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Based on observation, staff interview and record review, the facility failed to maintain corridor doors in the means of egress as required by NFPA 101 (2000), 8.2.3.2.1, 8.2.3.2.3.2, 7.2.1.7, and 7.2.1.8.

Findings include:

1. On 04/06/2015 observation during the interior tour from 10:00 a.m. to 12:15 p.m. of the 3rd and 2nd levels accompanied by the Director of Maintenance revealed single and double leaf corridor doors in the means of egress, in which self-closing devises had been removed and/or self-latching or automatic flush bolts, or labeled two-point latches had been disengaged. Double leaf doors were observed in which new flooring and thresholds had been installed covering the inactive leaf bottom flush bolt hole preventing the inactive leaf from being secure top and bottom to permit the active leaf to positively latch in place and hold in place in the event of fire. This was a sample of doors found and the facility is required to conduct a door survey to identify and re-install self-closers that have been removed and to repair and engage top and bottom latching devices on the inactive leaves of the double leaf doors. The sample of doors observed included the Utilization Review Room, the double leaf doors on the "Meeting Rooms" between units 31 and 32, units 33 and 34, units 21 and 22, as well as units 23 and 24. Staff interview of the Director of Maintenance, concurrent with tour, acknowledged the removal of self-closing devices and the disengagement of inactive leaves of double leaf doors top and bottom latching devices.

2. On 04/06/2015 observation during the interior tour from 10:00 a.m. to 12:15 p.m. accompanied by the Director of Maintenance revealed four closed units 32, 33, 22, 23 in which 2 of the 4 units fire/smoke barrier doors at the entrance to each of the two units (the means of egress) were open. Continuing observation revealed in 2 of 4 Units significant amounts of combustible material including non-rated wooden shelving, medical records and furniture. While all four sets of smoke barrier doors leading to the Units are on the fire alarm and would automatically release the facility is required to close the doors and secure them during all times in which personnel are not actively working in those locations.

On 04/06/2015, record review of NFPA 101, (2000), revealed the following exceptions to the requirement for self-closing devices on corridor doors in the means of egress: Note 1: Resident, (patient), room doors are not required to have self-closing devices as presented in NFPA 101 (2000), A.19.3.6.3.2..."While it is recognized that closed doors serve to maintain tenable conditions in a corridor and adjacent patient rooms, such doors, which under normal or fire conditions are self-closing, might create a special hazard for the personal safety of a room occupant. These closed doors might present a problem of delay in discovery, confining fire products beyond tenable conditions...In existing buildings, use of the following options reasonably ensures that patient room doors will be closed and remain closed during a fire: (1) Doors should have positive latches and a suitable program that trains staff to close the doors in an emergency should be established. Note 2: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials are not required to have self-closing devices as stated in NFPA 101 (2000), 19.3.6.3 Corridor Doors. 19.3.6.3.1..." "Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials. Exception No. 2: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, the door construction requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke." Note 3: As stated in NFPA 101 (2000), 19.3.6.3.3* Hold-open devices that release when the door is pushed or pulled shall be permitted. A.19.3.6.3.3 Doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

NFPA 101 (2000), 8.2.3.2.1, 8.2.3.2.3.2, 7.2.1.7, 7.2.1.8
References:

NFPA 101 (2000), 8.2.3.2 Fire Protection-Rated Opening Protectives. 8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following. (a) *Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies. Exception: The requirement of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1. (b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.

NFPA 101 (2000), 8.2.3.2.3.2 Where a 20-minute fire protection-rated door is required in existing buildings, an existing 13/4-in. (4.4-cm) solid, bonded wood-core door, or an existing steel-clad (tinclad) wood door, or an existing solid-core steel door with positive latch and closer shall be permitted.

NFPA 101 (2000), 7.2.1.5.4* A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.

