
(a) Patient care rooms, including infant nurseries, selected
acute nursing areas, psychiatric bed areas (omit receptacles),
and ward treatment rooms
(b) Medication preparation areas
(c) Pharmacy dispensing areas
(d) Nurses ' stations (unless adequately lighted by corridor
luminaires)
(4) Additional specialized patient care task illumination and
receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7)*Telephone equipment rooms and closets
(8) Task illumination, select receptacles, and select power circuits
for the following areas:
(a) General care beds with at least one duplex receptacle
per patient bedroom, and task illumination as required
by the governing body of the health care facility
(b) Angiographic labs
(c) Cardiac catheterization labs
(d) Coronary care units
(e) Hemodialysis rooms or areas
(f) Emergency room treatment areas (select)
(g) Human physiology labs
(h) Intensive care units
(i) Postoperative recovery rooms (select)
(9) Additional task illumination, receptacles, and select power
circuits needed for effective facility operation, including
single-phase fractional horsepower motors, which are permitted
to be connected to the critical branch"

Based on record review and facility staff interview, facility staff did not ensure all devices connected to the fire alarm system were inspected, tested and maintained per NFPA 72, National Fire Alarm and Signaling Code, 2010 edition. Additionally, facility staff failed to ensure fire alarm signaling devices were installed at all required locations. The facility census was 31.

1. Record review of the annual fire alarm inspection dated 6/27/2019 did not show the ortho roll down at the reception window was tested with the fire alarm.

2. Record review of the Special Hazards Inspection Report dated 1/16/2020, of the clean agent extinguishing system in the phone room, showed the following deficiencies:

"#1 The abort is seen at the panel but does not abort the agent release during countdown,
#2 There is no audible for first alarm,
#3 the strobes inside of the room and outside are on the same circuit and only activate on discharge,
#4 The manual pull causes a trouble at the suppression panel when activated and not an alarm,
The issues appear to be in the programming"

3. Observation showed two of two courtyards did not contain a fire alarm signaling/sounding device.

During an interview on 2/13/2020, the facility Maintenance Manager said he/she believed the fire alarm company installed and tested the fire alarm systems per code requirements. Additionally, he/she said the facility received the clean agent extinguishing system inspection report 2/13/2020.

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, Table 14.3.1, Table 14.4.2.2, Table 14.4.5, sections 14.4.5, 14.4.5.3.1 through section 14.4.5.4 for additional testing information.

Based on facility staff interview and record review, facility staff failed to inspect four of four wet sprinkler systems per NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition. This deficient practice has the potential to affect all patients, staff and visitors. Failure to inspect/test all components of the sprinkler system could prevent or delay activation of the sprinkler system in the event of a fire. The facility census was 31.

Record review on 03/12-13/2020 did not show the following testing, inspection and maintenance records:

- monthly gauge inspections,

- five year internal backflow prevention device inspections,

- quarterly testing,

- five year internal pipe inspections,

- five year gauge inspection/replacement records.

Record review of the annual sprinkler system's inspection report dated 2/13/2020 showed a note in the deficiencies section stating: "No inspector's test for the new addition riser."

During an interview on 02/13/2020 at 4:17 P.M., the facility Maintenance Manager said he/she believed the sprinkler inspection company did the inspections per code requirements.

Refer to NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition, Chapters 5 and 13 for additional information.

Based on facility staff interview and record review, facility staff failed to inspect, test and maintain the fire egress doors in accordance with the 2010 Editions of NFPA 80 (Standard for Fire Doors and Other Opening Protectives) and NFPA 105 (Standard for Fire Doors and Other Opening Protectives). The facility census was 31.

1. Review of the facility's inspection records did not show fire and smoke door inspections.

2. Observations on 2/12/2020 at approximately 5:00 P.M., of the surgical department showed a double corridor door assembly containing seven holes in each door. Observation showed the doors had 1 1/2 hour fire resistance labels attached.

3. Observation of operating room #3 at approximately 4:23 P.M., showed missing sections of the door covering on the door spine. Observation showed the missing door covering exposed the lead lining of the door.

