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Based on interview it was determined the facility failed to ensure the fire alarm system was inspected as required by NFPA 729.6.1.4. The failed practice had the potential to affect the health and safety of patients, staff, and visitors because the reliability of the fire alarm system devices to alert building occupants and the fire department of a fire emergency was not assured. The facility had a census of 35 patients on 01/27/14. The findings follow:

In an interview on 06/27/1201/28/14 at 1040 the Engineering/Maintenance Manager verified there was no fire alarm system inspection documentation available for review.

Based on interview it was determined the facility failed to inspect fire and smoke dampers every 4 years (or every six years under CMS Waiver per S&C Letter 10-04-LSC dated October 30, 2009). Failure to inspect fire and smoke dampers prevents the facility from ensuring the reliability of the dampers to close in the event of a fire or smoke event. The failed practice had the potential to affect 35 of 35 patients on census on 01/27/14 and all staff and visitors. The findings follow:

In an interview conducted on 01/27/14 at 1040 the Engineering/Maintenance Manager verified there was no documentation of fire and smoke damper inspection available for review.

(Reference NFPA 90A, Section 3-4.7)

Based on observation and interview it was determined the facility did not maintain egress corridors free of obstructions to allow instantaneous use in the event of an emergency. The failed practice had the potential to affect all patient, staff, and visitors due to potential delay in emergency egress presented by the corridor obstructions. The failed practice had the potential to affect 35 of 35 patients on census on 01/27/14 and all staff and visitors. The findings follow:

A. On 01/28/14 at 1350 four stacks of chairs and five infant beds were observed in the corridor by the exit door near the Laundry Department.
B. On 01/28/14 at 1435 five infant beds were observed in the corridor by the exit door near the Laundry Department.
C. On a tour of the facility with the Engineering/Maintenance on 01/29/14 at 0855 items were observed in the egress corridors as follows:
1. Four infant beds by the exit door near the Laundry Department
2. Two patient charting computer carts plugged into an egress corridor electrical outlet outside the Inpatient Rehabilitation Department.
3. Three patient charting computer carts plugged into an egress corridor electrical outlet near Patient Room 226.
D. In an interview conducted on 01/29/14 at 0930, the Engineering/Maintenance Manager acknowledged and verified the items located in the egress corridors.

Based on biomedical equipment inspection reports and interview it was determined the facility did not perform monthly testing on the eight of eight Line Isolation Monitors located in the Surgery Department (in Operating Rooms #1-#4) in accordance with NFPA 99, Section 3-3.3.4.2 (b) (1999 edition). Failure to test the line isolation monitor monthly had the potential to affect the health and safety of all patients in the surgical areas served by the monitors because proper functioning of the monitors to prevent electrical shock was not monitored and assured. The failed practice had the potential to affect all surgical patients. The findings follow:

A. In an interview on 01/28/14 at 0940 the Biomedical Engineer verified he only performed annual inspections of the Line Isolation Monitors, and did not perform monthly testing.
B. Review of the annual biomedical inspection documentation of the Line Isolation Monitors on 01/28/14 at 1315 revealed the facility had a total of eight Line Isolation Monitors located in the Surgery Department.
C. In an interview on 01/28/14 at 1405 the Operating Room Director verified she did perform monthly testing of the Line Isolation Monitors, but did not document the testing and there was no documentation available for review.

Based on interview it was determined the facility failed to ensure the fire alarm system was inspected as required by NFPA 729.6.1.4. The failed practice had the potential to affect the health and safety of patients, staff, and visitors because the reliability of the fire alarm system devices to alert building occupants and the fire department of a fire emergency was not assured. The facility had a census of 35 patients on 01/27/14. The findings follow:

In an interview on 06/27/1201/28/14 at 1040 the Engineering/Maintenance Manager verified there was no fire alarm system inspection documentation available for review.

Based on interview it was determined the facility failed to inspect fire and smoke dampers every 4 years (or every six years under CMS Waiver per S&C Letter 10-04-LSC dated October 30, 2009). Failure to inspect fire and smoke dampers prevents the facility from ensuring the reliability of the dampers to close in the event of a fire or smoke event. The failed practice had the potential to affect 35 of 35 patients on census on 01/27/14 and all staff and visitors. The findings follow:

In an interview conducted on 01/27/14 at 1040 the Engineering/Maintenance Manager verified there was no documentation of fire and smoke damper inspection available for review.

(Reference NFPA 90A, Section 3-4.7)

Based on observation and interview it was determined the facility did not maintain egress corridors free of obstructions to allow instantaneous use in the event of an emergency. The failed practice had the potential to affect all patient, staff, and visitors due to potential delay in emergency egress presented by the corridor obstructions. The failed practice had the potential to affect 35 of 35 patients on census on 01/27/14 and all staff and visitors. The findings follow:

A. On 01/28/14 at 1350 four stacks of chairs and five infant beds were observed in the corridor by the exit door near the Laundry Department.
B. On 01/28/14 at 1435 five infant beds were observed in the corridor by the exit door near the Laundry Department.
C. On a tour of the facility with the Engineering/Maintenance on 01/29/14 at 0855 items were observed in the egress corridors as follows:
1. Four infant beds by the exit door near the Laundry Department
2. Two patient charting computer carts plugged into an egress corridor electrical outlet outside the Inpatient Rehabilitation Department.
3. Three patient charting computer carts plugged into an egress corridor electrical outlet near Patient Room 226.
D. In an interview conducted on 01/29/14 at 0930, the Engineering/Maintenance Manager acknowledged and verified the items located in the egress corridors.

Based on biomedical equipment inspection reports and interview it was determined the facility did not perform monthly testing on the eight of eight Line Isolation Monitors located in the Surgery Department (in Operating Rooms #1-#4) in accordance with NFPA 99, Section 3-3.3.4.2 (b) (1999 edition). Failure to test the line isolation monitor monthly had the potential to affect the health and safety of all patients in the surgical areas served by the monitors because proper functioning of the monitors to prevent electrical shock was not monitored and assured. The failed practice had the potential to affect all surgical patients. The findings follow:

A. In an interview on 01/28/14 at 0940 the Biomedical Engineer verified he only performed annual inspections of the Line Isolation Monitors, and did not perform monthly testing.
B. Review of the annual biomedical inspection documentation of the Line Isolation Monitors on 01/28/14 at 1315 revealed the facility had a total of eight Line Isolation Monitors located in the Surgery Department.
C. In an interview on 01/28/14 at 1405 the Operating Room Director verified she did perform monthly testing of the Line Isolation Monitors, but did not document the testing and there was no documentation available for review.