HospitalInspections.org

Based on observation and staff interview the facility failed to ensure all corridor doors were resistant to the passage of smoke in 1 of 4 smoke compartments. The findings were:

Observation on 10/12/10 at 4:01 PM showed the corridor door to resident room #5 could not be latched into it's door frame. Further review showed the latch bolt did not insert into the strike plate. At the time of observation the facility manager reported all corridor doors were inspected on a monthly basis to ensure they were smoke resistant. He could not explain why this door had not been identified during a monthly inspection.

Based on observation and staff interview the facility failed to ensure hazardous areas were separated from use areas in 1 of 4 smoke compartments. The findings were:

Observation of the basement medical records storeroom on 10/12/10 at 4:20 PM showed the corridor door was not equipped with a self-closing device. At the time of observation the facility manager reported the room was just a temporary location. He further reported that he was not aware that all hazardous areas required a self-closing device that fully latches the door into its frame.

Based on record review and staff interview the facility failed to ensure emergency battery lights were properly tested during 12 of the past 12 months. The findings were:

Review of the emergency battery light testing records showed the facility did not have a record of the last time the annual 90-minute test was completed. Further review showed a monthly test had been completed, but the elapsed time the test was performed had not been noted. On 10/12/10 at 5:30 PM the facility manager confirmed these were the only records available to review. He was not sure why the annual test had not been performed, as he had only been employed in the facility for the past two months. He also reported the preventative maintenance program was not reviewed during the facility's quality assurance meeting.

Based on observation, policy review, record review, and staff interview the facility failed to ensure fire drills were performed on each shift during 4 of the past 4 quarters. In addition, the facility did not ensure staff were familiar with the required actions during a fire drill on 1 of 2 shifts. The findings were:

1. Observation of a fire drill on 10/12/10 at 3:30 PM showed the first responder to the fire did not announce "Code Red" or the location of the fire as specified in the facility's fire plan. Because patient room #18 was not transmitted to the nurses' station the intercom page announced the fire was at the clinic entrance, which was where the pull station was activated. After the drill, there was not an "all clear" intercom announcement as specified in the fire plan. After the drill the facility manager reported staff were not familiar with the actions needed during a fire because the previous manager had not performed the required drills.

2. Review of the fire drill testing records showed the facility had two nursing shifts that were 12 hours long occurring between 6 AM and 6 PM. Further review showed a fire drill had not been performed on the night shift in the past year. Review also showed a fire drill had not been performed during the fourth quarter of 2009 and the first quarter of 2010. On 10/12/10 at 5:30 PM the facility manager confirmed the above drills had not been done. He also reported the preventative maintenance program was not reviewed during the quality assurance meeting.

Based on observation, record review and staff interview the facility failed to ensure 1 of 4 supervisory signal devices were properly installed. The findings were:

Observation of the anti-freeze sprinkler system on 10/12/10 at 1:17 PM showed the supervisory signal in the facility manager's office was not connected to the fire alarm system. At the time of observation the facility manager reported that he didn't think it was required because it had never been connected.

Based on observation and staff interview the facility failed to ensure the facility had complete sprinkler coverage in 2 of 4 smoke compartments. The findings were:

1. Observation of patient rooms on 10/12/10 between 4 PM and 4:30 PM showed the sprinkler head in the closet of room #11 and #12 had been removed and the line capped with a black steel pipe. At 4:09 PM the facility manager reported he was unaware of the missing sprinkler heads. He further reported the annual sprinkler system inspection was completed that same day by an outside contractor, and they had failed to identify the missing heads.

2. Observation of the outdoor dining patio on 10/12/10 at 4:25 PM showed the area was provided with a 10 foot by 24 foot wood pergola. Further review showed the pergola was attached to the building's south wall and did not have sprinkler coverage. At the time of observation the facility manager reported he was not aware combustible canopies wider than 4 feet required sprinkler coverage.

