HospitalInspections.org

Based on document review, observation and interview, the facility failed to ensure not less than 50% of stairwell exits discharge directly to the outside in accordance with Section 7.7.2 (see tag K271), to maintain protection of 2 of 6 interior stairwells. LSC 19.3.1 requires vertical openings shall be enclosed or protected in accordance with Section 8.6 (see tag K311), to provide emergency lighting in 2 of 3 operating rooms where general anesthesia is administered in accordance with NFPA 99. NFPA 99, Health Care Facilities Code, 2012 Edition, Section 6.3.2.2.11.1 states one or more battery-powered lighting units shall be provided within locations where deep sedation and general anesthesia is administered (see tag K323), to ensure the humidity in 2 of 3 anesthetizing locations were maintained between 20% and 60%. NFPA 99 9.3.1.1 requires heating, cooling, ventilating, and process systems serving spaces or providing health care functions covered by this code or listed within ASHRAE 170, Ventilation of Health Care Facilities (see tag K323), to ensure 1 of 1 fire alarm systems was maintained in accordance with 9.6.1.3. LSC 9.6.1.3 requires a fire alarm system to be installed, tested, and maintained in accordance with NFPA 70, National Electrical Code and NFPA 72, National Fire Alarm Code (see tag K345), to ensure the documentation for the annual inspection/testing of all devices connected to 1 of 1 fire alarm system was complete. NFPA 72, National Fire Alarm Code, the 2010 Edition, at 14.6.2.4 requires a record of all inspections, testing, and maintenance shall be provided (see tag K345), to ensure 1 of over 50 rooms was separated from the corridor by a partition capable of resisting the passage of smoke as required in a sprinklered building, or met an Exception per 19.3.6.1(1) (see tag K361), to ensure all fire dampers in the facility were inspected and provided necessary maintenance at least every four years in accordance with NFPA 90A (see tag K521), to ensure 1 of 1 doors to linen chute rooms in the basement were maintained in accordance with LSC 9.5. Section 9.5.1.4 states the room accessing the chute opening shall be separated from other spaces in accordance with Section 8.7.1.1(3) for severe hazard (see tag K541), to provide documentation of a fire drill conducted on the: a. second shift for 2 of 4 quarters and b. third shift for 1 of 4 quarters (see tag K712), to ensure annual inspection and testing of all fire door assemblies were completed in accordance with LSC 19.1.1.4.1.1 (see tag K761), to ensure 1 of 1 indoor nonflammable gas storage areas was enclosed with a separation of 1 hour fire resistive construction (see tag K902), to protect 3 of 3 wet location Operating Rooms in accordance with NFPA 99, Health Care Facilities Code (see tag K913), to ensure documentation of electrical outlet receptacle testing at 24 of 25 patient bed locations within the most recent twelve month period was available for review in accordance with NFPA 99 (see tag K914), to ensure documentation of electrical outlet receptacle testing at 1 of 25 patient bed locations within the most recent twelve month period was available for review in accordance with NFPA 99 (see tag K914), to annually exercise two of three emergency generators with supplemental loads for diesel powered EPS installations that do not meet the requirements of NFPA 110, Section 8.4.2 (see tag K918), to document the transfer time to the alternate power source on monthly load tests for 3 of 3 emergency generators for 12 months of the most recent 12 months period to ensure the alternate power supply was capable of supplying service within 10 seconds (see tag K918), to ensure 3 of 3 emergency generators was allowed a 5 minute cool down period after a load test for 12 of 12 months (see tag K918), to ensure an annual fuel quality test was performed for the facility's three diesel powered generators (see tag K918), to ensure extension cords including power strips used in 1 of 3 Operating Rooms were not used as a substitute for fixed wiring. LSC 19.5.1 requires utilities to comply with Section 9.1. LSC 9.1.2 requires electrical wiring and equipment to comply with NFPA 70, National Electrical Code, 2011 Edition (see tag K920), to ensure 1 of 1 fire alarm systems was maintained in accordance with 4.6.12.3. LSC 4.6.12.3 requires existing life safety features obvious to the public if not required by the Code, shall be either maintained or removed (for building 02, see tag K345), to ensure 1 of 1 automatic sprinkler piping systems had a complete flushing program conducted following an obstruction investigation which indicated sufficient obstruction in accordance with 4.6.12.3. LSC 4.6.12.3 requires existing life safety features obvious to the public if not required by the Code, shall be either maintained or removed (for building 03, see tag K353), to ensure the sprinkler system was maintained in accordance with 4.6.12.3. LSC 4.6.12.3 requires existing life safety features obvious to the public if not required by the Code, shall be either maintained or removed (for building 03, see tag K353), to ensure 1 of 1 automatic sprinkler piping systems had a complete flushing program conducted following an obstruction investigation which indicated sufficient obstruction in accordance with 4.6.12.3. LSC 4.6.12.3 requires existing life safety features obvious to the public if not required by the Code, shall be either maintained or removed (for building 06, see tag K353).