4. Observations of the surgery department washer room corridor door showed multiple holes.

5. Observation of operating room #2 showed exposed wood at the bottom meeting edge of the door. Additionally, observation showed the wood covered with medical tape.

During an interview on 2/13/2019 at 4:27 P.M., the facility Maintenance Manager said he/she was unaware the required door inspections needed to be conducted by qualified outside vendors.


NFPA 101, 2012 Edition states:

19.2.2.2.1 Doors complying with 7.2.1 shall be permitted.

7.2.1.15 Inspection of Door Openings.

7.2.1.15.1* Where required by Chapters 11 through 43, the
following door assemblies shall be inspected and tested not
less than annually in accordance with 7.2.1.15.2 through
7.2.1.15.8:
(1) Door leaves equipped with panic hardware or fire exit
hardware in accordance with 7.2.1.7
(2) Door assemblies in exit enclosures
(3) Electrically controlled egress doors
(4) Door assemblies with special locking arrangements subject
to 7.2.1.6

7.2.1.15.2 Fire-rated door assemblies shall be inspected and
tested in accordance with NFPA 80, Standard for Fire Doors and
Other Opening Protectives. Smoke door assemblies shall be inspected
and tested in accordance with NFPA 105, Standard for
Smoke Door Assemblies and Other Opening Protectives.

7.2.1.15.3 The inspection and testing interval for fire-rated
and nonrated door assemblies shall be permitted to exceed 12
months under a written performance-based program in accordance
with 5.2.2 of NFPA 80, Standard for Fire Doors and Other
Opening Protectives.

7.2.1.15.4 A written record of the inspections and testing
shall be signed and kept for inspection by the authority having
jurisdiction.

7.2.1.15.5 Functional testing of door assemblies shall be performed
by individuals who can demonstrate knowledge and
understanding of the operating components of the type of
door being subjected to testing.

7.2.1.15.6 Door assemblies shall be visually inspected from
both sides of the opening to assess the overall condition of the
assembly.

7.2.1.15.7 As a minimum, the following items shall be verified:
(1) Floor space on both sides of the openings is clear of obstructions,
and door leaves open fully and close freely.
(2) Forces required to set door leaves in motion and move to
the fully open position do not exceed the requirements
in 7.2.1.4.5.
(3) Latching and locking devices comply with 7.2.1.5.
(4) Releasing hardware devices are installed in accordance
with 7.2.1.5.10.1.
(5) Door leaves of paired openings are installed in accordance
with 7.2.1.5.11.
(6) Door closers are adjusted properly to control the closing
speed of door leaves in accordance with accessibility requirements.
(7) Projection of door leaves into the path of egress does not
exceed the encroachment permitted by 7.2.1.4.3.
(8) Powered door openings operate in accordance with
7.2.1.9.
(9) Signage required by 7.2.1.4.1(3), 7.2.1.5.5, 7.2.1.6, and
7.2.1.9 is intact and legible.
(10) Door openings with special locking arrangements function
in accordance with 7.2.1.6
(11) Security devices that impede egress are not installed on
openings, as required by 7.2.1.5.12.

Based on record review and facility staff interview, the facility failed to ensure that all building systems had been assigned a risk assessment category and documented. The facility census was 31.

1. Review of the facility documents for fire safety, building system tests, and policies did not show categorical risk assessments for the building systems.

During an interview on 2/13/2020 at 4:24 P.M., the facility Maintenance Manager said he/she did not know the categorical risk assessments for building systems requirements.

The National Fire Protection Association 99 Health Care Facilities Code, 2012 edition, Chapter 4 states:

"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.

4.1.2* Category 2. Facility systems in which failure of such equipment
is likely to cause minor injury to patients or caregivers shall
be designed to meet system Category 2 requirements as defined
in this code.

4.1.3 Category 3. Facility systems in which failure of such equipment
is not likely to cause injury to patients or caregivers, but can
cause patient discomfort, shall be designed to meet system Category
3 requirements as defined in this code.

4.1.4 Category 4. Facility systems in which failure of such equipment
would have no impact on patient care shall be designed to
meet system Category 4 requirements as defined in this code.

4.2* Risk Assessment. Categories shall be determined by following
and documenting a defined risk assessment procedure.

