HospitalInspections.org

During the survey tour of 03/18/2015, between the hours of 1045 and 1230, while accompanied by the Facilities Manager, through record review, observation and staff interview, it was discovered that the facility has failed to maintain the construction requirements for the classification of construction. The facility has a Type III (211) classification by NFPA 220. This has the potential for the spread of smoke and fire into the structure in the event of a fire. These findings were acknowledged by the Facilities Manager.

The findings include but are not limited to:

Only the basement is protected by an Automatic Fire Sprinkler System.

During the survey tour of 03/18/2015, between the hours of 1400 and 1630, while accompanied by the PHA and Facilities Manager, through observation and staff interview, it was discovered that the facility has failed to maintain doors protecting corridor openings in other than required enclosures of vertical openings, exits or hazardous areas. This prevents the doors from resisting the passage of smoke due to doors failing to close and latch or being prevented from closing due to impediments being in the doors travel path. This could result in smoke passing into the corridor or into rooms in the event of a fire. These findings were acknowledged by the Facilities Manager.

The findings include but are not limited to:

1. Patient Room 11 - door binding, failed to properly close and latch when tested.

During the survey tour of 03/18/2015, between the hours of 1045 and 1230, while accompanied by the Facilities Manager, through record review and staff interview, it was discovered that the facility has failed to conduct fire drills for staff. This could result in staff ' s failure to provide for the safety of patients and visitors through a failure to respond to a fire emergency in accordance with the facility ' s published fire procedures. These findings were acknowledged by the Facilities Manager.

The findings are as follows:

Night Shift - missing 3rd Quarter 2014

During the survey tour of 03/18/2015, between the hours of 1045 and 1230, while accompanied by the Facilities Manager, through record review and staff interview, it was discovered that the facility has failed to maintain smoke detectors in accordance with the requirements of the National Fire Alarm Code (NFPA 72). The facility has failed to conduct sensitivity testing of smoke detectors as required (Chapter 10). This could allow for a device to initiate nuisance alarms or failure of a device to initiate the fire alarm causing a delay in the reporting of a fire, putting patients, visitors and staff at risk. These findings were acknowledged by the Facilities Manager.

The findings include but are not limited to:

There is no documentation or knowledge that sensitivity of smoke detectors has been tested in the last 5 years.

During the survey tour of 03/18/2015, between the hours of 1045 1230, while accompanied by the Facilities Manager, through record review, observation and staff interview, it was discovered that the facility has failed to provide automatic fire sprinkler protection as required by NFPA 13. This could result in a fire spreading in the unprotected area, placing patients and employees at risk. These findings were acknowledged by the Facilities Manager.

The findings include but are not limited to:

Only the basement is protected by an Automatic Fire Sprinkler System.

During the survey tour of 03/18/2015, between the hours of 1400 and 1630, while accompanied by the PHA and Facilities Manager, through observation and staff interview, it was discovered that the facility has failed to protect medical gas storage and administration areas in accordance with NFPA 99. This could result in ignition of oxidizers, placing residents, staff and visitors at risk. These findings were acknowledged by the Maintenance Director.

The findings include but are not limited to:

Compressed oxygen tanks are discovered stored in the Soiled Utility Room, butted-up to an electric wall heater. There is also an autoclave in the room.
· O2 tanks were immediately removed by staff

During the survey tour of 03/18/2015, between the hours of 1400 and 1630, while accompanied by the PHA and Facilities Manager, through observation and staff interview, it was discovered that the facility has failed to comply with the 2012 IFC 305.1 Clearance from ignition sources.
Clearance between ignition sources, such as luminaires, heaters, flame-producing devices and combustible materials, shall be maintained in an approved manner.

The findings include but are not limited to:

Boxes of combustibles are discovered stored next to and on top of baseboard wall heaters in the Radiology changing rooms (heaters are turned off).

During the survey tour of 03/19/2015, at approximately 1045, while accompanied by the Facilities Manager and Lab Manager, through record review and staff interview, it was discovered that the facility has failed to establish emergency procedures for controlling chemical spills (in the Lab Disaster Plan). This could result in placing staff and patients at risk of injury in event of a chemical spill.

During the survey tour of 03/19/2015, at approximately 1045, while accompanied by the Facilities Manager and Lab Manager, through record review and staff interview, it was discovered that the facility has failed to provide safety education for laboratory staff.

The finding is as follows:

1. There is no knowledge or records of continuing safety education or annual training of laboratory staff regarding spill handling other lab specific emergencies.

During the survey tour of 03/18/2015, between the hours of 1045 and 1230, while accompanied by the Facilities Manager, through record review and staff interview, it was discovered that the facility has failed to properly divide the Emergency Electrical System into the critical and life safety branches. Failure to properly divide the branches of the ESS places patients, staff and visitors at risk from the effects of an ESS malfunction.

The findings include, but are not limited to:
The facility was cited for this in the 08/2011 survey and again at the 09/2013 survey.

