HospitalInspections.org

Based upon observation and staff interview on April 17-18, 2018 during the physical tour of the facility between approximately 0800 to1600 hours the facility has failed to maintain doctor sleep rooms as seperate occupancies. This could potentially allow a fire to spread from the adjacent business occupancy into the ASC which could expose and endanger residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

The on-call sleep rooms did not have smoke detectors.

NFPA 110 26.3.4.5.1 Approved single-station smoke alarms, other than existing smoke alarms meeting the requirements of 26.3.4.5.3, shall be installed in accordance with 9.6.2.10 in every sleeping room.

The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on April 17-18, 2018 between approximately 0800 to 1600 hours the facility has failed maintain their exits free from obstructions. This could lead to the doors not functioning as required in a fire, endangering those inside the building.

The findings include, but are not limited to:

The exit across from the central services department required more than 5 lbs of force to open and the opening was difficult to open due to leaves in the exit discharge that had not been cleaned up.

The exit from the infusion courtyard was not obvious.
The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on April 17-18, 2018 between approximately 0800 to 1600 hours the facility has failed to maintain egress doors free of locks or latches requiring special knowledge or equipment. This could potentially delay safe egress from the facility in the event of an emergency.

The findings include, but are not limited to:

The path of egress from the administration area to the exit corridor had a fire door with a thumb lock installed. The facility removed the thumb lock before the survey ended.

The path of egress from the maintenance office to the exit corridor fire door had a thumb lock installed. The facility removed the thumb lock before the survey ended.

The path of egress from the executive directors office to the exit corridor had a thumb lock installed.

The path of egress from the events and volunteer corridinator office to the exit corridor had a thumb lock installed.

The path of egress from echocardiology room to the exit corridor had a thumb lock installed.

The path of egress from radiology to the exit corridor had a thumb lock installed.

The path of egress from the pedicatric gym to the exit corridor had a thumb lock installed.

The path of egress from the employee health to the exit corridor had a thumb lock installed.

The path of egress from sterile supplyto the exit corridor had a thumb lock installed.

The door to an office qualified as being in the path of egress because when you are inside the office the door is in your path of egress.


NFPA 101 7.2.1.5.10.2 The releasing mechanism shall open the door leaf with not more than one releasing operation, unless otherwise specified in 7.2.1.5.10.3, 7.2.1.5.10.4, or 7.2.1.5.10.6.

The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on April 17-18, 2018 between approximately 0800 to 1600 hours the facility has failed to maintain the minimum width requirement for corridors and aisles. This could cause an inability or delay in the evacuation of patients in the event of an emergency which would endanger residents, staff, and/or visitors.

The findings include, but are not limited to:
The OR corridors had a lot of medical supplies in it, restricting access to less than 5 feet in width.
The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on April 17-18, 2018 between approximately 0800 to 1600 hours the facility has failed to maintain the exit discharge free of obstructions and with an all-weather surface. This could cause an inability or delay in the evacuation of people within the facility.


The findings include, but are not limited to:

The exit from the OB wing to the helipad does not lead to the public way.


The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on April 17-18, 2018 between approximately 0800 to 1600 hours the facility has failed to maintain emergency power for the illumination of the means of egress so that in the event of a power failure the means of egress will remain illuminated. This could result in tripping and fall injuries and/or delay in evacuation of patients, staff and/or visitors.

The findings include, but are not limited to:

The sleep clinic emergency lighting did not function when tested.

The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on April 17-18, 2018 between approximately 0800 to 1600 hours the facility has failed to maintain proper exit signage. This could potentially misdirect patients, staff, and/or visitors during an emergency.
The findings include, but are not limited to:
The exit sign in the administration wing did not have continuous illumination.
The emergency room had an emergency exit, but no sign.
The Stairway 1 Level 1 had an emergency exit door but no sign.
The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on April 17-18, 2018 between approximately 0800 to 1600 hours the facility has failed to maintain doors and walls to hazardous areas. This could result in the spreading of the toxic products of combustion into the corridor in the event of a fire which would endanger patients, staff and/or visitors.
The findings include, but are not limited to:
The soiled linen utility room by the service elevator does not close and latch from the open position. Fixed at the time of inspection.
The soiled utility room by employee health does not have a doorknob and is a solid core fire rated door.
The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on April 17-18, 2018 between approximately 0800 to 1600 hours the facility has failed to properly install and maintain alcohol based hand rub dispensers. Dispensers installed improperly could result in hand rub coming in contact with an electrical source resulting in a fire causing potential danger to patients, staff and/or visitors within the facility.

