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Based on observation, record review and interview, the facility failed to maintain the emergency egress lighting system in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 7.9.2.1 and 19.2.9.1, by not ensuring emergency illumination be provided for a minimum of 1 1/2 hours in the event of failure of normal lighting. This deficient practice affects all emergency light fixtures in the facility, including all staff, residents and visitors. The facility had a capacity of 17 and a census of 4 residents at the time of the survey.

Findings include:

Record review and interview on 10/8/18, at 12:58 p.m., revealed the facility could not provide any documentation of conducting monthly and annual testing on all battery backup emergency lighting in the facility.

Maintenance Staff A and B verified this deficient practice at the time of the survey.

Based on observation, record review and interview, the facility failed to ensure corridor doors were not held open with a door stop or other impediments to hazardous areas in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 19.3.6.3, 8.4.3.5, and 7.2.1.8. This deficient practice could prevent the self-closing of doors when released to self-closing action, affecting staff in one of twelve smoke zones in the building. This facility had a capacity of 17 and a census of 4 residents at the time of the survey.

Findings include:

Observation and interview on 10/8/18, at 4:00 p.m., revealed there was a wooden door stop located behind the Boiler Room Door.

Record review of the facility layout showed the deficient practice affected one of twelve smoke zones.

Maintenance Staff A and B verified this finding during the survey.

Based on observations, interview and record review, this facility did not assure that two of twelve smoke barriers prevent the passage of smoke and fire to another smoke zone in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 19.3.7.3. This deficient practice affected staff, residents and visitors. This facility had a capacity of 17 and a census of 4 residents at the time of the survey.

Findings include:

Observations and interview on 10/8/18, between 5:25 p.m. and 5:40 p.m., revealed the following smoke barriers, above the lay-in tile ceiling, had openings that were not sealed with a fire rated material:

1) The barrier located in the Laboratory Corridor had a large cluster of blue ethernet cable passing through two large conduit pipes. The conduit pipes were not properly sealed to resist the passage of smoke.
2) The barrier located in the Outpatient Corridor had a large cluster of blue Ethernet cable passing through two large conduit pipes. The conduit pipes were not properly sealed to resist the passage of smoke.

Record review of the facility layout showed these deficient practices affected two of twelve barriers in the facility.

Maintenance Staff A and B verified these observations at the time of the survey process.

Based on observations and interview, the facility did not ensure corridor doors were not held open with a door stop or other impediments as required by National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.3.6.3/19.3.6.3. The facility failed to adjust door stops on restroom doors to prevent them from interfering with the corridor door. This deficient practice affected approximately 9 residents in two of twelve smoke zones, as the doors would not prevent the spread of fire and smoke. This facility had a capacity of 17 and a census of 4 residents at the time of the survey.

Findings include:

Observations and interview on 10/8/18, between 4:25 p.m. and 4:50 p.m., revealed the following deficiencies:

1) The following restroom doors did contain door stop mechanisms, however the restroom doors did interfere with the corridor doors in the following rooms: 2 through 10 and 14 through 18.

2) There was a brown rubber door stop holding the inside main entry door open in the Outpatient Office at 431 South Duff St. in Ames.

3) The Galley Room Door required too much force to close when tested.

Maintenance Staff A and B confirmed these findings at the time of the survey.

Based on record review and interview, the facility failed to adequately document and hold fire drills under varied conditions at different times of the day in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.7.1.6/19.7.1.6 for four of four quarters reviewed. The documentation showed the fire drills were not held at varied times as required. This had the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. This facility had a capacity of 17 and a census of 4 residents at the time of the survey.

Findings include:

Record review and interview on 10/8/18, at 12:52 p.m., of the facility fire drill documentation conducted during 2018 revealed the following: four of the four night shift drills were conducted at 4:45 a.m., 5:00 a.m., 5:05 a.m. and 5:10 a.m.

Results of the record review were acknowledged by Maintenance Staff A and B during the entrance conference.

Based on observation, record review and interview, this facility is not providing fire and/or smoke door assemblies in openings required to have a fire protection rating in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 8.3.3.1 and NFPA 80, Standard for Fire Doors and Other Opening Protectives, 5.2 by failing to inspect and test fire and/or smoke door assemblies annually. This deficient practice affects staff and visitors in one of twelve smoke compartments. This facility had a capacity of 17 and a census of 4 residents at the time of the survey.

Findings include:

Observation, record review and interview on 10/8/18, at 12:45 p.m., revealed the facility could not provide documentation of annual inspection and testing of fire and/or smoke door assemblies within the facility. The facility has one set of two hour fire rated doors separating the hospital from the clinic and all smoke/fire rated doors separating the barriers in the facility. These fire doors are required to be functionally tested annually by an individual with knowledge and understanding of the operating components of the type of door being subject to testing.

NFPA 80 Standard for Fire Doors and Other Opening Protectives, 2010 edition, 5.2* Inspections.

"5.2.1* 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.

5.2.3 Functional Testing.

5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing.

5.2.5 Horizontally Sliding, Vertically Sliding, and Rolling Doors.

5.2.5.1 Fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly.

5.2.6 Inspection shall include an operational test for automatic-closing doors and windows to verify that the assembly will close under fire conditions.