NFPA 80 (1999), 2-4.4.5 Where a pair of doors is needed for the movement of equipment and where the inactive leaf of the pair of doors is not required for exit purposes, labeled, top and bottom, self-latching or automatic flush bolts, or labeled two-point latches shall be permitted. Exception: Manually operated, labeled, top and bottom flush-mounted or surface-mounted bolts on the inactive leaf of a pair of doors shall be permitted to be used where acceptable to the authority having jurisdiction, provided they do not pose a hazard to safety to life. This provision limits their use to rooms not normally occupied by humans (for example, transformer vaults and storage rooms). The inactive leaf shall not require a closer.

NFPA 80 (1999), 2-4.4.3 All single doors and active leaves of pairs of doors shall be provided with an active latch bolt that cannot be held in a retracted position as specified in Table 2-4.4.3.

Based on record review and staff interview, the facility failed to provide documentation of the daily measurement of relative humidity of 35% or greater in the Electroconvulsive Therapy (ECT) anesthesia location as required by NFPA 101 (2000), 19.3.2.3, and NFPA 99 (1999), 5-4.1.

Findings include:

On 04/06/2015 staff interview of the facility maintenance representative concurrent with record review from 12:15 p.m. to 1:15 p.m. revealed the facility, serving behavioral health patients, did have piped in medical gases in an active anesthesia location on the first level of the building.

On 04/06/2015 staff interview of the nurse manager in the ECT anesthesia location during the afternoon tour from 1:15 p.m. to 4:30 p.m. accompanied by the facility maintenance representative revealed no documentation of daily relative humidity and no awareness of the requirement to measure on a daily basis the relative humidity in anesthesia locations and documentation demonstrating compliance with the 35% or greater relative humidity. Staff interview of the facility maintenance representative concurrent with the tour revealed the facility did have the instrument necessary to measure relative humidity and would provide the instrument to the ECT manager to start daily measurements and recording.

On 04/09/2015, record review of Centers for Medicare and Medicaid S&C letter 15-27, reveals a relative humidity of less than 35% may have an adverse impact on the performance of medical equipment. The facility is required to measure daily and record relative humidity in the ECT Unit and obtain medical equipment manufacturer's operational specifications for relative humidity and insure operation of the ECT Units ventilation system meets the equipment manufacturer's requirements.

NFPA 101 (2000), 19.3.2.3
NFPA 99 (1999), 5-4.1
Centers for Medicare and Medicaid, (CMS) S&C, (Survey and Certification Letter): 13-25
Centers for Medicare and Medicaid, (CMS) S&C, (Survey and Certification Letter): 15-27
Reference:
NFPA 99 (1999), 5-4.1* Ventilation-Anesthetizing Locations. 5-4.1.1* The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Centers for Medicare and Medicaid, (CMS) S&C, (Survey and Certification Letter): 13-25-LSC & ASC The 2012 edition of NFPA 99 has adopted the 2008 edition of the American Society for Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) Standard 170, Ventilation of Health Care Facilities. Addendum D of the ASHRAE standard requires RH in anesthetizing locations to be maintained between 20 - 60 percent. In addition, this ASHRAE standard has been incorporated into the Facility Guidelines Institute (FGI) 2010 Guidelines for Design and Construction of Health Care Facilities, and has been approved by the American Society for Healthcare Engineering of the American Hospital Association and the American National Standards Institute.

Centers for Medicare and Medicaid, (CMS) S&C, (Survey and Certification Letter): 15-27-Hospital, CAH & ASC. "Subsequently it has come to light that an RH level <30% is not compatible with the instructions for use (IFUs) for some sterile supplies and electro-medical equipment used in operating rooms. Multiple health-care related organizations convened by AAMI in 2014 to discuss this topic came to a consensus and released a Joint Communication on January 5, 2015.
(See http://www.aami.org/news/2015/Humidity_in_OR_Joint_Communication_to_HDOs_January_2 015.pdf). Among other things, the Joint Communication notes that, while manufacturers of supplies and equipment will be expanding the lower level of the RH range in which their products may function to 20%, the pace of this change is likely to take time. Moreover, for facilities that continue to use older equipment it could be many years before this older equipment is replaced and all of the equipment they use will function appropriately at lower RH levels. The Joint Communication offers a number of useful questions health care facility leadership should ask when assessing the risk of reducing RH in their ORs in light of the potential impact on equipment and supplies."

