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Based on tests to doors and observations made during the survey for life safety from fire with the facility's Safety Officer (employee #1) and Engineer (employee #2), it was determined that patient's doors protecting corridors on the fifth, third and second floors do not close completely (do not latch) as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.3.6.3.

Findings include:

1. During the tour for life safety from fire, patient's sleeping room doors were tested from 8/31/11 through 9/1/11 from 8:00 am till 4:00 pm with the facility's Safety Officer (employee #1) and Engineer (employee #2), it was found that the following patient's rooms do not have the capability of latching when the doors are in the closed position, this can permit smoke, fire and noxious gases to enter the rooms in the event of a fire:

a. Patient's rooms on the fifth, third and second floors: 5B-18, 5B-36, 5B-38, 5B-39, 5B-3A, B, C, D, 5B-51, 5B-52, 32A,B,C,D and 2B-36 (all room doors shall be verified for compliance).

Based on tests to doors and observations made during the survey for life safety from fire with the facility's Safety Officer (employee #1) and Engineer (employee #2), it was determined that the smoke barrier doors at the basement failed to latch closed when released from their hold open devices as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.2.1.8.2.

Findings include:

The smoke barrier doors located at the basement near the office of the Safety Officer was tested on 9/1/11 at 10:00 am and provided evidence that they did not latch closed when released from their hold open devices, this can permit smoke, fire and noxious gases to enter the smoke compartments in the event of a fire.

Based on tests to doors, observations made during survey for life safety from fire with the facility's Safety Officer (employee #1) and Engineer (employee #2), it was determined that exit components (stairway doors) do not provide protection against fire or smoke from other parts of the building due to the lack of the doors' ability to close completely at the first floor as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.3.1.1 and 19.3.2.1.

Findings include:

During the tour for life safety from fire, exit components (stair enclosures) were inspected and found that the enclosure (door) on the first floor of building C did not completely close (did not positively latch) as observed on 8/31/11 at 1:00 pm with the facility's Safety Officer (employee #1) and Engineer (employee #2). This fire door can be opened with a minimum force and can permit fire and toxic gases to enter this means of egress. All doors, exit components (stair enclosures) shall be verified for compliance.

Based on observations made during the survey for life safety from fire with the facility's Safety Officer (employee #1) and Engineer (employee #2), it was determined that the facility failed to ensure that emergency lighting (battery operated lamps) which provides light for a period of 90 minutes, enabling those inside to move about safely in an emergency are provided throughout the hallways of the hospital, x-ray department and in the medication preparation room of the Neonatal Intensive Care Unit, some emergency lamps did not illuminate when tested and no evidence was found that the facility is testing the emergency lamps on an annual basis as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.9.

Findings include:

1. The facility lacks emergency battery operated lamps (EBOL) for a period of 90 minutes as determined by the observational tour with the facility's Safety Officer (employee #1) and Engineer (employee #2) from 8/30/11 through 9/1/11 from 8:00 am till 4:00 pm in the following areas:
a. Throughout the hallways (means of egress) of the entire facility (floors one through six).
b. At the X-ray department (no windows).
c. In the medication preparation area of the Neonatal Intensive Care Unit (N.I.C.U).
(Emergency lamps are required to ensure adequate lighting until the essential electrical system (generator) turns on or in the event that the essential electrical system fails as required since March 13 of 2006).

2. The emergency battery operated lamps (EBOL) in the following areas were tested with the facility's Safety Officer (employee #1) and Engineer (employee #2) and did not illuminate as observed from 8/30/11 through 9/1/11 from 8:00 am till 4:00 pm:
a. The EBOL in the waiting area of the emergency room.
b. The EBOL near the office of the medical director of the emergency room.
c. The EBOL of the medication room of the emergency room.
d. The EBOL in front of cubicle #36 of the N.I.C.U.
e. The EBOL at the nursing station of the Pediatric Intensive Care Unit.
f. One light bulb of the EBOL in front of cubicle #40 of the N.I.C.U.
g. One light bulb of the EBOL near the physical therapy department on the fifth floor.