1. Based on document review, observation and interview, the facility failed to ensure not less than 50% of stairwell exits discharge directly to the outside in accordance with Section 7.7.2. Section 7.7.2 states exits shall be permitted to discharge through interior building areas, provided that all of the following are met:
(1) Not more than 50 percent of the required number of exits, and not more than 50 percent of the required egress capacity, shall discharge through areas on any level of discharge, except as otherwise permitted by one of the following:
(a) One hundred percent of the exits shall be permitted to discharge through areas on any level of discharge in detention and correctional occupancies as otherwise provided in Chapters 22 and 23.
(b) In existing buildings, the 50 percent limit on egress capacity shall not apply if the 50 percent limit on the required number of exits is met.
(2) Each level of discharge shall discharge directly outside at the finished ground level or discharge directly outside
and provide access to the finished ground level by outside stairs or outside ramps.
(3) The interior exit discharge shall lead to a free and unobstructed way to the exterior of the building, and such way
shall be readily visible and identifiable from the point of discharge from the exit.
(4) The interior exit discharge shall be protected by one of the following methods:
(a) The level of discharge shall be protected throughout by an approved automatic sprinkler system in accordance
with Section 9.7, or the portion of the level of discharge used for interior exit discharge shall be protected by an approved automatic sprinkler system in accordance with Section 9.7 and shall be separated from the nonsprinklered portion of the floor by fire barriers with a fire resistance rating meeting the requirements for the enclosure of exits. (See 7.1.3.2.1.)
(b) The interior exit discharge area shall be in a vestibule or foyer that meets all of the following criteria:
i. The depth from the exterior of the building shall be not more than 10 ft (3050 mm), and the length shall be not more than 30 ft (9.1 m).
ii. The foyer shall be separated from the remainder of the level of discharge by construction providing protection not less than the equivalent of wired glass in steel frames or 45 minutes fire-resistive construction.
iii. The foyer shall serve only as means of egress and shall include an exit directly to the outside.
(5) The entire area on the level of discharge shall be separated from areas below by construction having a fire resistance rating not less than that required for the exit enclosure, unless otherwise provided in 7.7.2(6).
(6) Levels below the level of discharge in an atrium shall be permitted to be open to the level of discharge where such
level of discharge is protected in accordance with 8.6.7.

Findings include:

Based on review of facility floor plan documentation during record review with the Vice President of Operations and the Facilities Director during record review from 10:15 a.m. to 3:50 p.m. on 08/20/19, the facility has six interior stairwells. Only one of the six interior stairwells discharges directly to the outside. Based on interview at the time of record review, the Facilities Director stated only one of six interior stairwells discharges directly to the outside. Based on observations with the Vice President of Operations, the Facilities Director and the Safety Coordinator during a tour of the facility from 9:15 a.m. to 1:00 p.m. on 08/21/19, only one of six interior stairwells discharges directly to the outside. The entire area on the level of discharge for the remaining five interior stairwells was not separated from other areas with construction having a fire resistance rating not less than that required for the exit enclosure.

2. Based on observation and interview, the facility failed to maintain protection of 2 of 6 interior stairwells. LSC 19.3.1 requires vertical openings shall be enclosed or protected in accordance with Section 8.6. LSC 8.6.1 requires every floor that separates stories in a building shall be constructed as a smoke barrier. LSC 8.6.5 states see 7.1.3.2.1 for enclosures of exits. LSC 7.1.3.2.1 states the separation shall have a minimum 1-hr fire resistance rating where the exit connects three stories or less. Existing penetrations shall be protected in accordance with 8.3.5. This deficient practice could affect over 20 residents, staff and visitors.

Findings include:

Based on observations with the Vice President of Operations, the Facilities Director and the Safety Coordinator during a tour of the facility from 9:15 a.m. to 1:00 p.m. on 08/21/19, the following was noted:
a. the stairwell door in the basement in the kitchen was not provided with latching hardware.
b. the latching mechanism for the stairwell door on the first floor by Room 1019 failed to protrude into the latching plate.
c. the latching plate for the stairwell door by Outpatient Surgery on the second floor was removed which caused to door to fail to latch into the door frame,
d. the stairwell door by Room 2060 on the second floor failed to latch into the door frame.
Based on interview at the time of the observations, the Facilities Director stated the stairwell doors are equipped with magnetic holding devices set to release with fire alarm system activation but agreed the aforementioned stairwell doors did not latch into the door frame.

3. Based on observation and interview, the facility failed to ensure 1 of 1 doors to linen chute rooms in the basement were maintained in accordance with LSC 9.5. Section 9.5.1.4 states the room accessing the chute opening shall be separated from other spaces in accordance with Section 8.7.1.1(3) for severe hazard. This deficient practice could affect over 5 staff and visitors in the vicinity of Room A0030 in the basement.

Findings include:

Based on observations with the Vice President of Operations, the Facilities Director and the Safety Coordinator during a tour of the facility from 9:15 a.m. to 1:00 p.m. on 08/21/19, the corridor door to Room A0030 in the basement which is a linen chute room was equipped with a self closing device but had no affixed fire resistance rating label indicating it was fire resistance rated for at least 45 minutes. Based on interview at the time of the observations, the Facilities Director agreed the corridor door to the room did not have an affixed fire resistance rating label.

