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Based on observation and interview, the facility failed to ensure each door in a rated barrier self closed in accordance with 19.2.2.2.7, NFPA 101, 2012 edition. This had the potential to affect all patients receiving services from the facility.

Findings include:

On 10/29/18 at 2:45 PM, a tour was taken of the facility with Staff Q.

On 10/31/18 at 3:39 PM, the corridor door that was two doors to the north of the double doors that lead to the operating room theater was observed to be in a one hour rated barrier. Observation of the door revealed it did not have a self closer.

On 10/31/18 at 3:39 PM in an interview, Staff Q confirmed the finding.

Based on observation, document review, and interview, the facility failed to test each battery powered emergency lighting in accordance with 19.2.9.1 and therefore 7.9 of NFPA 101, 2012 edition. This had the potential to affect all patients receiving services from the facility.

Findings include:

On 10/30/18 at 4:15 PM, emergency battery operated lights were observed in operating room one and two.

On 10/31/18, a review of the facility's life safety code documentation was completed. The review revealed a list of emergency battery operated lights that were tested. The list did not include the lights in the operating rooms.

On 10/31/18 at 4:15 PM in an interview, Staff Q confirmed the operating room emergency lights had not been tested.

Based on observation and interview, the facility failed to ensure each means of egress had signs marked in accordance with 19.2.10.1 and therefore 7.10, NFPA 101, 2012 edition. This had the potential to affect all patients receiving services from the facility.

Findings include:

On 10/31/18 at 8:45 AM, tour was taken of the facility with Staff Q. Observation of an evacuation plan as posted on a wall opposite the wall holding four framed accrediting organization certificates and near the sign that read in part "if you are pregnant" was completed. The observation revealed a path of egress traveling from that point south along the corridor then turning east (left) at the end of corridor.

Observation of the exit sign at the end of corridor revealed it had a chevron directing occupants to the west (right) at the end of the corridor.

On 10/31/18 at 8:45 AM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure the two hour rated barrier surrounding a hazardous area was free of penetrations. This had the potential to affect all patients receiving services from the facility.

Findings include:

On 10/29/18 at 2:45 PM, a tour was taken of the facility with Staff Q.

On 10/31/18 at 5:22 PM, observation of the two hour fire barrier surrounding a hazardous area and between the boiler room and clean linen room, as seen from the clean linen room, revealed a one foot wide by half foot tall penetration with three white pipes running through.

On 10/31/18 at 5:22 PM in an interview, Staff Q confirmed the finding.

Based on observation, interview, and document review, the facility failed to test each fire alarm notification device in accordance with NFPA 101, 2012 edition, 9.6.1.3 and therefore NFPA 72, 2010 edition, 14.4.5. This had the potential to affect all patients receiving services from the facility.

Findings include:

On 10/30/18 at 4:20 PM, a strobe was observed in the locked office by the ambulatory surgery unit.

On 10/30/18 at 5:00 PM, a horn/strobe was observed in a storage room near the medical surgical unit.

On 10/31/18, review of the facility's life safety code documentation was completed. The review revealed the alarm system was tested on 07/28/16. The review did not reveal where the aforementioned devices had been tested.

On 10/30/18 at 5:30 PM in an interview, Staff Q confirmed the observations.

Based on observation, interview and document review, the facility failed to inspect the sprinkler system's gauges and control valves monthly in accordance in accordance with table 5.1.1.2 and 5.2.4.1 and table 13.1.1.2 and 13.3.2.1.1. of NFPA 25, 2011 edition, failed to ensure its sprinkler heads were clean, and failed to have each sprinkler system control valve electronically monitored in accordance with 9.7.2.1, NFPA 101, 2012 edition. This had the potential to affect all patients receiving services from the facility.

Findings include:

1. Review of the facility's life safety code documentation did not reveal where the sprinkler's gauges, control valves and tamper switches therein, were inspected monthly.

On 10/31/18 at 5:30 PM in an interview, Staff Q confirmed the gauges and controls valves were not inspected monthly.

2. On 10/30/18 at 1:26 PM, observation of the sprinkler post indicator valve was completed. The observation revealed the post was locked with a standard u-lock. A supervisory attachment to indicate a condition that would signal the operational status of the sprinkler system was not satisfactory was not observed.

On 10/31/18 at 1:15 PM, Staff Q confirmed the observation in an interview.

3. On 10/31/18 at 9:22 AM, a tour was taken of the emergency department with Staff Q. Observation of the sprinkler heads by the air vent near patient room three and the tree of celebration in the waiting area revealed each was coated with particulate that made seeing the color of the fluid in the bulb difficult to see.

On 10/31/18 at 9:22 AM in an interview, Staff Q confirmed the observation.

On 10/31/18 at 9:39 AM observation of the sprinkler head by the double doors as one entered the waiting area revealed a sprinkler head with a missing eschuteon. Observation of a sprinkler head by the double doors to the exercise area and near the center of the room revealed each was coated with particulate that made seeing the color of the fluid difficult to see.

On 10/31/18 at 9:39 AM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to ensure its fire extinguisher signage complied with 19.3.5.12 and therefore 9.7.4.1 of NFPA 101, 2012 edition and therefore 6.1.3.3.2 of NFPA 10, 2010 edition. This had the potential to affect all patients receiving services from the facility.

Findings include:

On 10/31/18 at 8:45 AM, a tour was taken of the facility with Staff Q. At 8:58 AM a fire extinguisher sign was observed by the kitchen sinks pointing down. However no fire extinguisher was observed there.

On 10/31/18 at 9:22 AM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure its smoke barriers were free of penetrations. This had the potential to affect all patients receiving services from the facility.

Findings include:

On 10/29/18 at 2:45 PM, a tour was taken of the facility with Staff Q.

On 10/31/18 at 4:21 PM observation above the drop down ceiling of the one hour smoke barrier near the physician's lounge and across the "cattle chute" revealed a one inch open conduit with blue wires traveling out of it.

On 10/31/18 at 4:21 PM in an interview, Staff Q confirmed the finding.

Based on document review and interview, the facility failed to maintain its medical gas system in accordance with NFPA 99, 2012 edition, 5.1.12.2.6.6. This had the potential to affect all patients receiving services from the facility.

Findings include:

Review of the facility's medical gas inspection report was completed on 10/31/18. The review revealed the medical gas system was inspected on 10/12/18. The review revealed a leak in the vacuum outlet in room 132 and a leak at the left bed in the recovery room.

On 10/30/18 at 5:30 PM in an interview, Staff Q confirmed the leaks had not been fixed.

Based on interview and document review, the facility failed to perform preventative maintenance to its generator in accordance with NFPA 110, 2010 edition, 8.3. This had the potential to affect all patients receiving services from the facility.

Findings include:

On 10/31/18, a review of the facility's life safety code documentation was completed. The review revealed the generator had last been inspected, and maintenance service applied, on 11/21/16.

On 10/31/18 at 2:40 PM in an interview, Staff Q confirmed he/she did not have annual inspection and maintenance reports for 2017 for the generator.

Based on document review, interview and observation, the facility failed to assess the electrical system of its patient-care related electrical equipment in accordance with 10.3 of NFPA 99, 2012 edition. This had the potential to affect all patients receiving services from the facility.

Findings include:

On 10/31/18 at 8:50 AM, beds were observed from room 102B and 103B.

On 10/31/18, a review of the facility's life safety code documentation was completed. The review did not reveal where the beds' electrical system had been assessed in accordance with 10.3, NFPA 99, 2012 edition.

On 10/31/18 at 8:50 AM in an interview, Staff R confirmed the beds had not been tested.