HospitalInspections.org

Based on documentation review, observation and staff interview on July 10, 2018 between approximately 0800 and 1515 hours the facility has failed to maintain the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire and allow the fire to increase in size and intensity which would endanger the residents, staff, and/or visitors within the facility.
The findings include, but are not limited to:
The dry sprinkler head located at the operating room emergency exit is coated with paint or stucco. The sprinkler contractor's report reflects this as a yellow status deficiency on October 3, 2017 report.
The wet sprinkler heads located at, but not limited to the following locations have excessive grease, dust or other particulate on them:
Kitchen by the dishwasher and opening to the physical therapy department.
Room 105
Room 311
Emergency department nourishment area
Out-patient nurses station
Corridor outside the patient room/lobby doors and obstetrics door.
The above was discussed and acknowledged by the chief executive officer and plant operations manager.

Based on observation and staff interview on July 10, 2018 between approximately 0800 and 1515 hours the facility has failed to maintain doors without impediments to their closing and latching. This could result in a delay in getting the door to the room closed in the event of a fire. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the residents, staff and/or visitors within the smoke compartment.

The findings include, but are not limited to:

Doors located at, but not limited to, the following locations failed to close and latch:

Obstetrics door into D Wing - corrected during inspection

Patient Room 107 - corrected during inspection

Patient Room 105 - corrected during inspection

The above was discussed and acknowledged by the chief executive officer and plant operations manager.

Based on documentation review and staff interview on July 10, 2018 between approximately 0800 and 1515 hours the facility has failed to maintain and test fire and smoke dampers in accordance with NFPA 80 and NFPA 105. This could result in failure of the dampers to operate and close in the event of a fire, allowing the spread of the products of combustion from one compartment to another, endangering the patients, staff and/or visitors.

The findings include, but are not limited to:

The facility could not provide any documentation indicating their fire and smoke dampers have been inspected and tested within the last six years.

Per NFPA 90A, 5.4.8.1, fire dampers shall be maintained in accordance with NFPA 80. Per NFPA 80, 19.4.1, each damper shall be tested and inspected 1 year after installation and 19.4.1.1 The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years.

The above was discussed and acknowledged by chief executive officer and plant operations manager. who said they are currently scheduled for inspection in October 2018.

Based on observation and staff interview on July 10, 2018 between approximately 0800 and 1515 hours the facility has failed to provide the proper equipment at the approved staff smoking area(s). This could result in the ignition of the combustible materials adjacent to the staff smoking area which would endanger the residents, staff, and/or visitors within the facility.
The findings include, but are not limited to:
The facility has failed to make readily available in the staff smoking location a metal container with self-closing cover into which ashtrays can be emptied.
The above was discussed and acknowledged by the chief executive officer and plant operations manager.

Based on documentation review and staff interview on July 10, 2018 between approximately 0800 and 1515 hours the facility has failed to maintain their medical gas warning systems. This could endanger patients and those in the facility to be unaware if there is a problem with the system such as a leak or inadequate supply.

The findings include, but are not limited to:

The contractor's report cited the following deficiency, "master alarm panel by nurses station 'push to test' function is malfunctioning, making the panel go into a system fault".

The above was discussed and acknowledged by the chief executive officer and plant operations manager who stated it is a panel failure and not a systems failure and the facility has begun the process of replacing the panel.

Based on documentation review and staff interviews on July 10, 2018 between approximately 0800 and 1515 hours the facility has failed to properly maintain records of testing and maintenance of hospital grade receptacles at patient bed locations in accordance with NFPA 99. This could result in electrical malfunction which could potentially endanger residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

The facility was unable to provide a policy and documentation indicating they have conducted polarity, grounding and tension periodic testing as required by NFPA 99, 6.3.4 of non-hospital grade electrical receptacles located within six feet of patient care locations within the last 12 months and all hospital grade receptacles upon replacement or servicing of the device."

The above was discussed and acknowledged by the chief executive officer and plant operations manager.

Based on documentation review, observation and staff interview on July 10, 2018 between approximately 0800 and 1515 hours the facility has failed to maintain and test the emergency generator in accordance with NFPA 110. This could result in a failure of the emergency power system which would leave the facility without egress and task lighting in the event of a power failure which would endanger the residents, staff, and/or visitors within the facility.

The findings include, but are not limited to:

The generator remote stop switches are not labeled as required by 2010 NFPA 110, 5.6.5.6.1.

The facility could not provide documentation indicating an annual diesel fuel test has been conducted within the last 12 months as required by 2010 NFPA 110, 8.3.8.

The generator contractor's annual servicing report reported deficiencies for failure to replace filters in both generators.

The above was discussed and acknowledged by the chief executive officer and plant operations manager.

Based on observation and staff interview on July 10, 2018 between approximately 0800 and 1515 hours the facility has failed to restrict the use of extension cords and non-approved powerstrips in their facility. This could endanger people in the facility due to the increased fire risk.

The findings include, but are not limited to:

Extension cords and/or powerstrips were plugged into another at, but not limited to the following locations:

Operating room #2 - corrected during inspection

Human Resources reception area - corrected during inspection

Emergency Department nurses station - corrected during inspection

Information Desk in Admitting - corrected during inspection

The above was discussed and acknowledged by the chief executive officer and plant operations manager.

Based on observation and staff interview on July 10, 2018 between approximately 0800 and 1515 hours the facility has failed to maintain construction of oxygen storage areas as being smoke and fire resistant. This could result in the products of combustion traveling from the hazardous area into the exit corridor in the event of a fire which could endanger patients, first-responders, staff, and/or visitors. In addition the facility has failed to maintain exterior storage locations as secured to prevent unauthorized access. This could allow for the tampering with or damage to of oxygen storage cylinders, which could endanger patients, staff, and/or visitors.

The findings include, but are not limited to:

Oxygen cylinders for the central supply system are not secured as required by NFPA 99, 5.1.3.3.2 (7).

Oxygen empty and full oxygen cylinders located in the equipment storage room are not segregated from one an other as required by NFPA 99, 11.6.5.2.

The above was discussed and acknowledged by the chief executive officer and plant operations manager.