Part I

Based on document review and interview, the facility failed to follow the manufacturer's recommendations for the daily testing of a defibrillator, both as to type of checks (6 of 8 categories), and for 2 of 16 shifts.

Findings include:

1. In interview on 07-29-2019 at 10:50 am, employee #A5, Vice President Operations, indicated the facility had 2 nursing shifts.

2. Review of the manufacturer's manual for the defibrillator indicated the testing of the defibrillator should be performed at the start of each shift, according to the Operator's Shift Checklist for M Series products (Semi-Automatic). The tests included

3. Review of the manufacturer's manual for the defibrillator indicated the following were to be performed:
3. Paddles (if applicable)
Paddles clean, not pitted
Release from housing easily
4. Inspect cables for cracks, broken wires, connector
B. Defibrillator paddle cables
C. Multi-function cable, connector
5. Batteries
A. Fully charged battery in unit
B. Fully charged spare battery available
6. Disposable supplies
B. MFE Pads in sealed pouches - 2 sets
C. ECG electrodes
E. Alcohol wipes
F. Razors
7. Operational checks
E. Recorder
Press RECORDER button. Press again: Recorder stops

4. Review of defibrillator checks for the time period May 31, 2019 through June 8, 2019, indicated:

a. There were not checks for 2 of 16 shifts for the time period (6-1 7 P[M] and
6-3 7A[M]).

b. The above-stated recommended manufacturer checks in Finding 3 were not documented as having been done.

5. In interview on 07-30-2019 at 2:10 pm, employee #A5 confirmed all the above and no other documentation was provided prior to exit.


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Part II

1. Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm systems was maintained in accordance with 9.6.1.3. LSC 9.6.1.3 requires a fire alarm system to be installed, tested, and maintained in accordance with NFPA 70, National Electrical Code and NFPA 72, National Fire Alarm Code. NFPA 72, 2010 Edition, 14.2.1.2.1 states the requirements of Section 10.19 shall be applicable when a system is impaired. Section 14.2.1.2.2 states system defects and malfunctions shall be corrected. Section 14.6.2.4 states a record of all inspections, testing and maintenance shall be provided that includes all applicable information requested in Figure 14.6.2.4. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observations with the Vice President of Operations, the Facilities Director and the Safety Coordinator during a tour of the facility from 9:15 a.m. to 1:00 p.m. on 08/21/19, the main fire panel in the basement corridor had a system trouble light illuminated. Based on interview at the time of the observations, the Facilities Director contacted the Assistant Facilities Director who stated the fire panel has been in the trouble mode for over a week, the facility activated the alarm system during a drill last week and the system would activate if needed but a service call to repair the system has not yet been made. Based on interview at the time of the observations, the Facilities Director stated no one is actively trying to correct the issue but a service call to a repair contractor will be made at the time of the survey.

2. Based on record review and interview, the facility failed to ensure the documentation for the annual inspection/testing of all devices connected to 1 of 1 fire alarm system was complete. NFPA 72, National Fire Alarm Code, the 2010 Edition, at 14.6.2.4 requires a record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 14.6.2.4:
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency (ies)
(7) Designation of the detector(s) tested
(8) Functional test of detectors
(9)*Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Functional test of mass notification system control units
(13) Functional test of signal transmission to mass notification systems
(14) Functional test of ability of mass notification system to silence fire alarm notification appliances
(15) Tests of intelligibility of mass notification system speakers
(16) Other tests as required by the equipment manufacturer's published instructions
(17) Other tests as required by the authority having jurisdiction
(18) Signatures of tester and approved authority representative
(19) Disposition of problems identified during test (e.g., system owner notified, problem corrected/successfully retested, device abandoned in place)
This deficient practice could affect all patients, staff, and visitors.

Findings include:

Based on document review with the Vice President of Operations and the Facilities Director from 10:15 a.m. to 3:50 p.m. on 08/20/19, an itemized listing of fire alarm system devices inspected/tested within the most recent twelve month period was not available for review. The Facilities Director supplied records of monthly fire alarm system transmission records to the fire alarm monitoring company and stated an annual fire alarm system inspection was conducted by the fire alarm system inspection contractor in January 2019 but agreed documentation of the inspection/testing of all devices connected to the fire alarm system within the most recent twelve month period was not available for review at the time of the survey.