The findings include, but are not limited to:
The Radiology area had an ABHR over a plug for a copier.
The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on April 17-18, 2018 between approximately 0800 to 1600 hours the facility has failed to maintain the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire and allow the fire to increase in size and intensity which would endanger the patients, staff, and/or visitors within the facility.

The findings include, but are not limited to:
Clinical education office had one eschutcheon ring that had fallen down and one was missing.
The OR janitor's closet sprinkler head was obstructed.
The rehab gym had a excessive dirt sprinkler head.
The IT room had cords/pipes on the sprinkler lines. NFPA 25 5.2.2.2 Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on April 17-28, 2018 between approximately 0800 to 1600 hours the facility failed to maintain their fire extinguishers in accordance with NFPA 10. This potentially delays a quick response to contain a fire from spreading which could expose and endanger patients, staff, and/or visitors within the facility.
The findings include, but are not limited to:
The following fire extinguishers were blocked:
OR4-fire extinguisher was blocked by tubing.
OR1-fire extinguisher blocked by equipment.
The fire extinguisher in the electric room in the annex 1st floor was missing the March signoff.
The fire extinguisher in the elevator room by the old payroll office had a fire extinguisher where the top was greater than 5ft in height.
The lab managers office fire extinguisher was blocked by the fire extinguisher.
The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on April 17-18, 2018 between approximately 0800 to 1600 hours the facility has failed to maintain doors without impediments to their closing and latching. This could result in a delay in getting the door to the room closed in the event of a fire. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the patients, staff and/or visitors within the smoke compartment.

The findings include, but are not limited to:

The fire door from the purchasing office to the corridor fire rated tags were painted over and the door did not close and latch from the open position.

The fire door from sterile supplies did not close and latch from the open position.

The patient financial advocate door to the corridor did not close and latch.

The doctor dictation room in the cancer area to the corridor had a hanger that impeded the closing of the door.


The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on April 17-18, 2018 between approximately 0800 to 1600 hours the facility has failed to properly maintain fire/smoke barriers within the facility as capable of resisting the passage of smoke. This could result in the products of combustion traveling from one smoke compartment to another which would endanger the patients, staff, and/or visitors within the facility.

The findings include, but are not limited to:

The smoke barrier walls in the file storage room had large holes.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on April 17-18, 2018 between approximately 0800 to 1600 hours the facility has failed to ensure 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. The test and inspection frequency shall be every 4 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.

The findings include, but are not limited to:

The fire/smoke damper report from 11/14/2013 showed that 13 dampers had failed and there were was nothing to show that they have been repaired.


The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on April 17-18, 2018 between approximately 0800 to 1600 hours the facility has failed to maintain a written plan for the protection of all patients, staff and visitors and for their evacuation in the event of an emergency. At a minimum a written care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarms to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire

The findings include, but are not limited to:
The policy for reporting a fire stated that they are to call their "central station" and then "central station" to call 911. This could potentially cause a significant delay in the reporting of a fire. The person finding the fire should be calling 911.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on April 17-18, 2018 between approximately 0800 to 1600 hours the facility has failed to provide fire drill records reflecting drills being conducted on all shifts for each quarter for the past 12 months. This could potentially result in the staff not responding in a coordinated manner in the event of a fire or other emergency and endangering patients, staff and/or visitors.

The findings include, but are not limited to:
The Sleep Clinic which is a "B" occupancy could not provide any fire drill records. The Sleep Clinic personal (3 staff and one director) stated that it had been at least 4 years since their last fire drill. B occupancies are required to have at minimum one fire drill per year.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on April 17-18, 2018 between approximately 0800 to 1700 hours the facility has failed to maintain their construction areas in compliance with NFPA 241. This could lead to the rapid spread of fire, entrapment of people, and unsafe conditions.