4.3 Application. The Category definitions in Chapter 4 shall
apply to Chapters 5 through 11."

A.4.2 Risk assessment should follow procedures such as those
outlined in ISO/IEC 31010, Risk Management-Risk Assessment
Techniques, NFPA 551, Guide for the Evaluation of Fire Risk Assessments,
Guide for the Evaluation of Fire Risk Assessments, SEMI S10-
0307E, Safety Guideline for Risk Assessment and Risk Evaluation
Process, or other formal process. The results of the assessment
procedure should be documented and records retained.

Based on record review and facility staff interview, facility staff failed to categorize the medical gas, med air, surgical vacuum, WAGD, and supply air systems. The facility census was 31.

1. Review of the facility documents for fire safety, building system tests, and policies did not show categorical risk assessments for the gas, air and vacuum systems.

During an interview on 2/13/2020 at 4:25 P.M., with the facility Maintenance Manager, he/she said he/she did not know the categorical risk assessment regulations.

Refer to NFPA 99, 2012 edition, Chapter 5 for medical gas system requirements.

Based on observation, facility staff interview and record review, the facility failed to develop a maintenance program for the medical gas, vacuum, WAGD (Waste Anesthetic Gas Disposal), or support gas system within the facility. The facility census was 31.

1. Review of the facility maintenance program documentation did not show the facility had a program in place which includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets, and an inspection and maintenance schedule for this system.

2. Observation on 2/12/2020 at 4:42 P.M., during the building tour, showed the med vac outlet on the med gas boom in operating room #2 covered with medical tape.

During an interview on 2/13/2020 at 4:30 P.M., the facility Maintenance Manager said he/she did not know a qualified expert needed to inspect the med gas system in the building.

Section 5.1.14.2.2.1 of the National Fire Protection Association (NFPA 99) states: 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.

Based on record review and facility staff interview, the facility staff failed to assure they maintained records of inspections and testing of their piped in oxygen systems in accordance with National Fire Protection Association (NFPA) 99, 2012 edition. This facility census was 31.

1. Review of the facility's Life Safety Code documentation showed no evidence of inspections or testing of the piped-in oxygen system.

During an interview on 2/13/2020 at 4:30 P.M., the facility Maintenance Manager said he/she did not know a qualified expert needed to inspect the med gas system in the building.

Refer to NFPA 99, 2012 edition, Chapter 5 for medical gas inspection requirements.

Based on observation and record review, facility staff failed to ensure operating rooms were protected as wet locations. Failure to provide protection from the possibility of electric shock in a wet environment has the potential to effect patients and staff. The census was 31.

Observation on 2/12/2020 at 4:42 P.M., of operating room #2, showed a power tap connected to a patient warming device and the operating table.

Record review of the facility supplied records did not show a risk assessment for the operating rooms.

Record review did not show the power tap rated for use in a wet location.

NFPA 99, 2012 edition states:

"6.3.2.2.8.4* Operating rooms shall be considered to be a wet
procedure location, unless a risk assessment conducted by the
health care governing body determines otherwise.

A.6.3.2.2.8.4 In conducting a risk assessment, the health care
governing body should consult with all relevant parties, including,
but not limited to, clinicians, biomedical engineering
staff, and facility safety engineering staff.

6.3.2.2.8.7* Operating rooms defined as wet procedure locations
shall be protected by either isolated power or groundfault
circuit interrupters.

A.6.3.2.2.8.7 The health care governing body and designer
of record should evaluate the type of protection to be provided
against electrical shock to patients and caregivers in wet
procedure locations. The application considerations should
include but not be limited to the reliability of power to critical
equipment and systems."

Based on observation and record review, facility staff did not ensure the electrical receptacles in patient care areas and line isolation monitor's are tested. Facility staff failed to maintain testing records. The facility census was 31.

Record review of the facility supplied maintenance records did not show the electrical receptacles in patient care areas and line isolation monitors (LIMs) were tested.

Observation on 2/12/2020 at 4:42 P.M., of operating room #2, showed a power tap connected to a patient warming device and the operating table. Observation did not show the power tap equipped with a hospital grade receptacle.