Based on record review and staff interview, the facility failed to maintain electrical safety as required by NFPA 101 (2000), 19.5.1, 9.1.2, NFPA 70 (1999SB), 517-30, and NFPA 99 (1999), 3-4.4.1.2.

Findings include:

1. On 04/06/2015, the day of survey, record review from 12:15 p.m. to 1:15 p.m. revealed no documentation of a plan of exercise of the main and feeder circuit breakers of the Essential Electrical System. Staff interview of the facility maintenance manager revealed the main panel had been exercised, failed and was replaced. However, no "Plan" had been developed since the installation of the new main electrical panel for the inspection and periodic exercise of the main and feeder circuit breakers of the Essential Electrical System in accordance with the manufacturer's recommendations.

NFPA 101 (2000), 19.5.1, 9.1.2
NFPA 70 (1999SB), 517-30
NFPA 99 (1999), 3-4.4.1.2
References:
NFPA 70 (1999SB), "517-30. Essential Electrical Systems for Hospitals. (a) Applicability. The requirements of Part C, Sections 517-30 through 517-35, shall apply to hospitals where an essential electrical system is required. FPN No. 1: For performance, maintenance, and testing requirements of essential electrical systems in hospitals, see Standard for Health Care Facilities, NFPA 99-1996..."

NFPA 99 (1999), "3-4.4.1.2 Maintenance and Testing of Circuitry. (a)* Circuit Breakers. Main and feeder circuit breakers shall be inspected annually and a program for periodically exercising the components shall be established according to manufacturer's recommendations...3-4.4.2 Record keeping. A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction."

Based on observation, staff interview and record review, the facility failed to maintain corridor doors in the means of egress as required by NFPA 101 (2000), 8.2.3.2.1, 8.2.3.2.3.2, 7.2.1.7, and 7.2.1.8.

Findings include:

1. On 04/06/2015 observation during the interior tour from 10:00 a.m. to 12:15 p.m. of the 3rd and 2nd levels accompanied by the Director of Maintenance revealed single and double leaf corridor doors in the means of egress, in which self-closing devises had been removed and/or self-latching or automatic flush bolts, or labeled two-point latches had been disengaged. Double leaf doors were observed in which new flooring and thresholds had been installed covering the inactive leaf bottom flush bolt hole preventing the inactive leaf from being secure top and bottom to permit the active leaf to positively latch in place and hold in place in the event of fire. This was a sample of doors found and the facility is required to conduct a door survey to identify and re-install self-closers that have been removed and to repair and engage top and bottom latching devices on the inactive leaves of the double leaf doors. The sample of doors observed included the Utilization Review Room, the double leaf doors on the "Meeting Rooms" between units 31 and 32, units 33 and 34, units 21 and 22, as well as units 23 and 24. Staff interview of the Director of Maintenance, concurrent with tour, acknowledged the removal of self-closing devices and the disengagement of inactive leaves of double leaf doors top and bottom latching devices.

2. On 04/06/2015 observation during the interior tour from 10:00 a.m. to 12:15 p.m. accompanied by the Director of Maintenance revealed four closed units 32, 33, 22, 23 in which 2 of the 4 units fire/smoke barrier doors at the entrance to each of the two units (the means of egress) were open. Continuing observation revealed in 2 of 4 Units significant amounts of combustible material including non-rated wooden shelving, medical records and furniture. While all four sets of smoke barrier doors leading to the Units are on the fire alarm and would automatically release the facility is required to close the doors and secure them during all times in which personnel are not actively working in those locations.