Based on observation, record review and staff interview the facility failed to ensure sprinkler were unobstructed in 1 of 4 smoke compartments and failed to ensure 4 of 4 sprinkler system components were properly tested. The findings were:

1. Observation of the sprinkler system on 10/12/10 between 2:30 PM and 3 PM showed the heads in the X-ray restroom and laboratory restroom were obstructed. The sprinklers were installed within 12 inches of ceiling-mounted lights. The bottoms of the lights were below the level of the sprinklers deflectors. At 2:39 PM the facility manager reported he was unaware of the spacing requirement.

2. Review of the sprinkler system's testing records showed the supervisory signal, waterflow and main drain devices had not been tested on a quarterly basis. The devices had not been tested during the first and second quarters of 2010 and the fourth quarter of 2009. On 10/12/10 at 5:30 PM the facility manager confirmed the devices had not been tested. He also reported the preventative maintenance program was not reviewed during the quality assurance meeting.

3. Review of the sprinkler system testing records showed the back flow preventer had not been tested int he past year. On 10/12/10 at 5:30 PM the facility manager confirmed the devices had not been tested. He could not find records showing the last time the device was tested.

Based on observation, record review, and staff interview the facility failed to ensure all building and equipment modifications received plan approval as required by Wyoming Statutes 35-2-906(a) in 1 of 4 smoke compartments. The findings were:

Observation of the oxygen system on 10/12/10 at 4:17 PM showed the piping in the basement manifold room had been modified. Plan review revealed the system was originally installed with 6 "H" type oxygen tanks installed for the primary source and another 6 "H" type tanks installed as the back-up source. This was confirmed with the facility manager at the time of the observation. the primary source of oxygen was noted to be supplied by an outdoor liquid oxygen tank, located south of the building. After review of the facility's records the facility manager reported the oxygen system modification had not received plan approval. He further reported that he was not aware that all projects required plan approval by the Wyoming Department of Health.

Based on record review and staff interview the facility failed to ensure the essential electrical system (EES) was divided into life safety branch and critical branch for 1 of 3 EES panels. The findings were:

Observation of the life safety branch electrical panel LS-1 on 10/12/10 at 4:15 PM showed it supplied power to critical branch equipment. The electrical circuit #13 supplied power to the crawl space lights and receptacles, #14 supplied power a portable X-ray machine, #17 supplied power to telemetry receptacles, #18 supplied power to the ER blanket warmer, and #23 and #25 supplied power to "NB1" in the phone room. At the time of observation the facility manager was not aware the EES circuits were required to be divided into separate branches. He also reported that the EES electrical panels were not routinely inspected.

Based on observation the facility failed to ensure temporary electrical wiring did not replace permanent fixed wiring, failed to ensure outlets in wet locations were ground fault circuit interrupter (GFCI) protected, and failed to ensure electrical panels were unobstructed in 2 of 4 smoke compartments. The findings were:

1. Observation of the electrical system on 10/12/10 at 2:14 PM showed the calculator in the chief financial officers office was plugged into a surge protector which was, itself, plugged into another surge protector. At the time of observation the facility manager reported he was aware chaining of electrical adapters was prohibited. He further reported electrical appliances were inspected monthly. He could not explain why this wiring configuration had not been noticed and changed.

2. Observation of the electrical system on 10/12/10 at 3:05 PM showed the electrical outlets in the emergency room soiled utility room were located 12 inches from the sink and did not have GFCI protection. Further review showed an additional outlet in the area was protected with a GFCI outlet, but when the protected outlet was tripped the other outlets in the area were still active. At the time of observation the maintenance director reported he had not tested the outlets in wet locations to ensure they had GFCI protection.

3. Observation of the electrical system on 10/12/10 at 3:11 PM showed the two electrical panels in the medication room were obstructed by a trash can. At the time of observation the facility manager reported he was aware electrical panels required 36 inches of unobstructed workspace. At the same time the director of nursing reported she was aware of the spacing requirement, but the trash can was stored there because there was not other place for the can.

Based on observation and staff interview the facility failed to ensure all corridor doors were resistant to the passage of smoke in 1 of 4 smoke compartments. The findings were:

Observation on 10/12/10 at 4:01 PM showed the corridor door to resident room #5 could not be latched into it's door frame. Further review showed the latch bolt did not insert into the strike plate. At the time of observation the facility manager reported all corridor doors were inspected on a monthly basis to ensure they were smoke resistant. He could not explain why this door had not been identified during a monthly inspection.

Based on observation and staff interview the facility failed to ensure hazardous areas were separated from use areas in 1 of 4 smoke compartments. The findings were:

Observation of the basement medical records storeroom on 10/12/10 at 4:20 PM showed the corridor door was not equipped with a self-closing device. At the time of observation the facility manager reported the room was just a temporary location. He further reported that he was not aware that all hazardous areas required a self-closing device that fully latches the door into its frame.

Based on record review and staff interview the facility failed to ensure emergency battery lights were properly tested during 12 of the past 12 months. The findings were:

Review of the emergency battery light testing records showed the facility did not have a record of the last time the annual 90-minute test was completed. Further review showed a monthly test had been completed, but the elapsed time the test was performed had not been noted. On 10/12/10 at 5:30 PM the facility manager confirmed these were the only records available to review. He was not sure why the annual test had not been performed, as he had only been employed in the facility for the past two months. He also reported the preventative maintenance program was not reviewed during the facility's quality assurance meeting.

Based on observation, policy review, record review, and staff interview the facility failed to ensure fire drills were performed on each shift during 4 of the past 4 quarters. In addition, the facility did not ensure staff were familiar with the required actions during a fire drill on 1 of 2 shifts. The findings were:

1. Observation of a fire drill on 10/12/10 at 3:30 PM showed the first responder to the fire did not announce "Code Red" or the location of the fire as specified in the facility's fire plan. Because patient room #18 was not transmitted to the nurses' station the intercom page announced the fire was at the clinic entrance, which was where the pull station was activated. After the drill, there was not an "all clear" intercom announcement as specified in the fire plan. After the drill the facility manager reported staff were not familiar with the actions needed during a fire because the previous manager had not performed the required drills.

2. Review of the fire drill testing records showed the facility had two nursing shifts that were 12 hours long occurring between 6 AM and 6 PM. Further review showed a fire drill had not been performed on the night shift in the past year. Review also showed a fire drill had not been performed during the fourth quarter of 2009 and the first quarter of 2010. On 10/12/10 at 5:30 PM the facility manager confirmed the above drills had not been done. He also reported the preventative maintenance program was not reviewed during the quality assurance meeting.

Based on observation, record review and staff interview the facility failed to ensure 1 of 4 supervisory signal devices were properly installed. The findings were:

Observation of the anti-freeze sprinkler system on 10/12/10 at 1:17 PM showed the supervisory signal in the facility manager's office was not connected to the fire alarm system. At the time of observation the facility manager reported that he didn't think it was required because it had never been connected.

Based on observation and staff interview the facility failed to ensure the facility had complete sprinkler coverage in 2 of 4 smoke compartments. The findings were:

1. Observation of patient rooms on 10/12/10 between 4 PM and 4:30 PM showed the sprinkler head in the closet of room #11 and #12 had been removed and the line capped with a black steel pipe. At 4:09 PM the facility manager reported he was unaware of the missing sprinkler heads. He further reported the annual sprinkler system inspection was completed that same day by an outside contractor, and they had failed to identify the missing heads.

2. Observation of the outdoor dining patio on 10/12/10 at 4:25 PM showed the area was provided with a 10 foot by 24 foot wood pergola. Further review showed the pergola was attached to the building's south wall and did not have sprinkler coverage. At the time of observation the facility manager reported he was not aware combustible canopies wider than 4 feet required sprinkler coverage.

Based on observation, record review and staff interview the facility failed to ensure sprinkler were unobstructed in 1 of 4 smoke compartments and failed to ensure 4 of 4 sprinkler system components were properly tested. The findings were:

1. Observation of the sprinkler system on 10/12/10 between 2:30 PM and 3 PM showed the heads in the X-ray restroom and laboratory restroom were obstructed. The sprinklers were installed within 12 inches of ceiling-mounted lights. The bottoms of the lights were below the level of the sprinklers deflectors. At 2:39 PM the facility manager reported he was unaware of the spacing requirement.

2. Review of the sprinkler system's testing records showed the supervisory signal, waterflow and main drain devices had not been tested on a quarterly basis. The devices had not been tested during the first and second quarters of 2010 and the fourth quarter of 2009. On 10/12/10 at 5:30 PM the facility manager confirmed the devices had not been tested. He also reported the preventative maintenance program was not reviewed during the quality assurance meeting.

3. Review of the sprinkler system testing records showed the back flow preventer had not been tested int he past year. On 10/12/10 at 5:30 PM the facility manager confirmed the devices had not been tested. He could not find records showing the last time the device was tested.

Based on observation, record review, and staff interview the facility failed to ensure all building and equipment modifications received plan approval as required by Wyoming Statutes 35-2-906(a) in 1 of 4 smoke compartments. The findings were:

Observation of the oxygen system on 10/12/10 at 4:17 PM showed the piping in the basement manifold room had been modified. Plan review revealed the system was originally installed with 6 "H" type oxygen tanks installed for the primary source and another 6 "H" type tanks installed as the back-up source. This was confirmed with the facility manager at the time of the observation. the primary source of oxygen was noted to be supplied by an outdoor liquid oxygen tank, located south of the building. After review of the facility's records the facility manager reported the oxygen system modification had not received plan approval. He further reported that he was not aware that all projects required plan approval by the Wyoming Department of Health.

Based on record review and staff interview the facility failed to ensure the essential electrical system (EES) was divided into life safety branch and critical branch for 1 of 3 EES panels. The findings were:

Observation of the life safety branch electrical panel LS-1 on 10/12/10 at 4:15 PM showed it supplied power to critical branch equipment. The electrical circuit #13 supplied power to the crawl space lights and receptacles, #14 supplied power a portable X-ray machine, #17 supplied power to telemetry receptacles, #18 supplied power to the ER blanket warmer, and #23 and #25 supplied power to "NB1" in the phone room. At the time of observation the facility manager was not aware the EES circuits were required to be divided into separate branches. He also reported that the EES electrical panels were not routinely inspected.

Based on observation the facility failed to ensure temporary electrical wiring did not replace permanent fixed wiring, failed to ensure outlets in wet locations were ground fault circuit interrupter (GFCI) protected, and failed to ensure electrical panels were unobstructed in 2 of 4 smoke compartments. The findings were:

1. Observation of the electrical system on 10/12/10 at 2:14 PM showed the calculator in the chief financial officers office was plugged into a surge protector which was, itself, plugged into another surge protector. At the time of observation the facility manager reported he was aware chaining of electrical adapters was prohibited. He further reported electrical appliances were inspected monthly. He could not explain why this wiring configuration had not been noticed and changed.

2. Observation of the electrical system on 10/12/10 at 3:05 PM showed the electrical outlets in the emergency room soiled utility room were located 12 inches from the sink and did not have GFCI protection. Further review showed an additional outlet in the area was protected with a GFCI outlet, but when the protected outlet was tripped the other outlets in the area were still active. At the time of observation the maintenance director reported he had not tested the outlets in wet locations to ensure they had GFCI protection.

3. Observation of the electrical system on 10/12/10 at 3:11 PM showed the two electrical panels in the medication room were obstructed by a trash can. At the time of observation the facility manager reported he was aware electrical panels required 36 inches of unobstructed workspace. At the same time the director of nursing reported she was aware of the spacing requirement, but the trash can was stored there because there was not other place for the can.