HospitalInspections.org

Based on observation and staff interview, the facility failed to provide means of egress that have all-weather surfaces to the public way. The deficient practice would prevent these exits from being arranged so that they are readily available and accessible in all weather conditions, affecting 10 patients and all occupants in 1 of 4 smoke zones. The facility has a capacity of 14 with a census of 5.

During the tour conducted on 7/22/15, between 9 am and 12 pm, the following is observed:

1.) At approximately 11:15 am it is discovered that the concrete sidewalk does not end at a public way from the North Designated Exit near the Nurses Station.

Adminstrative Staff A and B were present and acknowledged the finding.

NFPA Standard: Exits shall terminate directly at a public way or an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. 2000 NFPA 101, 7.7.1.

Based on observation and staff interview the facility failed to maintain emergency lighting as required. This deficient practice of not providing egress lighting when needed at the time of a power outage would impede exiting, affecting all 14 patients and occupants in 4 of 4 smoke zones. The facility has a capacity of 14 with a census of 5.

During the tour conducted on 7/22/15, between 9 am and 12 pm, the following is observed:

1.) At approximately 9:59 am it is discovered that there is no documentation of emergency lighting being tested monthly or annually from July 2014 to April 2015 available.

Administrative Staff A was present and acknowledged the finding.

NFPA Standard: Emergency lighting for means of egress shall be provided in accordance with Section 7.9 for the following: buildings or structures where required by the occupancy chapters, underground and windowless structures as required by Section 11.7, high-rise buildings as required by other sections of this Code, doors equipped with delayed egress locks, and stair shaft and vestibules of smoke proof enclosures. For the purposes of this requirement, exit access shall include designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit and exit discharge shall include designated stairs, ramps, aisles, walkways, and escalators leading to a public way. 2000 NFPA 101, 7.9.1.1

Based on record review and staff interview, the facility is not conducting fire drills as required quarterly on each shift and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency, affecting all 14 patients and occupants in 4 of 4 smoke zones. The facility has a capacity of 14 with a census of 5.

During the tour conducted on 7/22/15, between 9 am and 12 pm, the following is observed:

1.) At approximately 9:28 am it is discovered that there is no documentation of fire drills being performed for the 2nd shift during the 3rd and 4th quarters of 2014 or the 1st quarter of 2015 available.

Administrative Staff A was present and acknowledged the finding.

NFPA Standard: Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 2000 NFPA 101, 19.7.1.2.

Based on observation, staff interview and record review, the facility failed to maintain and test the emergency generator power supply as required. The deficient practice may prevent the emergency power supply from being available at the time of a power loss, affecting all 14 patients and occupants in 4 of 4 smoke zones. The facility has a capacity of 14 with a census of 5.

During the tour conducted on 7/22/15, between 9 am and 12 pm, the following is observed:

1.) At approximately 9:24 am it is discovered that there is no documentation of the generator being tested between July 2014 through May 2015.

Administrative Staff A was present and acknowledged the finding.

NFPA Standard: Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10 second interval specified in 3 4.1.1.8 and 3 4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
(b) Inspection and Testing.
1.* Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
2. Test Conditions. The scheduled test under load conditions shall include a complete simulated cold start and automatic and manual transfer of all essential electrical system loads.
3. Test Personnel. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures. 1999 NFPA 99 3.4.4.1.

Based on observation and staff interview, the facility did not ensure that electrical wiring and equipment is installed and maintained in accordance with NFPA 70, National Electrical Code. This deficient practice does not ensure prevention of an electrical fire or electric shock hazard, affecting all 14 patients and occupants in 3 of 4 smoke zones. The facility has a capacity of 14 with a census of 5. One of the affected areas contains the Central Dining Room.

During the tour conducted on 7/22/15, between 9 am and 12 pm, the following is observed:

1.) At approximately 9:38 am it is discovered that there is an open junction box with open wiring splices above the generator transfer switches in the Maintenance Office/Electrical Room.

2.) At approximately 10:05 am it is discovered that there is an unsupervised space heater on and being powered by a power strip in Room 502.

3.) At approximately 10:15 am it is discovered that there is a multiplug adaptor in use in the Phycians Dictation Room.

4.) At approximately 10:23 am it is discovered that there is a power strip being powered by another power strip in the Business Office.

5.) At approximately 10:47 am it is discovered that there is a power strip being powered by another power strip in the Kitchen Office Area.

Administrative Staff B was present and acknowledged the findings.