NFPA 99, 2012 edition section 6.3.4 states:

"6.3.4* Administration of Electrical Systems
6.3.4.1 Maintenance and Testing of Electrical Systems.

6.3.4.1.1 Where hospital-grade receptacles are required at patient
bed locations and in locations where deep sedation or general
anesthesia is administered, testing shall be performed after
initial installation, replacement, or servicing of the device.

6.3.4.1.2 Additional testing of receptacles in patient care
rooms shall be performed at intervals defined by documented
performance data.

6.3.4.1.3 Receptacles not listed as hospital-grade, at patient
bed locations and in locations where deep sedation or general
anesthesia is administered, shall be tested at intervals not exceeding
12 months.

6.3.4.1.4 The LIM circuit shall be tested at intervals of not more
than 1 month by actuating the LIM test switch (see 6.3.2.6.3.6).
For a LIM circuit with automated self-test and self-calibration capabilities,
this test shall be performed at intervals of not more
than 12 months. Actuation of the test switch shall activate both
visual and audible alarm indicators.

6.3.4.1.5 After any repair or renovation to an electrical distribution
system, the LIM circuit shall be tested in accordance
with 6.3.3.3.2.

6.3.4.2 Record Keeping.
6.3.4.2.1* General.
6.3.4.2.1.1 A record shall be maintained of the tests required
by this chapter and associated repairs or modification.

6.3.4.2.1.2 At a minimum, the record shall contain the date,
the rooms or areas tested, and an indication of which items
have met, or have failed to meet, the performance requirements
of this chapter.

6.3.4.2.2 Isolated Power System (Where Installed). A permanent
record shall be kept of the results of each of the tests.

6.3.2.6.3.6 A reliable test switch shall be mounted on the line
isolation monitor to test its capability to operate (i.e., cause
the alarms to operate and the meter to indicate in the "alarm
on" zone). This switch shall transfer the grounding connection
of the line isolation monitor from the reference grounding
point to a test impedance arrangement connected across
the isolated line; the test impedance(s) shall be of the appropriate
magnitude to produce a meter reading corresponding
to the rated total hazard current at the nominal line voltage,
or to a lesser alarm hazard current if the line isolation monitor
is so rated. The operation of this switch shall break the
grounding connection of the line isolation monitor to the reference
grounding point before transferring this grounding
connector to the test impedance(s), so that making this test
will not add to the hazard of a system in actual use; nor will the
test include the effect of the line-to-ground stray impedance of
the system. The test switch shall be of a self-restoring type.

Based on observation, the facility staff failed to ensure surge protectors met NFPA requirements and not used for non-movable patient care equipment in a critical care patient location. The facility census was 31.

Observation on 2/12/2020 at 4:42 P.M., of operating room #2, showed a power tap connected to a patient warming device and the operating table.

During an interview on 2/13/2020 at 4:44 P.M., facility Maintenance Manager said he/she did not know a power tap was being used in an operating room.


Refer to NFPA 70, National Electrical Code, 2011 edition, Article 400.8 for additional information.

Based on observation, facility staff interview and record review, facility staff failed to provide continuing education regarding the safety guidelines and usage requirements for medical gases and their cylinders to staff involved with the application, handling and maintenance of medical gases and their cylinders. Failure to provide education has the potential for improper handling of medical gases and cylinders which poses an increased risk of fire and injury to patients and staff. This failure has the potential to affect all facility occupants. The facility census 31.

1. Observation on 2/12-13/2020, during the build tour, showed all the patient rooms equipped with a piped vacuum/oxygen system.

Observation on 2/13/2020 at 1:54 P.M., of the medical gas manifold and storage room showed a large number of various medical gas cylinders of various sizes and two manifold systems requiring medical gas tanks to be connected and disconnected to supply the systems.

Review of the facility's personnel continuing education records did not contain documentation of education provided to the facility staff involved with the application, handling and maintenance of medical gases regarding the safety guidelines and usage requirements for medical gases or their cylinders.


NFPA 99, 2012 Edition, Section 11.5.2.1 (Qualifications and Training of Personnel), states:

"11.5.2 Gases in Cylinders and Liquefied Gases in Containers.

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."