3. Documentation about tests to emergency lighting reviewed on 9/1/11 at 11:50 am with the facility's Safety Officer (employee #1) provided evidence that the facility is not documenting the annual tests which should be for 90 minutes. Also all of the EBOLs in the facility are not included in their maintenance documentation (the EBOLs of the pharmacy are not included) and the facility shall verify all EBOLs to ensure that they are included in the monthly checklist for the 30 second tests.

4. The EBOL's located at the surgery ward on the second floor were observed with the
facility's Safety Officer (employee #1) and Engineer (employee #2) on 8/31/11 at 3:30 pm
and found to be too small to properly illuminate the area if power is lost.

Based on the review of written documents related to conducted fire drills during the survey for life safety from fire with the facility's Safety Officer (employee #1), it was determined that the facility failed to ensure that fire drills are conducted under varying conditions related to initial fire location, early rate of growth in the fire severity and smoke generation and failed to perform exit fire drills which is not in accordance with the requirements of the LSC 2000 section 19.7.1.2 and section 5.5.

Findings include:

1. Written documents about conducted fire drills for the facility were reviewed with the facility's Safety Officer (employee #1) on 9/1/11 at 11:40 am and provided evidence that fire drill documentation does not include evidence that they are performed under varying conditions related to:
a. Initial fire location.
b. Early rate of growth in the fire severity.
c. Smoke generation.
LSC 2000 section 5.5 has eight "Design Fire Scenarios" that should be considered to comply with the above. Fire drills provide opportunities to improve on tasks during emergency and hurried events and should be used to constantly improve.

2. Written documents about conducted fire drills for the hospital were reviewed on 9/1/11 at 11:45 am with the facility's Safety Officer (employee #1) and it was found that the facility failed to perform fire exit drills for the proper protection of patients; drills for the purpose of relocating patients to an area of safety.

Based on observations made during the survey for life safety from fire with the facility's Safety Officer (employee #1) and Engineer (employee #2), it was determined that the facility failed to ensure that smoke detectors are available at all required areas, fire alarm documentation about sensitivity tests was not found, smoke detectors were found dirty, strobe lights are needed in public bathrooms and the fire alarm system lacks annunciation to an approved central station as required by the applicable requirements of NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Findings include:

1. Smoke detectors connected to the fire alarm panel are needed in the following areas as observed with the facility's Safety Officer (employee #1) and Engineer (employee #2) from 8/30/11 through 9/1/11 from 8:00 am till 4:00 pm:
a. In a utility room located at the emergency room (E.R) found with a refrigerator.
b. In the formula room of the emergency room, found with a large refrigerator.
c. In the pantry of the Oncology ward.
d. In the pantry of the 5th floor south ward.
e. Another smoke detector is needed in the main medical record storage area (the area has a microwave and refrigerator).
f. In the formula room of the Pediatric Intensive Care Unit (P.I.C.U).
g. The storage room located near the nursing supervisor's office of the P.I.C.U.
h. In the janitor's closet of the follow-up clinic.

2. The smoke detectors in the Neonatal Intensive Care Unit (N.I.C.U) were observed on 8/31/11 at 8:45 am with the facility's Safety Officer (employee #1) and Engineer (employee #2) with an accumulation of dust in the sensing chamber which could effect its sensitivity.

3. The facility has an outside company that services the fire alarm system and they provide the facility with a certification once a year as evidenced on 9/1/11 at 11:15 am with the facility's Safety Officer (employee #1), however no evidence was found of the following:
a. Smoke detector sensitivity tests and readings.

4. It was determined that the facility has bathrooms that are accessible to visitors and the public (both male and female) as found from 8/30/11 through 9/1/11 from 8:00 am till 4:00 pm with the facility's Safety Officer (employee #1) and Engineer (employee #2) and provided evidence that they do not have strobe lights to alert deaf persons using these bathrooms in the event that the fire alarm is activated.

5. The fire alarm system lacks annunciation to an approved central station as reviewed on 8/30/11 at 3:50 pm with the facility's Safety Officer (employee #1) and Engineer (employee #2). The fire alarm system must be arranged to transmit an alarm automatically via a central station to alert the municipal fire department and fire brigade.