3. Based on document review and interview, the facility failed to ensure all fire dampers in the facility were inspected and provided necessary maintenance at least every four years in accordance with NFPA 90A. LSC 9.2.1 requires heating, ventilating and air conditioning (HVAC) ductwork and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. NFPA 90A, 2012 Edition, Section 5.4.8.1 states fire dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. NFPA 80, 2010 Edition, Section 19.4.1 states each damper shall be tested and inspected 1 year after installation. Section 19.4.1.1 states the test and inspection frequency shall then be every 4 years except for hospitals where the frequency is every 6 years. If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in-place if so equipped. The damper shall not be blocked from closure in any way. All inspections and testing shall be documented, indicating the location of the fire damper, date of inspection, name of inspector and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on document review with the Vice President of Operations and the Facilities Director from 10:15 a.m. to 3:50 p.m. on 08/20/19, fire damper inspection and maintenance documentation within the most recent six year period stated was not available for review. The review of facility blueprint documentation for the original building built in 1949 stated fire dampers were located in the building. Based on interview at the time of record review, the Facilities Director stated fire damper inspection and testing documentation within the most recent six year period was not available for review.

4. Based on document review, observation and interview; the facility failed to ensure annual inspection and testing of all fire door assemblies were completed in accordance with LSC 19.1.1.4.1.1. Communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire door assemblies. (See also Section 8.3.) LSC 8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code. NFPA 80 5.2.1 states fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ. NFPA 80, 5.2.4.1 states fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly.

NFPA 80, 5.2.4.2 states as a minimum, the following items shall be verified:
(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.
This deficient practice could affect all residents, staff and visitors in the facility.

Findings include:

Based on document review of with the Vice President of Operations and the Facilities Director from 10:15 a.m. to 3:50 p.m. on 08/20/19, annual fire door inspection documentation for the facility within the most recent twelve month period was not available for review. Based on interview at the time of record review, the Facilities Director stated annual fire door inspection documentation for the facility within the most recent twelve month period was not available for review at the time of the survey. Based on observations with the Vice President of Operations, the Facilities Director and the Safety Coordinator during a tour of the facility from 9:15 a.m. to 1:00 p.m. on 08/21/19, the facility has fire rated door assemblies which includes all stairwell doors.

5. Based on document review and interview, the facility failed to protect 3 of 3 wet location Operating Rooms in accordance with NFPA 99, Health Care Facilities Code. NFPA 99, 2012 Edition, Section 6.3.2.2.8.4 states that operating rooms shall be considered to be a wet location unless a risk assessment conducted by the health care governing body determines otherwise. Section 6.3.2.2.8.1 requires wet procedure locations shall be provided with special protection against electrical shock. This deficient practice could affect staff and up to 3 patients.

Findings include:

Based on document review with the Vice President of Operations and the Facilities Director from 10:15 a.m. to 3:50 p.m. on 08/20/19, no risk assessment documentation was available for review. Based on interview at the time of record review, the Vice President of Operations stated she did not know if the facility's three operating rooms were considered wet procedure locations and agreed risk assessment documentation was not available for review at the time of the survey.

6. Based on document review, observation and interview; the facility failed to ensure documentation of electrical outlet receptacle testing at 24 of 25 patient bed locations within the most recent twelve month period was available for review in accordance with NFPA 99. NFPA 99, Health Care Facilities Code, 2012 Edition, Section 6.3.4.1.1 states hospital-grade receptacles testing shall be performed after initial installation, replacement or servicing of the device. Section 6.3.3.2, Receptacle Testing in Patient Care Rooms requires the physical integrity of each receptacle shall be confirmed by visual inspection. The continuity of the grounding circuit in each electrical receptacle shall be verified. Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed; and retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 grams (4 ounces). Section 6.3.4.2.1.2 states, 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. This could affect 24 patients.

Findings include:

Based on document review of with the Vice President of Operations and the Facilities Director from 10:15 a.m. to 3:50 p.m. on 08/20/19, documentation of an itemized listing of hospital-grade receptacle testing at patient bed locations and in locations where deep sedation or general anesthesia is used within the most recent twelve month period was not available for review. Based on interview at the time of record review, the Facilities Director stated documentation of an itemized listing of hospital-grade receptacle testing at patient bed locations within the most recent twelve month period was not available for review. Based on observations with the Vice President of Operations, the Facilities Director and the Safety Coordinator during a tour of the facility from 9:15 a.m. to 1:00 p.m. on 08/21/19, all electrical receptacles installed at all patient bed locations were hospital-grade receptacles except for the four red receptacles in a wall mounted outlet box with a red cover plate near the head of the bed in patient Room 202. The four red receptacles were not equipped with a green dot which would indicate it was a hospital grade receptacle. Based on interview at the time of the observations, the Facilities Director agreed hospital-grade receptacles were installed in the patient care vicinity in all patient rooms except in Room 202.

7. Based on document review, observation and interview; the facility failed to ensure documentation of electrical outlet receptacle testing at 1 of 25 patient bed locations within the most recent twelve month period was available for review in accordance with NFPA 99. NFPA 99, Health Care Facilities Code, 2012 Edition, Section 6.3.4.1.3 states receptacles not listed as hospital-grade at patient bed locations and in locations where deep sedation or general anesthesia shall be tested at intervals not exceeding 12 months. Section 6.3.3.2, Receptacle Testing in Patient Care Rooms requires the physical integrity of each receptacle shall be confirmed by visual inspection. The continuity of the grounding circuit in each electrical receptacle shall be verified. Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed; and retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 grams (4 ounces). Section 6.3.4.2.1.2 states, 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. This could affect one patient.

Findings include:

Based on document review of with the Vice President of Operations and the Facilities Director from 10:15 a.m. to 3:50 p.m. on 08/20/19, documentation of an itemized listing of testing electrical outlet receptacles not listed as hospital-grade testing at patient bed locations within the most recent twelve month period was not available for review. Based on interview at the time of record review, the Facilities Director stated documentation of an itemized listing of testing electrical outlet receptacles not listed as hospital-grade at patient bed locations within the most recent twelve month period was not available for review. Based on observations with the Vice President of Operations, the Facilities Director and the Safety Coordinator during a tour of the facility from 9:15 a.m. to 1:00 p.m. on 08/21/19, all electrical receptacles installed at all patient bed locations were hospital grade receptacles except for the four red receptacles in a wall mounted outlet box with a red cover plate near the head of the bed in patient Room 202. The four red receptacles were not equipped with a green dot which would indicate it was a hospital grade receptacle. Based on interview at the time of the observations, the Facilities Director agreed nonhospital-grade receptacles were installed in the patient care vicinity in Room 202.

8. Based on document review, observation and interview; the facility failed to annually exercise two of three emergency generators with supplemental loads for diesel powered EPS installations that do not meet the requirements of NFPA 110, Section 8.4.2. NFPA 99, Health Care Facilities Code, 2012 Edition, Chapter 6.4.4.1.1.4(A) requires monthly testing of the generator serving the emergency electrical system to be in accordance with NFPA 110, the Standard for Emergency and Standby Powers Systems, Chapter 8. NFPA 110, 2010 Edition, Section 8.4.2 requires diesel generator sets in service to be exercised at least once monthly, for a minimum of 30 minutes using one of the following methods:
(1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
(2) Under operating temperature conditions and at not less than 30% of the nameplate kW rating.
Section 8.4.2.3 requires diesel-powered EPS installations that do not meet the requirement less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than ents of 8.4.2 shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at 1.5 continuous hours.
NFPA 99, Section 6.4.4.2 requires a written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice could affect all patients, staff and visitors in the facility.

Findings include:

Based on review of "Emergency Generator - Monthly Test Log" documentation with the Vice President of Operations and the Facilities Director during document review from 10:15 a.m. to 3:50 p.m. on 08/20/19, monthly emergency generator load testing documentation for the most recent twelve month period indicated the diesel fired emergency generators identified as generator #2 (500 kW) and generator # 3 (600 kW) each did not meet or exceed 30% load during monthly load testing October and November 2018 was not available for review. Based on interview at the time of document review, the Facilities Director stated load bank testing documentation within the most recent twelve month period was not available for review and agreed monthly load testing documentation for the two generators did not state the generators each met or exceeded 30% load during monthly load tests. Based on observations with the Vice President of Operations, the Facilities Director and the Safety Coordinator during a tour of the facility from 9:15 a.m. to 1:00 p.m. on 08/21/19, the facility has three diesel fired emergency generators rated at 300 kW, 500 kW and 600 kW located outside the facility inside three separate generator sheds.

9. Based on document review and interview, the facility failed to document the transfer time to the alternate power source on monthly load tests for 3 of 3 emergency generators for 12 months of the most recent 12 months period to ensure the alternate power supply was capable of supplying service within 10 seconds. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of "Emergency Generator - Monthly Test Log" documentation with the Vice President of Operations and the Facilities Director during document review from 10:15 a.m. to 3:50 p.m. on 08/20/19, monthly load testing documentation for the most recent twelve month period for three of three emergency generators did not include the transfer time from normal power to emergency power. Based on interview at the time of document review, the Facilities Director stated the facility has a total of three generators and stated load testing documentation for the most recent twelve month period for the three facility emergency generators did not include the transfer time from normal power to emergency power.

10. Based on document review, observation and interview; the facility failed to ensure 3 of 3 emergency generators was allowed a 5 minute cool down period after a load test for 12 of 12 months. LSC 19.2.9.1 refers to LSC 7.9 which refers to LSC 7.9.2.4 which requires emergency generators providing power to emergency lighting systems to be installed, tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, 2010 Edition. NFPA 110, Section 6.2.10 Time Delay on Engine Shutdown requires a minimum time delay of 5 minutes shall be provided for unloaded running of the Emergency Power Supply (EPS) prior to shutdown to allow for engine cool down. This time delay shall not be required on small (15 kW or less) air-cooled prime movers. NFPA 110, Section 8.3.4 states a permanent record of the Emergency Power Supply Systems (EPSS) inspections, tests, exercising, operation, and repairs shall be maintained and readily available. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of "Emergency Generator - Monthly Test Log" documentation with the Vice President of Operations and the Facilities Director during record review from 10:15 a.m. to 3:50 p.m. on 08/20/19, monthly load testing documentation for the most recent twelve month period for three of three emergency generators did not include cool down time. Based on interview at the time of document review, the Facilities Director stated the emergency generator is tested monthly for at least 30 minutes under load but agreed cool down time is not included in monthly load testing documentation. Based on observations with the Vice President of Operations, the Facilities Director and the Safety Coordinator during a tour of the facility from 9:15 a.m. to 1:00 p.m. on 08/21/19, the facility has three diesel fired emergency generator rated at 300 kW, 500 kW and 600 kW located outside the facility inside three separate generator sheds.