5.2.7 Assembly shall be reset after a successful test.

5.2.8 Resetting of the release mechanism shall be done in accordance with manufacturer's instructions.

5.2.9 Hardware shall be examined, and inoperative hardware, parts, or other defects shall be replaced without delay.

5.2.10 Tin-clad and kalamein doors shall be inspected for dry rot of the wood core.

5.2.11 Chains or cables employed shall be inspected for excessive wear and stretching."

Maintenance Staff A and B verified this deficient practice at the time of the survey.

Based on record review and interview, the facility failed to conduct and document electrical receptacle testing in patient care rooms as required by National Fire Protection Association (NFPA) 99, Health Care Facilities Code, 2012 edition, 6.3.3.2 and 6.3.4.2. The deficient practice affects all smoke compartments and all residents, staff, and visitors. The facility had a capacity of 46 and a census of 29 residents at the time of the survey.

Findings include:

Record review and interview on 10/8/18, at 2:15 p.m., revealed the facility failed to complete testing of all hospital grade electrical outlets at patient care areas where deep sedation or general anesthesia is administered throughout the building at the time of installation.

6.3.3.2 Receptacle Testing in Patient Care Rooms.
6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz)."

Maintenance Staff A and B verified this record review during the survey process.

Based on record review and interview, this facility did not maintain and test essential electrical system (EES) circuitry as required by National Fire Protection Association (NFPA) 99, Health Care Facilities Code, 2012 edition, 6.4.4.1.2 and 6.4.4.2. The facility failed to maintain the emergency generator by maintaining complete weekly and monthly documentation, conducting an annual load bank test and conduct annual fuel quality test approved by the American Section of the International Association for Testing Materials (ASTM) on the diesel generator as required by National Fire Protection Association (NFPA) 110, Standard for Emergency and Standby Power Systems, 2010 edition, 8.3.1 or 8.3.4. The deficient practices of not providing complete and verifiable documentation on the inspection, testing, and maintenance of the generator did not ensure proper operation and prompt repair affecting all occupants. This facility had a capacity of 17 and a census of 4 residents at the time of the survey.

Findings include:

Record review and interview conducted on 10/8/18, between 1:26 p.m. and 2:00 p.m., of the facilities generator inspection testing and maintenance records revealed:

1) The available documentation did not indicate the time to transfer on the monthly load tests.
2) The facility was unable to provide documentation of an annual fuel quality test approved by the American Section of the International Association for Testing Materials (ASTM) on the diesel generator.
3) The facility was also unable to provide evidence of an annual load bank test in lieu of the 30% monthly test showing the appropriate increments, as required.
4) The available weekly inspection documentation of the generator indicated the facility failed to inspect the generator during the following weeks: 4/20/18 and 4/27/18.

These deficient practices were confirmed by Maintenance Staff A and B at the time of the survey.

Based on observation and interview, the facility failed to maintain the building's electrical system in accordance with National Fire Protection Association, NFPA 70, 2011 Edition by failing to provide the proper clearance around all electrical panels. This deficient practice may create an electrical arc or fire affecting approximately one occupant in one of twelve smoke zones. This facility had a capacity of 17 and a census of 4 residents at the time of the survey.

Findings include:

Observation and interview on 10/8/18, between 4:12 p.m. and 4:18 p.m., revealed the following deficiencies:

1) There was a large monitor stored near electrical panel CP1. This panel was located in the panel room near the Recovery Area.

2) There were two metal ladders leaning against an electrical panel in the Electrical Room.

Maintenance Staff A and B verified this deficient practice at the time of the survey.

Based on observation and staff interview, the facility did not prohibit the use of extension cords in accordance with National Fire Protection Association (NFPA) 99, Health Care Facilities Code, 2012 edition and NFPA 70, National Electrical Code, 2011 edition. This deficient practice may create electrical injury and fire hazards affecting approximately two occupants in one of one smoke zone. This facility had a capacity of 17 and a census of 4 residents at the time of the survey.

Findings include:

Observation and staff interview on 10/8/18, at 2:30 p.m., revealed there was an unapproved extension cord supplying power to a lamp in Room 1.

This deficient practice was confirmed by Maintenance Staff A and B at the time of discovery.

Based on observations, interview and record review, the facility did not store oxygen tanks in accordance with National Fire Protection Association (NFPA) 99, Health Care Facilities Code, 2012 edition, 11.6.5, by ensuring empty and full tanks were adequately separated and labeled to prevent confusion when choosing tanks in an emergency. This deficient practice occurred in one oxygen storage room and affected the staff. This facility had a capacity of 17 and a census of 4 residents at the time of the survey.

Findings include:

Observations and interview on 10/8/18, at 4:52 p.m., revealed the Oxygen Storage Room contained multiple "E" cylinders that were not physically separate or appropriately labeled full and empty. The room had sections labeled 'full' and 'empty' however, the full side had two empty cylinders mixed in with the full cylinders.

Record review of the facility layout showed the deficient practice affected one of twelve smoke zones.

Maintenance Staff A and B verified these observations at the time of the survey process.