Based on the review of written documents related to the preventive maintenance of the fire alarm system and its components during the survey for life safety from fire with the facility's Safety Officer (employee #1), it was determined that the facility is not performing visual inspections, sensing chamber tests or battery tests to the fire alarm system in accordance with NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Findings include:

1. Written evidence reviewed on 9/1/11 at 11:00 am with the facility's Safety Officer (employee #1) about the tests to the fire alarm system and its components indicates that the facility is not documenting the following tests:

a. Visual inspections to the main control panel to verify trouble signals and check battery electrolyte level (monthly).

b. All smoke detectors must be tested in place to ensure smoke entry into sensing chamber and an alarm response which includes the smoke detectors in the air conditioner system (twice a year).

c. Ability of batteries to meet standby and alarm requirements shall be verified, corrosion and leakage, tightness of connections and battery terminals shall be cleaned (monthly).

d. Location of pull-down stations and tests (monthly).

e. Visible (strobe lights) and audible signal tests (monthly).

Based on observations made during the survey for life safety from fire with the facility's Safety Officer (employee #1) and Engineer (employee #2), it was determined that the facility failed to ensure that the automatic sprinkler system is continuously maintained in reliable operating condition and are inspected and tested periodically as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5.

Findings include:

1. Review of documentation and observations of the sprinkler system on 9/1/11 at 11:30 am with the facility's Safety Officer (employee #1) and Engineer (employee #2) and the following was determined:
a. No evidence was found of the control valve identification with a sign indicating the system or portion of the system it controls.
b. No evidence was found of the weekly valve inspection (hose valves, pressure-regulating valves and valves that isolate backflow prevention devices).
c. No evidence was found of the fire department connection inspection on a quarterly basis to verify visibility and accessibility, coupling and swivels not damaged and rotate smoothly.
d. No evidence was found of tests performed on the sprinkler system (such as weekly no-flow tests and annual flow condition test of the fire pump).

Based on the review of maintenance documentation and observations made during the survey for life safety from fire with the facility's Safety Officer (employee #1) and Engineer (employee #2), it was determined that the facility failed to ensure that portable fire extinguisher are maintained related to appropriate inspections, are conveniently accessible off of the floor and no evidence was found of carbon dioxide fire extinguisher conductivity inspections as stated in the 2000 edition of the Life Safety Code of the NFPA Section 9.7.4.1 and NFPA 10.

Findings include:

1. Written evidence about the required monthly visual inspections and maintenance to the fire extinguishers was reviewed with the facility's safety Officer (employee #1) on 9/1/11 at 11:00 am, however a monthly inspection checklist that provides a permanent record must be kept on file that includes: date of inspection, initials of person performing inspection, proper location, if fully charged, hose and nozzle inspection, pin placement and if it is operable.

2. During observations made of the hospital with the facility's Safety Officer (employee #1) and Engineer (employee #2) from 8/30/11 through 9/1/11 from 8:00 am till 4:00 pm, the following was determined related to fire extinguishers:
a. Fire extinguishers located in the general storage area and machine rooms were found on the ground and not on suspension hooks above the floor.

3. Written evidence about the required annual carbon dioxide fire extinguisher conductivity inspections of the extinguisher's hose system was not provided by the facility on 9/1/11 at 11:10 am when requested of the facility's Safety Officer (employee #1).

Based on observations made during the survey for life safety from fire with the facility's Safety Officer (employee #1) and Engineer (employee #2), it was determined that the facility failed to monitor means of egress at the emergency room hallway, south exit staircase of building C and at the exit door of the general storage area of the basement to ensure that they are maintained free from all obstructions in accordance with the 2000 edition of the Life Safety Code of the NFPA Section 7.1.10.1.

Findings include:

1. During the observational tour of the Emergency Room (E.R) on 8/30/11 from 9:00 am till 10:30 am with the facility's Safety Officer (employee #1) and Engineer (employee #2) it was found that the hallway in front of patient's rooms had stretchers and cribs lined up against the wall. Privacy curtains were also found around and between the cribs and stretchers. Crib #1 was found within one foot of the exit door for this hallway and reduced the doors' width to less than three feet. Due to the privacy curtains, personnel and family members of the patient and carts (medication cart and housekeeping cart) this hallway was reduced at times to one foot. "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".

2. The main entrance of the general storage area at the basement was visited on 9/1/11 at 9:30 am with the facility's Safety Officer (employee #1) and Engineer (employee #2) and it was found that one leaf of the front door was blocked with ten boxes. "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".

3. The south exit staircase of building C was visited on 9/1/11 at 10:30 am with the facility's Safety Officer (employee #1) and Engineer (employee #2) and it was found that there was a potted plant and a chair that reduced the accessibility of this staircase. "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".

Based on observations during the survey for Life safety from fire with the facility's Safety Officer (employee #1) and Engineer (employee #2) and interview, it was found that this facility does not comply with other Life Safety Code requirements not in CMS-2786-R related to standpipe maintenance, oxygen storage, regular electrical receptacle located next to a water source, facility is using mult-plugs, the follow-up clinic does not have exit plans,
no evidence was found of seamise connection maintenance documentation, an exit sign was not properly maintained and the smoke barrier doors located near the main reception desk were found with two pieces of wood holding the two door leafs in the open position.

Findings include:

1. The facility has an oxygen storage room located on the fourth floor as observed on 8/31/11 at 11:10 am with the facility's Safety Officer (employee #1) and Engineer (employee #2). The facility failed to be in compliance with the National Fire Protection Association (NFPA) 99, 1999 edition, section 4-3.1.1.2 (Storage requirements-location, Construction, Arrangement) (a) Nonflammable Gases (Any Quantity; In-storage, connected, or both) and with State law number #99 from November 7, 1999 from the Department of Health of Puerto Rico, Article C, Section #6 related to the following:
a. 12 type H oxygen cylinders that were not secured to the wall or in bases to protect against tipping.
b. The light switch in the room is located below five feet (needs to be above five feet).
c. This room does not have a dedicated mechanical ventilation system (please refer to NFPA 99, 1999 edition, section 4-3.1.1.2(b)4 and (c)).
d. No smoke detector.
e. No door closer.
f. The door knob is not fire rated.
g. No sign on the door related to its contents.

2. When oxygen cylinders are not in use (connected to a patient), they are to be stored in an appropriate area as stated in the National Fire Protection Association (NFPA) 99, 1999 edition, section 4-3.1.1.2. However, during the observational tour of the entire facility from 8/30/11 through 9/1/11 from 8:00 am till 4:00 pm with the facility's Safety Officer (employee #1) and Engineer (employee #2) type H and Type E oxygen tanks were found in areas that do not meet minimum requirements:
a. In the clean utility room on the 5th floor (ten type E oxygen cylinders).
b. Five type E oxygen cylinders were found in the dirty linen room of the operating room department.
c. Eighteen type E oxygen cylinders at the general storage room of the basement.
d. Two type E oxygen cylinders at the nursing station of the follow-up clinic.
e. During the observational tour of the entire hospital (Neonatal Intensive Care Unit (N.I.C.U), emergency room, patient's wards and the Pediatric Intensive Care Unit (P.I.C.U) these areas were found with bedside type H oxygen cylinders in bases. The facility was cited by the Joint Commission in their last visit deficiencies related to a non functioning master alarm audible signal for the oxygen system. As part of the facility's contingency plan for the Joint Commission they included personnel round the clock at the main oxygen farm to ensure appropriate oxygen operating pressure and to notify changes immediately and the facility also has two backup systems if the main oxygen system fails. The facility's Administrator (employee #4) was interviewed on 8/30/11 at 9:00 am and he stated that the Joint Commission performed a follow-up visit and they told him that the bedside oxygen cylinders were not a problem and they could be left next to the patients in protective bases and used in the event of an emergency. Since the facility has a contingency plan where oxygen is monitor round the clock and two backup oxygen systems are in place if the main system fails, they failed to evaluate patient life safety concerns related to the excessive storage of oxygen cylinders not in use near patients. The two backup oxygen systems will give the facility enough time to retrieve the type H oxygen cylinders from an area that meets the above minimum requirements if the main oxygen system fails. If the facility considers that they do not have enough areas that meet these minimum requirements or they are not close enough, then they failed to evaluate other possible storage methods such as flammable cabinets which can be placed at designated areas and will provide a level of protection for patients and persons in this area.