During the survey tour of 03/18/2015, between the hours of 1400 and 1630, while accompanied by the PHA and Facilities Manager, through observation and staff interview, it was discovered that the facility has failed to comply with NFPA 70, also known as the National Electric Code (NEC). This could allow for electrical arcing starting a fire, placing patients, staff and visitors at risk. The findings were acknowledged by the Facilities Manager.
The findings include, but are not limited to:
1. An unapproved multi-plug adapter was discovered in the Clean Utility Room (removed during survey).
2. Room 7 has been temporarily converted to office use and an extension cord is discovered plugged into a multi-strip adapter being powered by another multi-strip adapter (piggy-backed).

During the survey tour of 03/18/2015, between the hours of 1045 and 1230, while accompanied by the Facilities Manager, through record review, observation and staff interview, it was discovered that the facility has failed to maintain the construction requirements for the classification of construction. The facility has a Type III (211) classification by NFPA 220. This has the potential for the spread of smoke and fire into the structure in the event of a fire. These findings were acknowledged by the Facilities Manager.

The findings include but are not limited to:

Only the basement is protected by an Automatic Fire Sprinkler System.

During the survey tour of 03/18/2015, between the hours of 1400 and 1630, while accompanied by the PHA and Facilities Manager, through observation and staff interview, it was discovered that the facility has failed to maintain doors protecting corridor openings in other than required enclosures of vertical openings, exits or hazardous areas. This prevents the doors from resisting the passage of smoke due to doors failing to close and latch or being prevented from closing due to impediments being in the doors travel path. This could result in smoke passing into the corridor or into rooms in the event of a fire. These findings were acknowledged by the Facilities Manager.

The findings include but are not limited to:

1. Patient Room 11 - door binding, failed to properly close and latch when tested.

During the survey tour of 03/18/2015, between the hours of 1045 and 1230, while accompanied by the Facilities Manager, through record review and staff interview, it was discovered that the facility has failed to conduct fire drills for staff. This could result in staff ' s failure to provide for the safety of patients and visitors through a failure to respond to a fire emergency in accordance with the facility ' s published fire procedures. These findings were acknowledged by the Facilities Manager.

The findings are as follows:

Night Shift - missing 3rd Quarter 2014

During the survey tour of 03/18/2015, between the hours of 1045 and 1230, while accompanied by the Facilities Manager, through record review and staff interview, it was discovered that the facility has failed to maintain smoke detectors in accordance with the requirements of the National Fire Alarm Code (NFPA 72). The facility has failed to conduct sensitivity testing of smoke detectors as required (Chapter 10). This could allow for a device to initiate nuisance alarms or failure of a device to initiate the fire alarm causing a delay in the reporting of a fire, putting patients, visitors and staff at risk. These findings were acknowledged by the Facilities Manager.

The findings include but are not limited to:

There is no documentation or knowledge that sensitivity of smoke detectors has been tested in the last 5 years.

During the survey tour of 03/18/2015, between the hours of 1045 1230, while accompanied by the Facilities Manager, through record review, observation and staff interview, it was discovered that the facility has failed to provide automatic fire sprinkler protection as required by NFPA 13. This could result in a fire spreading in the unprotected area, placing patients and employees at risk. These findings were acknowledged by the Facilities Manager.

The findings include but are not limited to:

Only the basement is protected by an Automatic Fire Sprinkler System.

During the survey tour of 03/18/2015, between the hours of 1400 and 1630, while accompanied by the PHA and Facilities Manager, through observation and staff interview, it was discovered that the facility has failed to protect medical gas storage and administration areas in accordance with NFPA 99. This could result in ignition of oxidizers, placing residents, staff and visitors at risk. These findings were acknowledged by the Maintenance Director.

The findings include but are not limited to:

Compressed oxygen tanks are discovered stored in the Soiled Utility Room, butted-up to an electric wall heater. There is also an autoclave in the room.
· O2 tanks were immediately removed by staff

During the survey tour of 03/18/2015, between the hours of 1400 and 1630, while accompanied by the PHA and Facilities Manager, through observation and staff interview, it was discovered that the facility has failed to comply with the 2012 IFC 305.1 Clearance from ignition sources.
Clearance between ignition sources, such as luminaires, heaters, flame-producing devices and combustible materials, shall be maintained in an approved manner.

The findings include but are not limited to:

Boxes of combustibles are discovered stored next to and on top of baseboard wall heaters in the Radiology changing rooms (heaters are turned off).

During the survey tour of 03/18/2015, between the hours of 1045 and 1230, while accompanied by the Facilities Manager, through record review and staff interview, it was discovered that the facility has failed to properly divide the Emergency Electrical System into the critical and life safety branches. Failure to properly divide the branches of the ESS places patients, staff and visitors at risk from the effects of an ESS malfunction.

The findings include, but are not limited to:
The facility was cited for this in the 08/2011 survey and again at the 09/2013 survey.

During the survey tour of 03/18/2015, between the hours of 1400 and 1630, while accompanied by the PHA and Facilities Manager, through observation and staff interview, it was discovered that the facility has failed to comply with NFPA 70, also known as the National Electric Code (NEC). This could allow for electrical arcing starting a fire, placing patients, staff and visitors at risk. The findings were acknowledged by the Facilities Manager.
The findings include, but are not limited to:
1. An unapproved multi-plug adapter was discovered in the Clean Utility Room (removed during survey).
2. Room 7 has been temporarily converted to office use and an extension cord is discovered plugged into a multi-strip adapter being powered by another multi-strip adapter (piggy-backed).