On 04/06/2015, record review of NFPA 101, (2000), revealed the following exceptions to the requirement for self-closing devices on corridor doors in the means of egress: Note 1: Resident, (patient), room doors are not required to have self-closing devices as presented in NFPA 101 (2000), A.19.3.6.3.2..."While it is recognized that closed doors serve to maintain tenable conditions in a corridor and adjacent patient rooms, such doors, which under normal or fire conditions are self-closing, might create a special hazard for the personal safety of a room occupant. These closed doors might present a problem of delay in discovery, confining fire products beyond tenable conditions...In existing buildings, use of the following options reasonably ensures that patient room doors will be closed and remain closed during a fire: (1) Doors should have positive latches and a suitable program that trains staff to close the doors in an emergency should be established. Note 2: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials are not required to have self-closing devices as stated in NFPA 101 (2000), 19.3.6.3 Corridor Doors. 19.3.6.3.1..." "Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials. Exception No. 2: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, the door construction requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke." Note 3: As stated in NFPA 101 (2000), 19.3.6.3.3* Hold-open devices that release when the door is pushed or pulled shall be permitted. A.19.3.6.3.3 Doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

NFPA 101 (2000), 8.2.3.2.1, 8.2.3.2.3.2, 7.2.1.7, 7.2.1.8
References:

NFPA 101 (2000), 8.2.3.2 Fire Protection-Rated Opening Protectives. 8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following. (a) *Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies. Exception: The requirement of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1. (b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.

NFPA 101 (2000), 8.2.3.2.3.2 Where a 20-minute fire protection-rated door is required in existing buildings, an existing 13/4-in. (4.4-cm) solid, bonded wood-core door, or an existing steel-clad (tinclad) wood door, or an existing solid-core steel door with positive latch and closer shall be permitted.

NFPA 101 (2000), 7.2.1.5.4* A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.

NFPA 80 (1999), 2-4.4.5 Where a pair of doors is needed for the movement of equipment and where the inactive leaf of the pair of doors is not required for exit purposes, labeled, top and bottom, self-latching or automatic flush bolts, or labeled two-point latches shall be permitted. Exception: Manually operated, labeled, top and bottom flush-mounted or surface-mounted bolts on the inactive leaf of a pair of doors shall be permitted to be used where acceptable to the authority having jurisdiction, provided they do not pose a hazard to safety to life. This provision limits their use to rooms not normally occupied by humans (for example, transformer vaults and storage rooms). The inactive leaf shall not require a closer.

NFPA 80 (1999), 2-4.4.3 All single doors and active leaves of pairs of doors shall be provided with an active latch bolt that cannot be held in a retracted position as specified in Table 2-4.4.3.

Based on record review and staff interview, the facility failed to provide documentation of the daily measurement of relative humidity of 35% or greater in the Electroconvulsive Therapy (ECT) anesthesia location as required by NFPA 101 (2000), 19.3.2.3, and NFPA 99 (1999), 5-4.1.

Findings include:

On 04/06/2015 staff interview of the facility maintenance representative concurrent with record review from 12:15 p.m. to 1:15 p.m. revealed the facility, serving behavioral health patients, did have piped in medical gases in an active anesthesia location on the first level of the building.

On 04/06/2015 staff interview of the nurse manager in the ECT anesthesia location during the afternoon tour from 1:15 p.m. to 4:30 p.m. accompanied by the facility maintenance representative revealed no documentation of daily relative humidity and no awareness of the requirement to measure on a daily basis the relative humidity in anesthesia locations and documentation demonstrating compliance with the 35% or greater relative humidity. Staff interview of the facility maintenance representative concurrent with the tour revealed the facility did have the instrument necessary to measure relative humidity and would provide the instrument to the ECT manager to start daily measurements and recording.