NFPA Standard: Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction. 2000 NFPA 101, 9.1.2

Based on observation and staff interview, the facility failed to provide means of egress that have all-weather surfaces to the public way. The deficient practice would prevent these exits from being arranged so that they are readily available and accessible in all weather conditions, affecting 10 patients and all occupants in 1 of 4 smoke zones. The facility has a capacity of 14 with a census of 5.

During the tour conducted on 7/22/15, between 9 am and 12 pm, the following is observed:

1.) At approximately 11:15 am it is discovered that the concrete sidewalk does not end at a public way from the North Designated Exit near the Nurses Station.

Adminstrative Staff A and B were present and acknowledged the finding.

NFPA Standard: Exits shall terminate directly at a public way or an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. 2000 NFPA 101, 7.7.1.

Based on observation and staff interview the facility failed to maintain emergency lighting as required. This deficient practice of not providing egress lighting when needed at the time of a power outage would impede exiting, affecting all 14 patients and occupants in 4 of 4 smoke zones. The facility has a capacity of 14 with a census of 5.

During the tour conducted on 7/22/15, between 9 am and 12 pm, the following is observed:

1.) At approximately 9:59 am it is discovered that there is no documentation of emergency lighting being tested monthly or annually from July 2014 to April 2015 available.

Administrative Staff A was present and acknowledged the finding.

NFPA Standard: Emergency lighting for means of egress shall be provided in accordance with Section 7.9 for the following: buildings or structures where required by the occupancy chapters, underground and windowless structures as required by Section 11.7, high-rise buildings as required by other sections of this Code, doors equipped with delayed egress locks, and stair shaft and vestibules of smoke proof enclosures. For the purposes of this requirement, exit access shall include designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit and exit discharge shall include designated stairs, ramps, aisles, walkways, and escalators leading to a public way. 2000 NFPA 101, 7.9.1.1

Based on record review and staff interview, the facility is not conducting fire drills as required quarterly on each shift and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency, affecting all 14 patients and occupants in 4 of 4 smoke zones. The facility has a capacity of 14 with a census of 5.

During the tour conducted on 7/22/15, between 9 am and 12 pm, the following is observed:

1.) At approximately 9:28 am it is discovered that there is no documentation of fire drills being performed for the 2nd shift during the 3rd and 4th quarters of 2014 or the 1st quarter of 2015 available.

Administrative Staff A was present and acknowledged the finding.

NFPA Standard: Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 2000 NFPA 101, 19.7.1.2.

Based on observation, staff interview and record review, the facility failed to maintain and test the emergency generator power supply as required. The deficient practice may prevent the emergency power supply from being available at the time of a power loss, affecting all 14 patients and occupants in 4 of 4 smoke zones. The facility has a capacity of 14 with a census of 5.

During the tour conducted on 7/22/15, between 9 am and 12 pm, the following is observed:

1.) At approximately 9:24 am it is discovered that there is no documentation of the generator being tested between July 2014 through May 2015.

Administrative Staff A was present and acknowledged the finding.

NFPA Standard: Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10 second interval specified in 3 4.1.1.8 and 3 4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
(b) Inspection and Testing.
1.* Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
2. Test Conditions. The scheduled test under load conditions shall include a complete simulated cold start and automatic and manual transfer of all essential electrical system loads.
3. Test Personnel. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures. 1999 NFPA 99 3.4.4.1.

Based on observation and staff interview, the facility did not ensure that electrical wiring and equipment is installed and maintained in accordance with NFPA 70, National Electrical Code. This deficient practice does not ensure prevention of an electrical fire or electric shock hazard, affecting all 14 patients and occupants in 3 of 4 smoke zones. The facility has a capacity of 14 with a census of 5. One of the affected areas contains the Central Dining Room.

During the tour conducted on 7/22/15, between 9 am and 12 pm, the following is observed:

1.) At approximately 9:38 am it is discovered that there is an open junction box with open wiring splices above the generator transfer switches in the Maintenance Office/Electrical Room.

2.) At approximately 10:05 am it is discovered that there is an unsupervised space heater on and being powered by a power strip in Room 502.

3.) At approximately 10:15 am it is discovered that there is a multiplug adaptor in use in the Phycians Dictation Room.

4.) At approximately 10:23 am it is discovered that there is a power strip being powered by another power strip in the Business Office.

5.) At approximately 10:47 am it is discovered that there is a power strip being powered by another power strip in the Kitchen Office Area.

Administrative Staff B was present and acknowledged the findings.

NFPA Standard: Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction. 2000 NFPA 101, 9.1.2