11. Based on document review, observation and interview; the facility failed to ensure an annual fuel quality test was performed for the facility's three diesel powered generators. NFPA 99, Health Care Facilities Code, 2012 Edition Section 6.5.4.1.1.2 states Type 2 EES (Essential Electrical System) generator sets shall be inspected and tested in accordance with Section 6.4.4.1.1.3. Section 6.4.4.1.1.3 states maintenance shall be performed in accordance with NFPA110, Standard for Emergency and Standby Power Systems, 2010 Edition, Chapter 8. NFPA 110, Section 8.3.8 states a fuel quality test shall be performed at least annually using tests approved by ASTM standards. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on document review with the Vice President of Operations and the Facilities Director from 10:15 a.m. to 3:50 p.m. on 08/20/19, documentation of an annual fuel quality test for three of three diesel fuel fired emergency generators was not available for review. At the time of record review, the facility supplied "Composite Analysis July 2019" documentation which appeared to be a fuel analysis report for five different fuels supplied to Midwestern cities by an unknown fuel supplier. Based on interview at the time of records review, the Facilities Director stated the facility has three diesel fired emergency generators and diesel fuel sampling and agreed documentation of an annual fuel quality test for three diesel fuel fired emergency generators was not available for review at the time of the survey. Based on observations with the Vice President of Operations, the Facilities Director and the Safety Coordinator during a tour of the facility from 9:15 a.m. to 1:00 p.m. on 08/21/19, the facility has three diesel fired emergency generator rated at 300 kW, 500 kW and 600 kW located outside the facility inside three separate generator sheds.

In building 02
12. Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm systems was maintained in accordance with 4.6.12.3. LSC 4.6.12.3 requires existing life safety features obvious to the public if not required by the Code, shall be either maintained or removed. LSC 9.6.1.3 requires a fire alarm system to be installed, tested, and maintained in accordance with NFPA 70, National Electrical Code and NFPA 72, National Fire Alarm Code. NFPA 72, 2010 Edition, 14.2.1.2.1 states the requirements of Section 10.19 shall be applicable when a system is impaired. Section 14.2.1.2.2 states system defects and malfunctions shall be corrected. Section 14.6.2.4 states a record of all inspections, testing and maintenance shall be provided that includes all applicable information requested in Figure 14.6.2.4. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observations with the Vice President of Operations, the Facilities Director and the Safety Coordinator during a tour of the facility from 2:00 p.m. to 2:10 p.m. on 08/21/19, one of two telephone dialers was disconnected from the telephone port in the main fire panel in the corridor. Based on interview at the time of the observations, the Facilities Director stated he was unsure if a second telephone dialer was a digital system but agreed the second hardwired telephone dialer for the facility's fire alarm system was disconnected from the telephone port in the main fire panel in the corridor.

Based on observation and interview, the facility failed to ensure housekeeping in two operating room dressing rooms (men's and women's).

Findings include:

1. On 7/29/2019, at approximately 1:28 pm, the following was observed. Men's Operating Room Dressing Room had three flies in the lights.

2. Interview on 7/29/2019, at approximately 1:28 pm, with N8 (Director of Surgery) confirmed the above.

3. On 7/29/2019, at approximately 1:30 pm, the following was observed. Women's Operating Room Dressing Room had two flies in the lights.

4. Interview on 7/29/2019, at approximately 1:30 pm, with N8 (Director of Surgery) confirmed the above.

1. Based on observation and interview, the facility failed to provide emergency lighting in 2 of 3 operating rooms where general anesthesia is administered in accordance with NFPA 99. NFPA 99, Health Care Facilities Code, 2012 Edition, Section 6.3.2.2.11.1 states one or more battery-powered lighting units shall be provided within locations where deep sedation and general anesthesia is administered. The lighting level of each unit shall be sufficient to terminate procedures intended to be performed within the operating room. The sensor for units shall be wired to the branch circuit(s) serving general lighting within the room. Units shall be capable of providing lighting for 90 minutes and shall be tested monthly for 30 seconds and annually for 30 minutes. Section 3.3.17 defines battery-powered lighting units as individual unit equipment for backup illumination consisting of a rechargeable battery, battery-charging means, provisions for one or more lamps mounted on the equipment, or with terminals for remote lamps, or both, and relaying device arranged to energize the lamps automatically upon failure of the supply to the unit equipment. This deficient practice could affect two patients and staff in two of three operating rooms where general anesthesia or life support equipment is used.

Findings include:

Based on the interview at the entrance conference at 9:30 a.m. on 08/20/19, the Vice President of Operations stated general anesthesia can be administered in two of three operating rooms in the facility. Based on observations with the Facilities Director during a tour of the facility from 9:15 a.m. to 1:00 p.m. on 08/21/19, none of the three operating rooms were provided with battery operated emergency lighting to provide continuous illumination. Based on interview at the time of the observations, the Facilities Director agreed there is no battery operated back up emergency lighting systems to provide continuous illumination in each of the three operating rooms in the facility.

2. Based on document review and interview, the facility failed to ensure the humidity in 2 of 3 anesthetizing locations were maintained between 20% and 60%. NFPA 99 9.3.1.1 requires heating, cooling, ventilating, and process systems serving spaces or providing health care functions covered by this code or listed within ASHRAE 170, Ventilation of Health Care Facilities. ASHRAE 170, requires mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 20 percent or greater. CMS requires Operating Rooms not to exceed 60% humidity per S&C 13-25-LSC. This deficient practice could affect staff and up to 2 patients.

Findings include:

Based on document review with the Vice President of Operations and the Facilities Director from 10:15 a.m. to 3:50 p.m. on 08/20/19, documentation of the relative humidity in 2 of 3 operating rooms where general anesthesia is used was not available for review. Based on interview at the time or document review, the Vice President of Operations stated general sedation or general anesthesia is used in two of three operating rooms and relative humidity is not documented in those two operating rooms and agreed documentation of the relative humidity in two of three operating rooms where general anesthesia is used was not available for review at the time of the survey.

1. Based on observation and interview, the facility failed to ensure 1 of over 50 rooms was separated from the corridor by a partition capable of resisting the passage of smoke as required in a sprinklered building, or met an Exception per 19.3.6.1(1). LSC 19.3.6.1(1) states smoke compartments protected throughout by an approved supervised automatic sprinkler system in accordance with 19.3.5.8 shall be permitted to have spaces that are unlimited in size and open to the corridor, provided that all of the following criteria are met:
(a)*The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas.
(b) The corridors onto which the spaces open in the same smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the smoke compartment in which the space is located is protected throughout by quick-response sprinklers.
(c) The open space is protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the entire space is arranged and located to allow direct supervision by the facility staff from a nurses' station or similar space.
(d) The space does not obstruct access to required exits.
This deficient practice could affect over 10 patients, staff and visitors in the vicinity of the Family Lounge on the second floor.

Findings include:

Based on observations with the Vice President of Operations, the Facilities Director and the Safety Coordinator during a tour of the facility from 9:15 a.m. to 1:00 p.m. on 08/21/19, the corridor door to the Family Lounge on the second floor was removed which caused the room to be open to the corridor. The rooms was not equipped with an electrically supervised automatic smoke detection system. The smoke compartment containing the room was not equipped with quick response sprinklers and the room did not have direct supervision by the facility staff from a nursing station or similar space at all times. Based on interview at the time of the observations, the Facilities Director agreed the corridor door to the room had been removed and the room was not equipped with an electrically supervised automatic smoke detection system.

2. Based on document review and interview, the facility failed to provide documentation of a fire drill conducted on the:
a. second shift for 2 of 4 quarters.
b. third shift for 1 of 4 quarters.
This deficient practice affects all patients, staff and visitors.

Findings include:

Based on review of "Fire Drill Observer Checklist (Main Hospital)" documentation with the Vice President of Operations and the Facilities Director during record review from 10:15 a.m. to 3:50 p.m. on 08/20/19, documentation of a fire drill conducted on the second shift in the fourth quarter (October, November, December) 2018 and the second quarter quarter (April, May, June) 2019 was not available for review. Documentation of a fire drill conducted on the third shift in the third quarter (July, August, September) 2018 was also not available for review. Based on interview at the time of record review, the Facilities Director agreed documentation of a fire drill conducted on the aforementioned shifts and quarters was not available for review at the time of the survey.

3. Based on observation and interview, the facility failed to ensure 1 of 1 indoor nonflammable gas storage areas was enclosed with a separation of 1 hour fire resistive construction. NFPA 99, Standard for Health Care Facilities, 2012 Edition, Section 5.1.3.3.2(4) states locations for central supply systems and the storage of positive-pressure gases, if indoors, shall be constructed and use interior finishes of noncombustible or limited-combustible materials such that all walls, floors, ceilings, and doors are of a minimum 1-hour fire resistance rating. Section 5.1.3.3.2(2) states they shall be secured with lockable doors or gates or otherwise secured. NFPA 80, Standard for Fire Doors and Other Opening Protectives, 2010 Edition, Section 6.1.4.2.1 states self closing doors shall swing easily and freely and shall be equipped with a closing device to cause the door to close and latch each time it is opened. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observations with the Facilities Director during a tour of the facility from 9:15 a.m. to 1:00 p.m. on 08/21/19, each of the two doors in the entry door set to the piped gas central supply room in the basement for nitrous gas was not equipped with a self closing device. Based on interview at the time of the observations, the Facilities Director agreed each of the two entry doors in the door set to the room were not equipped with a self closing device.