On 04/09/2015, record review of Centers for Medicare and Medicaid S&C letter 15-27, reveals a relative humidity of less than 35% may have an adverse impact on the performance of medical equipment. The facility is required to measure daily and record relative humidity in the ECT Unit and obtain medical equipment manufacturer's operational specifications for relative humidity and insure operation of the ECT Units ventilation system meets the equipment manufacturer's requirements.

NFPA 101 (2000), 19.3.2.3
NFPA 99 (1999), 5-4.1
Centers for Medicare and Medicaid, (CMS) S&C, (Survey and Certification Letter): 13-25
Centers for Medicare and Medicaid, (CMS) S&C, (Survey and Certification Letter): 15-27
Reference:
NFPA 99 (1999), 5-4.1* Ventilation-Anesthetizing Locations. 5-4.1.1* The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Centers for Medicare and Medicaid, (CMS) S&C, (Survey and Certification Letter): 13-25-LSC & ASC The 2012 edition of NFPA 99 has adopted the 2008 edition of the American Society for Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) Standard 170, Ventilation of Health Care Facilities. Addendum D of the ASHRAE standard requires RH in anesthetizing locations to be maintained between 20 - 60 percent. In addition, this ASHRAE standard has been incorporated into the Facility Guidelines Institute (FGI) 2010 Guidelines for Design and Construction of Health Care Facilities, and has been approved by the American Society for Healthcare Engineering of the American Hospital Association and the American National Standards Institute.

Centers for Medicare and Medicaid, (CMS) S&C, (Survey and Certification Letter): 15-27-Hospital, CAH & ASC. "Subsequently it has come to light that an RH level <30% is not compatible with the instructions for use (IFUs) for some sterile supplies and electro-medical equipment used in operating rooms. Multiple health-care related organizations convened by AAMI in 2014 to discuss this topic came to a consensus and released a Joint Communication on January 5, 2015.
(See http://www.aami.org/news/2015/Humidity_in_OR_Joint_Communication_to_HDOs_January_2 015.pdf). Among other things, the Joint Communication notes that, while manufacturers of supplies and equipment will be expanding the lower level of the RH range in which their products may function to 20%, the pace of this change is likely to take time. Moreover, for facilities that continue to use older equipment it could be many years before this older equipment is replaced and all of the equipment they use will function appropriately at lower RH levels. The Joint Communication offers a number of useful questions health care facility leadership should ask when assessing the risk of reducing RH in their ORs in light of the potential impact on equipment and supplies."

Based on record review and staff interview, the facility failed to maintain electrical safety as required by NFPA 101 (2000), 19.5.1, 9.1.2, NFPA 70 (1999SB), 517-30, and NFPA 99 (1999), 3-4.4.1.2.

Findings include:

1. On 04/06/2015, the day of survey, record review from 12:15 p.m. to 1:15 p.m. revealed no documentation of a plan of exercise of the main and feeder circuit breakers of the Essential Electrical System. Staff interview of the facility maintenance manager revealed the main panel had been exercised, failed and was replaced. However, no "Plan" had been developed since the installation of the new main electrical panel for the inspection and periodic exercise of the main and feeder circuit breakers of the Essential Electrical System in accordance with the manufacturer's recommendations.

NFPA 101 (2000), 19.5.1, 9.1.2
NFPA 70 (1999SB), 517-30
NFPA 99 (1999), 3-4.4.1.2
References:
NFPA 70 (1999SB), "517-30. Essential Electrical Systems for Hospitals. (a) Applicability. The requirements of Part C, Sections 517-30 through 517-35, shall apply to hospitals where an essential electrical system is required. FPN No. 1: For performance, maintenance, and testing requirements of essential electrical systems in hospitals, see Standard for Health Care Facilities, NFPA 99-1996..."

NFPA 99 (1999), "3-4.4.1.2 Maintenance and Testing of Circuitry. (a)* Circuit Breakers. Main and feeder circuit breakers shall be inspected annually and a program for periodically exercising the components shall be established according to manufacturer's recommendations...3-4.4.2 Record keeping. A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction."