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Based on observation and interview, the facility failed to provide the minimum clear width for one of two door leafs for the automatic sliding front entry doors when operated in manual mode. This deficient practice would delay egress during an emergency. The facility census was 9 patients.

Findings are:
Observations on 1-30-17 at 11:56 am revealed that when manually testing the Front Entry sliding doors, one of two leafs of the door failed to provide the required 41 1/2 inches of clear width.

During an interview on 1-30-17 at 11:56 am, Maintenance Staff A confirmed the doors failed to operate as designed during a manual test.

Based on record review and interview, the facility failed to conduct an annual 90 minute test of the battery powered backup emergency lights throughout the facility. This condition increased the probability that the lights would fail to activate during loss of power, leaving those areas in darkness. The facility census was 9 patients.

Findings are:
Record review of the testing documentation for the battery backup emergency lights on 1-31-17 at 11:43 am did not include an annual test of the lights for 90 minutes.

During an interview on 1-31-17, at 11:43 am, Maintenance Staff C confirmed the emergency lights were not tested annually for 90 minutes.


NFPA Standard:
NFPA 101, 2012, 7.9.3.1.1
Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).
(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
(3) Functional testing shall be conducted annually for a minimum of 11/2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Based on observation and interview the facility allowed an exit sign to direct occupants through an area under construction. This deficient practice directed the occupants through a hazardous area putting them at risk of injury during evacuation. Facility census was 9 patients.

Findings are:
Observation on 1-30-17 at 1:33 pm revealed an exit sign that directed occupants through the area under construction.

During an interview on 1-30-17 at 1:23 pm, Maintenance Staff A confirmed that the exit sign should be removed.

Based on observation and interview, the facility failed to protect hazardous areas with either (1)one-hour fire resistant construction or (2) automatice fire sprinkler protection and smoke resistant construction. The deficient practice would allow smoke and fire to migrate into the exit corridors. The facility census was 9 patients.

Findings are:
Observations on 1-30-17 at 12:16 pm and 2:45 pm revealed:
1. There was numerous unsealed penetrations in the IT Switch Room.
2. Ceiling tile was out of place in the Med Room near the Nurses Station.
3. The door to the "old" Autoclave closet failed to close and latch within the door frame.
4. The "Old" OR Prep room was used for storage and nor self closing device was provided on the door.
5. The door to the Boiler Room failed to close and latch within the door frame.
6. The Food Storage door in the Kitchen was held open by storage the rack.
7. The under-cut of the Central Supply door was greater than ¾ inch.
8. There was numerous unsealed penetrations in the Electrical Room located in Central Supply.
9. The door to Pharmacy Storage Room failed to provide latching hardware.
10. The Exam Room in ER was used for a storage area. The door was obstructed by a bed and the door failed to be provided with a self-closing device.
11. The "Cave" door was held open with wire chain.
12. The door to the Transfer switch room was blocked open with a large metal pipe.

During an interview on 1-30-17 at 12:16 pm and 2:45 pm, Maintenance Staff A confirmed the findings.

Based on interview and record review, the facility failed to provide documentation of cleaning for the kitchen exhaust hood. This deficient practice would affect the efficiency of the hood extinguishing system in the event of a fire. Facility census was 9 patients.

Findings are:
Record review on 1-31-17 at 1:12 pm revealed, the facility failed to provide any type of hood cleaning documentation.

During an interview on 1-31-17 at 1:12 pm, Maintenance A indicated that only visible areas of the hood were cleaned by Kitchen staff and there was not an outside contractor doing any type of cleaning.

NFPA Standard:
NFPA 96, 2011, 11.4
Systems serving moderate-volume cooking operations shall be inspected for grease build up and cleaned semiannually.

Based on observation and interview, the facility failed to use materials in accordance with the interior finish requirements for walls in healthcare occupancies. Facility failed to provide documentation for the flame spread rating of the wood on the wall in the IT Switch Room. The deficient would allow rapid fire spread in the room which could then extend outside the room. The facility census was 9 patients.

Findings are:
Observations on 1-30-17 at 12:13 pm revealed, untreated wood installed on the wall of the IT Switch Room.

During an interview on 1-30-17 at 12:13 pm, Maintenance Staff A confirmed the wood on the wall.

Based on observation, record review and interview, the facility failed to provide required documentation for the fire alarm system inspection and failed to ensure that all devices were securely instaled. This deficient practice failed to ensure that all fire alarm devices were inspected and increased the potential that the fire alarm would fail to operate during a fire. The facility census was 9 patients.

Findings are:
Observations on 1-31-17 at 12:12 pm, revealed a smoke detector in the IT Switch Room hanging by its wires.

During an interview on 1-31-17 at 12:12 pm, Maintenance Staff A confirmed the finding.

Record review on 1-31-17 at 1:20 pm, revealed the facility failed to provide current fire alarm inspection reports.

During an interview on 1-31-17 at 1:20 pm, Maintenance Staff A confirmed the lack of fire alarm inspections.

NFPA Standard:
2010 NFPA 72, 14.6.2.4*
A record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 14.6.2.4:
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested
(8) Functional test of detectors
(9)*Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Functional test of mass notification system control units
(13) Functional test of signal transmission to mass notification systems
(14) Functional test of ability of mass notification system to silence fire alarm notification appliances
(15) Tests of intelligibility of mass notification system speakers
(16) Other tests as required by the equipment manufacturer's published instructions
(17) Other tests as required by the authority having jurisdiction
(18) Signatures of tester and approved authority representative
(19) Disposition of problems identified during test (e.g., system owner notified, problem corrected/successfully retested, device abandoned in place)

Based on observation and interview the facility failed to install an automatic sprinkler system to provide complete coverage for all portions of the building, and in lieu of complete sprinkler coverage, failed to provide a 2-hour fire separation between sprinkled and unsprinkled portions of the building. The facility census was 9 patients.

Findings are:
Observations on 1-30-17 at 12:13 pm and 1:44 pm revealed:
1. No sprinkler protection was provided in the newly remodeled LDRP1 Room closet.
2. No sprinkler protection was provided in the newly remodeled LDRP2 Room closet.
3. Facility failed to provide suppression system in the Server Room.

During an interview on 1-30-17 at 12:13 pm and 1:44 pm, Maintenance Staff A confirmed the lack of sprinklers.

NFPA Standard:
2012 NFPA 101, 19.3.5.3
Where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.

Based on observation, documentation review and interview, the facility failed to provide all required accessories for the automatic sprinkler devices and alowed non-sprinkler related items to be attached to sprinkler piping. The deficient practices could impact the response and effectiveness of the sprinkler head and a larger fire could spread outside of the room into the exit corridor, and could cause damage to sprinkler piping leading to failure of the sprinkler system. The facility census was 9 patients.

Findings are:
Observations on 1-30-17 at 12:40 pm and 2:20 pm revealed:
1. A missing sprinkler escutcheon on the sprinkler head in the Med Room.
2. Numerous wires were attached to the sprinkler pipe in the IT Switch Room.

During an interview on 1-30-17 at 12:40 pm and 2:20 pm, Maintenance Staff A confirmed the findings.

Based on interview and documentation review, the facility failed to implement and inspection and testing program to document the integrity and operation of all smoke doors throughout the facility. This deficient practice had the potential for doors throughout the facility not to operate as designed and would allow the spread smoke and fire throughout the facility. The facility census was 9 patients.

Findings are:
Documentation review on 1-30-17 at 4:14 pm revealed, that the facility did not have a program in place to inspect and test the operation of the smoke doors throughout the facility.

During an interview on 1-30-17 at 4:14 pm, Maintenance Staff A confirmed the lack of a smoke door inspections and stated that they were unaware of the requirement.

NFPA Standard:
2010 NFPA 105, 5.2.1
5.2.1.1 Smoke door assemblies shall be inspected annually.
5.2.1.2 Doors shall be operated to confirm full closure.
5.2.1.3 Hardware and gaskets shall be inspected annually, and any parts found to be damaged or inoperative shall be replaced.
5.2.1.4 Tin clad and Kalamein doors shall be inspected regularly for dry rot.
5.2.1.5 A written record shall be maintained and shall be made available to the authority having jurisdiction.
5.2.1.6 Records shall be maintained for not less than 3 years.

Based on observation and interview, the facility failed to provide an accurate panel box directory. This deficient practice would not allow circuits to be identified and the incorrect breaker could be turned off. Facility census was 9 patients.

Findings are:
Observations on 1-31-17 at 12:18 pm revealed, that the panel box directory in panel box in the Server room failed to provide a directory to identify circuits and failed to identify the panel box to indicate which branch of the essential electrical system it powered.

During an interview on 1-31-17 at 12:18 pm, Maintenance Staff A confirmed that a directory for the panel box had not been provided and that the box failed to be identified.

Based on observation and interview, the facility failed to install a suspended heating unit so that it was out of reach of people using the area. This deficient practice would increase the potential for harm to staff. The facility census was 9 patients.

Findings are:
Observations on 1-31-17 at 1:43 pm revealed the suspending heating units installed in the Bulk Oxygen Storage Building were low enough to be touched.

During an interview on 1-31-17 at 1:43 pm, Maintenance Staff A confirmed the heating unit was installed so that it was in reach.

NFPA Standard:
2012 NFPA 101, 18.5.2.3(1), 19.5.2.3(1)
Suspended unit heaters are permitted provided the following are met:
Not located in means of egress or in patient rooms.
Located high enough to be out of reach of people in the area.
Has a safety feature to stop fuel and shut down equipment if there is excessive temperature or ignition failure. 18.5.2.3(1), 19.5.2.3(1)

Based on observation and interview, the facility failed to provide documentation that the heating element of a portable space heating device used in the facility did not exceed 212 degrees Fahrenheit. This deficient practice increased the potential of a fire throughout the facility. The facility census was 9 patients.

Findings are:
Observations on 1-30-17 at 11:54 am revealed a portable space heater in the Revenue Cycle Director's office.