4. Based on observation and interview, the facility failed to ensure extension cords including power strips used in 1 of 3 Operating Rooms were not used as a substitute for fixed wiring. LSC 19.5.1 requires utilities to comply with Section 9.1. LSC 9.1.2 requires electrical wiring and equipment to comply with NFPA 70, National Electrical Code, 2011 Edition. NFPA 70, Article 400.8 requires that, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. LSC Section 4.5.7 states any building service equipment or safeguard provided for life safety shall be designed, installed and approved in accordance with all applicable NFPA standards. NFPA 99, Standard for Health Care Facilities, 2012 edition, defines patient care areas as any portion of a health care facility wherein patients are intended to be examined or treated. Patient care vicinity is defined as a space, within a location intended for the examination and treatment of patients, extending 6 ft (1.8 m) beyond the normal location of the bed, chair, table, treadmill, or other device that supports the patient during examination and treatment. A patient care vicinity extends vertically to 7 ft 6 in. (2.3 m) above the floor. NFPA 99, Section 10.4.2.3 states household or office appliances not commonly equipped with grounding conductors in their power cords shall be permitted provided they are not located within the patient care vicinity. This deficient practice could affect one patient in Operating Room 2.

Findings include:

Based on observations with the Facilities Director during a tour of the facility from 9:15 a.m. to 1:00 p.m. on 08/21/19, Coviden rack equipment medical devices were plugged into a power strip affixed to the rack in Operation Room 2. The UL listing of the power strip could not be determined. Based on interview at the time of the observations, the Facilities Director agreed the UL listing of the power strip could not be determined and was being used in the patient care vicinity and as a substitute for fixed wiring at the aforementioned location.

Building 03
1. Based on document review and interview, the facility failed to ensure 1 of 1 automatic sprinkler piping systems had a complete flushing program conducted following an obstruction investigation which indicated sufficient obstruction in accordance with 4.6.12.3. LSC 4.6.12.3 requires existing life safety features obvious to the public if not required by the Code, shall be either maintained or removed. NFPA 25, Standard or the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 14.3.3 states if an obstruction investigation indicates the presence of sufficient material to obstruct pipe or sprinklers, a complete flushing program shall be conducted by qualified personnel. Section 4.3.1 states records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request. This deficient practice affects all patients, staff and visitors.

Findings include:

Based on review of the sprinkler system contractor's "5 Year Internal Inspection" documentation dated 01/09/19 with the Vice President of Operations and the Facilities Director during document review from 10:15 a.m. to 3:50 p.m. on 08/20/19, the facility's sprinkler systems are in need of internal cleaning. The "Results of Initial Examination" section of the aforementioned documentation stated "The sprinkler systems are in need of internal cleaning. Some of the pipes were found to be partially full of foreign materials." Additional inspection comments by the contractor stated "Main piping found to have tuberculation building up on bottom of piping as evident in pictures where I opened up 4" cross main." Based on interview at the time of document review, the Facilities Director stated sprinkler system flushing is scheduled to be done in the Fall of 2019 and stated documentation of sprinkler system flushing on or after 01/09/19 was not available for review.

2. Based on document review and interview, the facility failed to ensure the sprinkler system was maintained in accordance with 4.6.12.3. LSC 4.6.12.3 requires existing life safety features obvious to the public if not required by the Code, shall be either maintained or removed. LSC 9.7.5 requires all sprinkler systems shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 2011 Edition, Section 4.1.1 states the property owner or designated representative shall be responsible for properly maintaining a water based fire protection system. Section 4.1.4.1 states the property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test, and maintenance required by this standard. This deficient practice could affect all patients, staff and visitors.

Building 06
1. Based on document review and interview, the facility failed to ensure 1 of 1 automatic sprinkler piping systems had a complete flushing program conducted following an obstruction investigation which indicated sufficient obstruction in accordance with 4.6.12.3. LSC 4.6.12.3 requires existing life safety features obvious to the public if not required by the Code, shall be either maintained or removed. NFPA 25, Standard or the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 14.3.3 states if an obstruction investigation indicates the presence of sufficient material to obstruct pipe or sprinklers, a complete flushing program shall be conducted by qualified personnel. Section 4.3.1 states records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request. This deficient practice affects all patients, staff and visitors.

Findings include:

Based on review of the sprinkler system contractor's "5 Year Internal Inspection" documentation dated 01/09/19 with the Vice President of Operations and the Facilities Director during document review from 10:15 a.m. to 3:50 p.m. on 08/20/19, the facility's sprinkler systems are in need of internal cleaning. The "Results of Initial Examination" section of the aforementioned documentation stated "The sprinkler systems are in need of internal cleaning. Some of the pipes were found to be partially full of foreign materials." Additional inspection comments by the contractor stated "Main piping found to have tuberculation building up on bottom of piping filling approx 1/4 of the inside of pipe where I opened the 2 1/2 inch cross main." Based on interview at the time of document review, the Facilities Director stated sprinkler system flushing is scheduled to be done in the Fall of 2019 and stated documentation of sprinkler system flushing on or after 01/09/19 was not available for review.