The findings include, but are not limited to:
The fire extinguisher in the Peri-Op construction area last annual inspection was completed in 2016.
The fire extinguisher in the construction area was missing 8 monthly signoff's.
The fire extinguisher in the construction area was missing 2 monthly signoff's.
Construction area for new pharmacy fire extinguisher was missing 10 monthly signoff's.
Construction area for new pharmacy fire extinguisher was missing 1 monthly signoff.
The administration offices under construction fire extinguisher was dated 2017 and had no monthly signoff's.
The area under construction had a fire extinguisher dated 2016 and was discharged.
NFPA 241 7.7.1 7.7.1* The suitability, distribution, and maintenance of extinguishers shall be in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
The facility could not produce fire watch records for when the smoke detector system was down during construction.
The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on April 17-18, 2018 during the physical tour of the facility between approximately 0800 to 1600 hours the facility has failed to ensure their central medical gas manifold storage location is maintained in accordance with the requirements set forth by the Authority Having Jurisdiction. This could result in a fire hazard or explosion risk due to misuse or improper storage, endangering the patients, staff and/or visitors within the facility.



The findings include, but are not limited to:

The OR corridors had their gas shut off valves obstructed.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on April 17-18, 2018 between approximately 0800 to 1600 hours, the facility has failed to properly maintain the Type 1 EES in the facility. This could result in electrical malfunction which could potentially endanger patients, staff, and/or visitors within the facility.

The findings include, but are not limited to:

The facility fails to properly separate the electrical branches as required including, but not limited to 97 electrical panels and 14 distribution branches.

NFPA 99 6.4.2.2.1.1

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on April 17-18, 2018 between approximately 0800 to 1600 hours the facility has failed to maintain and test the emergency generator in accordance with NFPA 110. This could result in a failure of the emergency power system which would leave the facility without egress and task lighting in the event of a power failure which would endanger the patients, staff, and/or visitors within the facility.

The findings include, but are not limited to:

The monthly generator inspection checklist did not include: the percentage of load, run hours, oil temperature.

The "old" generator needed 4109 gallons of fuel for seismic design category of the facility. The facility only had 1300 gallons on hand.

NFPA 110 5.1.2 Seismic design category C, D, E, or F, as determined in accordance with ASCE 7, shall require a Level 1 EPSS Class X (minimum of 96 hours of fuel supply).

The "old" generator does not have emergency lighting in the enclosed generator walk-in work area.

NFPA 110 7.3.1 The Level 1 or Level 2 EPS equipment location(s) shall be provided with battery-powered emergency lighting. This requirement shall not apply to units located outdoors in enclosures
that do not include walk-in access.


The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on April 17-18, 2018 between approximately 0800 to 1600 hours the facility failed to restrict the use of extension cords and non-approved power strips in their facility. This could endanger people in the facility due to the increased fire risk.

The findings include, but are not limited to:

The elevator room by the old payroll office has an extension cord in use.

The patient care corridor had a space heater plugged into a powerstrip. Fixed at the time of inspection.

The education office had a refrigerator plugged into a powerstrip.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on April 17-18, 2018 between approximately 0800 to 1600 hours the facility has failed to maintain construction of oxygen storage areas as being smoke and fire resistant. This could result in the products of combustion traveling from the hazardous area into the exit corridor in the event of a fire which could endanger patients, first-responders, staff, and/or visitors. In addition the facility has failed to maintain exterior storage locations as secured to prevent unauthorized access. This could allow for the tampering with or damage to of oxygen storage cylinders, which could endanger patients, staff, and/or visitors.

The findings include, but are not limited to:

Facility fails to protect compressed gas storage from the weather.

NFPA 99 11.6.5.4 Cylinders stored in the open shall be protected as follows:
(1) Against extremes of weather and from the ground beneath to prevent rusting
(2) During winter, against accumulations of ice or snow
(3) During summer, screened against continuous exposure to direct rays of the sun in those localities where extreme temperatures prevail.

Facility wide the empty versus full medical gas cylinders were not marked full or empty.

The above was discussed and acknowledged by the facility staff.