During an interview on 1-30-17 at 11:54 am, Administrative Staff A stated that they unaware that the space heater was in the room and stated the facility did not have the manufactures specification for the heater and could not confirm the heating element of the device did not exceed 212 degrees Fahrenheit.

NFPA Standard:
2012 NFPA 101, 19.7.8
Portable space heating devices shall be prohibited in all health care occupancies, unless both of the following criteria are met:
(1) Such devices are used only in nonsleeping staff and employee areas.
(2) The heating elements of such devices do not exceed 212°F (100°C).

Based on record review and interview, the facility failed to conduct retention tests on non-hospital receptacles at patient bed locations or where anesthesia is administered. The facility failed to provide testing documentation for the line isolation monitor "LIM". These deficient practices have the potential to affect how equipment operates which could result in an electrical fire and harm to the patient. The facility census was 9 patients.

Findings are:
Documentation review on 1-30-17 at 3:48 pm revealed,
1. No retention testing had been conducted on the non-hospital grade receptacles at patient care areas.
2. The facility failed to provide documentation for testing of the LIM in the OR.

During an interview on 1-31-17 at 3:48 pm, Maintenance Staff A confirmed the lack of documentation for LIM testing and stated that they were unaware of the retention testing requirements.

NFPA Standard:
2012 NFPA 99
6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.
6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modification.
6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.
6.3.4.1.4 The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch (see 6.3.2.6.3.6). For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.
6.3.4.1.5 After any repair or renovation to an electrical distribution system, the LIM circuit shall be tested in accordance with 6.3.3.3.2.

Based on observation and interview, the facility failed to provide electrical outlets in the OR which were hospital grade or that were identified to be dedicated to the critical branch of the generator. This deficient practice would affect patient during an electrical emergency. The facility census was 9 patients.

Findings are:
Observations on 1-31-17 at 1:27 pm revealed, that none of the outlets provided in the OR were identified as being dedicated to the critical branch of the generator and none were listed as hospital grade.

During an interview on 1-31-17 at 1:27 pm, Maintenance Staff B confirmed the lack of hospital grade outlets and the distinctive colored of those outlets, and stated that the facility was "grandfathered" and not required to follow the requirements.

NFPA Standard:
2012 NFPA 99
1.3.2.3 An existing system that is not in strict compliance with the provisions of this code shall be permitted to be continued in use, unless the authority having jurisdiction has determined that such use constitutes a distinct hazard to life.

2012 NFPA 99, 6.4.2.2.6.2
(C)* The electrical receptacles or the cover plates for the electrical receptacles supplied from the life safety and critical branches shall have a distinctive color or marking so as to be readily identifiable.

Based on observation and interview the facility failed to securely install electrical equipment and failed to provide an approved cover for a junction box. This deficient practice would allow an electrical fire to spread outside of the junction box and cause the electrical cord to be damaged increasing the potential for an electrical fire. The facility census was 9 patients.

Findings are:
Based on observation on 1-30-17 at 10:59 am and 2:04 pm revealed:
1. The electrical junction box in the IT Switch Room failed to be secured to the wall and was hanging on the fire suppression system tank.
2. The junction box behind the heater in the Chiller Plant did not have a cover.

During an interview on 1-30-17 between 10:59 am to 2:20 pm, Maintenance Staff A confirmed the unsecured electrical box and that there was a cover missing for a junction box.

NFPA Standard:
2011 NFPA 70, 400.8
Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B)
(5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings
(6) Where installed in raceways, except as otherwise permitted in this Code
(7) Where subject to physical damage

2011 NFPA 70, 314.28
Boxes and conduit bodies used as pull or junction boxes shall comply with 314.28(A) through (E).
(C) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where used, metal covers shall comply with the grounding requirements of 250.110.

Based on observation and interview, the facility failed to prohibit power-strips as permanent wiring. This deficient practice would increase the potential for an electrical fire. The facility census was 19 patients.

Findings are:
Observations on 1-30-17 at 12:34 pm revealed, the refrigerator in the Med Room was plugged into a power-strip.

During an interview on 1-30-17 at 12:34 pm, Maintenance Staff A confirmed the refrigerator was plugged into a power-strip.

Based on observation and interview, the facility failed to segregate full oxygen cylinders from empty ones, failed to provide labels identifying whether the oxygen cylinders were full or empty and failed to secure cylinders in a rack or by other approved means. This deficient practice occurred in the Oxygen Storage Room which increased the potential that staff would inadvertently choose an empty oxygen cylinder in an emergency when a full one was needed. The facility census was 9 patients.

Findings are:
Observations on 1-31-17 at 12:51 pm revealed, 27 full oxygen cylinders and 1 empty stored in the same rack with no signage to indicate which tanks were full or empty and 3 unsecured oxygen cylinders in Oxygen Storage Building.

During an interview on 1-31-17 at 12:51 pm, Maintenance Staff A confirmed that an empty oxygen cylinder was intermixed and full cylinders and no signage was provided.

NFPA Standard:
2012 NFPA 99, 11.6.5.1
Storage shall be planned so that cylinders can be used in the order in which they are received from the supplier. 11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders.