HospitalInspections.org

Based on observations and interviews during the survey, it was determined through on-going dialog with the Maintenance Director that the facility failed to maintain the integrity of smoke separations for hazardous rooms in 1 of 5 sampled smoke compartments within the building. This resulted in the potential for uncontrolled smoke migration into the egress corridor in the event of a fire, causing the exposure of residents & staff to hazardous products of fire (LSC 19/18.3.6.1, .2, .5). Findings include, but are not limited to:

1. On 11/8/2012, at 10:45 a.m., there were 3 unsealed ceiling penetrations within the OR closest. Two unsealed penetrations were 1" in diameter and the third was 1 1/2" in diameter.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Maintenance Director that the facility failed to maintain exit corridor doors resist the passage of smoke into the means of egress in the event of a hostile fire event 3 of 5 sampled smoke compartments. (LSC 18.2.3.5, Table 19/18.3.2.1, 19/18.3.6.3, Exception 2; A19/18.3.6.3.3). Findings include, but are not limited to:

1. On 11/8/2012, between 11:04 a.m. and 11:28 a.m., the cross-corridor doors near rooms 102-2 were sticking and not closing properly, the cross-corridor doors near room 101 and the Lobby on the main floor were not latching properly, the door at the elevator lobby was not closing completely and doors from the main floor to the second floor near the Administrative Office were not closing properly.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Maintenance Director that the facility failed to maintain emergency preparedness plan current & readily available to all staff, affecting the entire building. This resulted in the potential for limited staff effectiveness during emergency conditions (LSC 19/18.7.1.1). Findings include, but are not limited to:

1. On 11/8/2012, at 1:00 p.m., the facilities disaster plan was not specific to the building and included common policies and procedures not just emergency plans. The Disaster Plan did not have tabs making it difficult to find necessary items. A Hazard Assessment had not been completed on the specific hazards the facility may encounter. The disaster plan did not have information for "Defend in Place" measures, was still using "Dr. Red" rather than "Code Red", and "RACE" rather than "RACER". The transportation agreement was last reviewed 9/06.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Maintenance Director that the facility failed to install fire alarm system in accordance with NFPA 72 throughout the building. This resulted in the potential for system and device failure during fire emergencies (LSC 18.3.4, 9.6). Findings include, but are not limited to:

1. On 11/8/2012, between 10:29 a.m. and 11:00 a.m., there were fire alarm notification devices in Nuclear Medicine, the CT Scan Room, Room 112 across from the OR, the bathroom in Room 111, the ED Restroom, the bathrooms in Rooms 102-2, the Ultra-Sound Room, the bathroom in X-Ray along with horn strobes in several patient rooms and restrooms throughout the facility.

2. On 11/8/2012, at 10:59 a.m., the Staff Sleeping Lounge was missing a fire alarm notification device.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Maintenance Director that the facility failed to ensure that there was a complete sprinkler system installed in accordance with NFPA 13 for 1 patient room closet of the building. This resulted in the potential for uncontrolled fire progression in the event of a fire (LSC 18.3.5.1, NFPA 13 5-6.3.3, .4, NFPA 25). Findings include, but are not limited to:

1. On 11/8/2012, at 11:01 a.m., there was a missing sprinkler head for the closet of room 104 in the ICU/CCU.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Maintenance Director that the facility failed to ensure the sprinkler system is continuously maintained & in reliable operating condition affecting the entire building. This resulted in the potential for system failure during fire emergencies (LSC 4.6.12.1, NFPA 13 3-2.91, .2, .3, NFPA 25 9.6.2.1, .2 & 8.17.4.6). Findings include, but are not limited to:

1. On 11/8/2012, at 10:32 a.m., there was a damaged sprinkler head in the CT Scan room. The sprinkler head had been pushed up into the ceiling.

2. On 11/8/2012, at 10:47 a.m., there were three sprinkler heads missing their escutcheon rings in the Scrub Room.

3. On 11/8/2012 between 10:36 a.m. and 11:45 a.m., there were painted sprinkler heads in Recovery Room closet, the OR Dirty Room and the Dining Room.

4. On 11/8/2012, between 11:09 a.m. and 11:17 a.m., there were sprinkler heads that were corroded at the ambulance entrance overhang and main entrance overhang near gift shop.

5. On 11/8/2012, at 11:44 a.m., the sprinkler heads that are installed in the Linen Storage Room are installed in the wrong orientation. Heads installed were pendent sprinkler heads in a upright orientation. The sprinkler heads in the Linen Storage also had paint on them.

6. On 11/8/2012, at 1:00 p.m., the facility provided documentation for the forward flow test from the 3rd party testing company indicating that there was not adequate water available to supply the sprinkler system as designed.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Maintenance Director that the facility failed to maintain fire extinguishers in accordance with adopted standards for 1 of 5 sampled smoke compartments of the facility. This resulted in the potential for fires to progress beyond incipient stage (LSC 19/18.3.5.6, 4.6.12.1, 9.7.4.1, NFPA 10). Findings include, but are not limited to:

1. On 11/8/2012, at 10:34 a.m., there was a fire extinguisher that was installed over 60" high within the Recovery Room.

2. On 11/8/2012, at 11:08 a.m., the fire extinguisher within the elevator room was missing a maintenance tag.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Maintenance Director that the facility failed to ensure safe smoking practices by residents in the facility in accordance with facility policies and life safety regulations affecting the entire building. This resulted in the potential for exposing residents to a fire and/or smoke environment (LSC 19/18.7.4). Findings include, but are not limited to:

1. On 11/8/2012, at 11:10 a.m., there were cigarette butts improperly discarded in the landscaping outside the ambulance bay doors. Smoking policy for hospital states that employees and visitors may smoke within their private vehicles provided they are approximately 75 feet from the facility.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on observations and interviews it was determined, through on-going dialog with the Maintenance Director that the facility failed to properly install building service equipment for 2 mechanical rooms of the building. This resulted in the potential for unexpected fire (LSC 19/18.5.2.1, 19/18.5.2.2, 9.2, NFPA 90A). Findings include, but are not limited to:

1. On 11/8/2012, at 11:07 a.m., there were combustible materials, consisting of carpet, flooring, plywood and chairs found within the main elevator mechanical room. There were combustible materials within the secondary elevator mechanical room.

Surveyor was accompanied by the Maintenance Director who acknowledged these conditions.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Maintenance Director that the facility failed to ensure that no furnishings or decorations of highly flammable character are used, unless in limited quantities or flame retardant. This resulted in the potential for excessive fire spread (LSC 19/18.7.5.4). Findings include, but are not limited to:

1. On 11/8/2012, at 11:07 a.m., there was a trash can located within the Main Elevator lobby on second floor.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Maintenance Director that the facility failed to provide safe storage for compressed gas in 2 of 5 sampled smoke compartments of the building. This resulted in the potential for injury to staff and residents from a damaged compressed gas cylinder releasing unexpectedly. (LSC 18.3.2.4, 4.3.1.1.2). Findings include, but are not limited to:

1. On 11/8/2012, at 10:58 a.m., there were 3 oxygen cylinders stored in the equipment storage room adjacent to the Emergency Department. Electrical outlets and switches within the storage room were not installed at the minimum 5-feet off the finish floor.

2. On 11/8/2012, between 11:37 a.m. and 11:50 a.m., there were compressed gas cylinders (helium and oxygen) that were secured only with one chain within the corridor of the Receiving area and Loading Dock area.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on observations, record review and interviews it was determined through on-going dialog with the Maintenance Director that the facility failed to properly maintain the generator. This resulted in the potential for the lack of emergency electrical power (LSC 4.6.12.1, NFPA 110, NFPA 99, 3.4.4.1, 6.4.2) affecting the entire facility. Findings include, but are not limited to:

1. On 11/8/2012, at 11:54 a.m., there was no remote shutoff for the generator installed outside the generator enclosure.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Maintenance Director that the facility failed to provide an alternate source of power in accordance with NFPA 99 3.6, which would provide a minimum of 90 minutes of power in an outage affecting the entire facility. This resulted in the potential for panic and confusion for staff and residents in a power outage. Findings include, but are not limited to:

1. On 11/8/2012, at 1:00 p.m., the facility could not provide proper documentation supporting the monthly 30-second and annual 90-minute emergency light testing.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Maintenance Director that the facility failed to ensure that that electrical wiring & equipment was used/maintained and in accordance with NFPA 70 for 4 of 5 smoke compartments of the building. This resulted in the potential for injury to residents & staff (NFPA 70 550.13 (B), 9.1.2, NEC 110-3.8). Findings include, but are not limited to:

1. On 11/8/2012, at 10:35 a.m., there was a non-GFCI protected outlet at the sink in the Recovery Room.

2. On 11/8/2012, at 10:35 a.m., there was a extension cord in use powering a microwave within the Recovery Room.

3. On 11/8/2012, between 10:37 a.m. and 11:30 a.m., there were relocatable power taps on the floor of the Recovery Room and Director of Nurse Services Room.

4. On 11/8/2012 at 10:55 a.m., there was a non-patient relocatable power tap in the electrical room across from room 108.

5. On 11/8/2012 at 11:02 a.m., there was a missing light switch cover on the light switch in ICU Med. Room. Maintenance Director indicated that they were in the process of installing new wall finishes.

6. On 11/8/2012, at 11:13 a.m., there was a household microwave in use within the Laboratory Breakroom.

7. On 11/8/2012, at 11:15 a.m., the electrical outlets near the sinks within the Laboratory were not identified to be protected by a GFCI circuit.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on the observations and interviews during the survey, it was determined through on-going dialog with the Maintenance Director that the facility failed to install alcohol gel hand sanitizing dispensing stations away from sources of ignition for 1 resident room of the building. This resulted in the potential for injury to residents and staff (LSC 18.2.3.7, CFR 403.744, 418.100, 460.72, 482.41, 483.70, 486.623, 485.623). Findings include, but are not limited to:


1. On 11/8/2012, at 11:30 a.m., there was an alcohol based hand rub station (ABHR) installed above an electrical switch in a room near the Director of Nurse Services Office.


Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.