3. A regular electrical receptacle located at the pantry of the emergency room was found within three feet from a water source was observed on 8/30/11 at 9:20 am with the facility's Safety Officer (employee #1) and Engineer (employee #2). A Ground Fault Interrupter receptacle is required near water sources which will prevent electrical short circuits if there is contact with water.

4. The formula room of the emergency room was visited on 8/30/11 at 10:00 am with the facility's Safety Officer (employee #1) and Engineer (employee #2) and was found with a multi-plug. Multi-plugs are not recommended due to the potential for them to over heat.
a. A multi-plug was also observed at the basement storage room on 9/1/11 at 9:30 am with the facility's Safety Officer (employee #1) and Engineer (employee #2) with a refrigerator and a coffee machine plugged into it.

5. The seamise connection to be used by the fire department was verified on 8/30/11 at 11:40 am with the facility's Safety Officer (employee #1) and Engineer (employee #2), however no evidence was found of this connection inspection on a quarterly bases to verify visibility and accessibility, coupling and that the swivels are not damaged and rotate smoothly.

6. During the observational tour of the entire hospital from 8/30/11 through 9/1/11 from 8:00 am till 4:00 pm, it was found that regular electrical receptacles located at the medical record department had an adapter which converted the two wall outlets into six. Multi-outlet adapters are not recommended due to the potential for them to over heat.

7. During the observational tour of the facility with the facility's Safety Officer (employee #1) and Engineer (employee #2) on 9/1/11 at 9:30 am, it was found that the smoke barrier doors located near the main reception desk on the first floor were found with two pieces of wood holding the two door leafs in the open position.

8. The back door of the general storage area at the basement was visited on 9/1/11 at 9:30 am with the facility's Safety Officer (employee #1) and Engineer (employee #2) and it was found that the exit sign was illuminated. However it was being maintained illuminated by a wooden stick that was pushed up against the button of the exit sign and wedged against the wall.

9. The follow-up clinic was visited on 9/1/11 at 10:10 am with the facility's Safety Officer (employee #1) and Engineer (employee #2) and it was found that this area does not have exit plans (for evacuation purposes) posted on walls to provide evidence of the closest exits, location of extinguishers, fire hoses and pull station.

10. Standpipes (fire hoses) were observed during the life safety observational tour with the facility's Safety Officer (employee #1) and Engineer (employee #2) from 8/30/11 through 9/1/11 from 8:00 am till 4:00 pm and review of maintenance documentation on 9/1/11 at 11:20 am, the following was determined:
a. No evidence was found of standpipe and Hose System Inspection, Testing and maintenance in accordance with NFPA 25 chapter 6 related with: control valves, pressure regulating devices, piping, hose connections, cabinet, hose, hose storage device, alarm device, hose nozzle, pressure control device, pressure reducing valve, hydrostatic test, flow test, main drain test, hose connections and valves (all types).

Based on observations and documents reviewed during the survey for life safety from fire with the facility's Safety Officer (employee #1) and Engineer (employee #2), it was determined that the facility failed to test electrical receptacles that are supplied by the essential electrical system at least twice a year in accordance with NFPA 99 Section 7-6.2.1.2.

Findings include:

Written evidence was reviewed on 9/1/11 at 11:00 am with the facility's Safety Officer (employee #1) about preventive maintenance to the receptacles indicates that they are testing the receptacles supplied by the generator once a year. However, receptacles that are supplied by the essential electrical system (generator) supply power to critical care areas and equipment (cardiac monitors, life support equipment, Intensive Care Unit equipment and wet locations). Equipment or wiring faults can cause abnormal temperature increases, these abnormal temperatures may cause fire and explosions. Critical care areas, wet locations and areas where critical care equipment are plugged into the essential electrical receptacles are required to be tested in intervals not exceeding six months because even brief interruptions of power can cause malfunctions of some equipment and appliances.