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Based upon observations made in the presence of the plant manager on 07/12/2016, it was determined that the facility did not maintain corridor doors to be positively latching and to resist the passage of smoke in accordance with NFPA 101 19.3.6.3.2.

The deficiency affected 1 of 6 smoke compartments.

Findings include:

During the testing of the fire alarm system it was observed that the Kitchen door failed to close to the latching position.

Based upon observations made in the presence of the plant manager on 07/12/2016, it was determined that the facility did not maintain hazardous areas to be fire and smoke separated from other sections of the facility in accordance with NFPA 101 19.3.2.1.

This deficiency affected 1 of 6 smoke compartments.

Findings include:

During the tour portion of the survey it was observed that the radiology storeroom contained a hole in the wall near the ceiling that penetrated the corridor wall reducing the fire rating of the storeroom in accordance with NFPA 101 19.3.2.1.

Based upon observations made in the presence of the plant manager on 07/12/2016, it was determined that the facility did not provide an emergency lighting system in accordance with NFPA 19.2.9.1

This deficiency affected 1 of several required tests.

Findings Include:

During the record review portion of the survey it was determined that the facility failed to provide documentation that the facilities emergency lights had been tested annually for a duration of not less than 1.5 hours in accordance with 19.2.9 (7.9.3)

Based upon staff interview and records reviewed made in the presence of the plant manager on 07/12/2016, it was determined that the facility did not conduct fire drills held at unexpected times under varying conditions at least quarterly on each shift in accordance with NFPA 101 19.7.1.

The deficiency effected 1 of 8 fire drills.

Findings Include:

During the the record review portion of the survey it was observed that the fourth quarter NOC drill was not completed, the facility failed to show the documentation supporting the drill.

Based upon observations made in the presence of the plant manager on 07/12/2016, it was determined that the facility did not maintain the fire sprinkler system in accordance with NFPA 19.3.4.1

The deficiency effected 2 of the 4 required tests per NFPA 19.3.4.1

Findings include:

During the record review portion of the survey it was determined the facility failed to provide documentation for the two required tamper switch tests, Only one test was documented in accordance with NFPA 101 19.3.4.1, 9.6.1.4 and NFPA 72 table 7-3.2,

During the record review portion of the survey it was determined that the facility failed to provide documentation for all of the flow tests that are required to be completed. The facility documented that they had done 2 of the 4 tests in accordance with NFPA 9.6.1.4 and NFPA 72 table 7-3.2.

Based upon observations made in the presence of the plant manager on 07/12/2016, it was
determined that the facility did not maintain flame retardant treatment on combustible decorations in accordance with NFPA 101 19.7.5.4.

The deficiency effected 2 of 6 smoke compartments

Findings include:

During the tour portion of the survey it was determined that there was unapproved flammable decorations in Rm ' s 5, 6, 10, 16, 17 and the Physician ' s lounge, these findings were Valences and curtains.

Based upon observations made in the presence of the plant manager on 07/12/2016, it was determined that the facility did not maintain medical gas storage in accordance with NFPA 101 19.3.2.4 and NFPA 99 4-3.1.1.2.

The deficiency effected 1 of the 6 smoke compartments.

Findings include:

During the building tour it was observed that three E cylinders of compressed gas were not secured in the kitchen to protect them from accidental damage in accordance with NFPA 99 4-3.1.1.2.

During the record review portion of the survey the hospital failed to provide the required documentation that the annual inspection of the medical gas manifold system had been conducted annually in accordance with NFPA 99 9.8/9.8.4 and compressed Gas Association. 8.6.2.5.2

Based on observations made in the presence of the plant manager on 7/12/2016 it was determined that the facility life support equipment shall have a Type I Essential Electric System for hospitals and inpatient hospices with life support in accordance with NFPA 99 3.4.2.2; 3.4.2.1.4.

This deficiency affected 1 of 1 generator.

Findings include:

During the tour of the facility and staff interview it was determined that the facility generator was lacking the required control panel located outside the generator room that annunciates the following and has a battery back up;

(a) Individual visual signals shall indicate the
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. over crank (failed to start)
6. over speed
In accordance with NFPA 99 16-3.3.2, 3-4.1.1.4(a); NFPA 110 3-5.5.6.

Based upon observations made in the presence of the plant manager on 07/12/2016, it was determined that the facility did not maintain electrical equipment in accordance with NFPA 101 19.5.1 and 9.1.2.

The deficiency effected 2 of 2 line isolation monitors in the operating suites.

Findings include:

During the tour of the operating rooms it was found that 2 of 2 line isolation monitors in O.R. suites 1 and 2 had carts stored in front of them and were not in compliance with the following codes. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical code 9.1.2, electrical panels shall have 36 inches of clear space in front of them at all times.

Based upon record review and staff interview made in the presence of the plant manager on 07/12/2016, it was determined that the facility did not have in place a fire watch policy for the disruption of the fire sprinkler system in accordance with NFPA 101 9.7.6.1.

This deficiency affected 1 of several facility policies.

Findings include:

During record review it was determined the facilities fire watch policy did not contain instructions to notify the authorities having jurisdiction, local fire and state health departments, in case the fire sprinkler system is out of service for more than 4 hours in any 24 hour period.

Based upon observations made in the presence of the plant manager on 07/12/2016, it was determined that the facility did not maintain corridor doors to be positively latching and to resist the passage of smoke in accordance with NFPA 101 19.3.6.3.2.

The deficiency affected 1 of 6 smoke compartments.

Findings include:

During the testing of the fire alarm system it was observed that the Kitchen door failed to close to the latching position.

Based upon observations made in the presence of the plant manager on 07/12/2016, it was determined that the facility did not maintain hazardous areas to be fire and smoke separated from other sections of the facility in accordance with NFPA 101 19.3.2.1.

This deficiency affected 1 of 6 smoke compartments.

Findings include:

During the tour portion of the survey it was observed that the radiology storeroom contained a hole in the wall near the ceiling that penetrated the corridor wall reducing the fire rating of the storeroom in accordance with NFPA 101 19.3.2.1.

Based upon observations made in the presence of the plant manager on 07/12/2016, it was determined that the facility did not provide an emergency lighting system in accordance with NFPA 19.2.9.1

This deficiency affected 1 of several required tests.

Findings Include:

During the record review portion of the survey it was determined that the facility failed to provide documentation that the facilities emergency lights had been tested annually for a duration of not less than 1.5 hours in accordance with 19.2.9 (7.9.3)

Based upon staff interview and records reviewed made in the presence of the plant manager on 07/12/2016, it was determined that the facility did not conduct fire drills held at unexpected times under varying conditions at least quarterly on each shift in accordance with NFPA 101 19.7.1.

The deficiency effected 1 of 8 fire drills.

Findings Include:

During the the record review portion of the survey it was observed that the fourth quarter NOC drill was not completed, the facility failed to show the documentation supporting the drill.

Based upon observations made in the presence of the plant manager on 07/12/2016, it was determined that the facility did not maintain the fire sprinkler system in accordance with NFPA 19.3.4.1

The deficiency effected 2 of the 4 required tests per NFPA 19.3.4.1

Findings include:

During the record review portion of the survey it was determined the facility failed to provide documentation for the two required tamper switch tests, Only one test was documented in accordance with NFPA 101 19.3.4.1, 9.6.1.4 and NFPA 72 table 7-3.2,

During the record review portion of the survey it was determined that the facility failed to provide documentation for all of the flow tests that are required to be completed. The facility documented that they had done 2 of the 4 tests in accordance with NFPA 9.6.1.4 and NFPA 72 table 7-3.2.

Based upon observations made in the presence of the plant manager on 07/12/2016, it was
determined that the facility did not maintain flame retardant treatment on combustible decorations in accordance with NFPA 101 19.7.5.4.

The deficiency effected 2 of 6 smoke compartments

Findings include:

During the tour portion of the survey it was determined that there was unapproved flammable decorations in Rm ' s 5, 6, 10, 16, 17 and the Physician ' s lounge, these findings were Valences and curtains.

Based upon observations made in the presence of the plant manager on 07/12/2016, it was determined that the facility did not maintain medical gas storage in accordance with NFPA 101 19.3.2.4 and NFPA 99 4-3.1.1.2.

The deficiency effected 1 of the 6 smoke compartments.

Findings include:

During the building tour it was observed that three E cylinders of compressed gas were not secured in the kitchen to protect them from accidental damage in accordance with NFPA 99 4-3.1.1.2.

During the record review portion of the survey the hospital failed to provide the required documentation that the annual inspection of the medical gas manifold system had been conducted annually in accordance with NFPA 99 9.8/9.8.4 and compressed Gas Association. 8.6.2.5.2

Based on observations made in the presence of the plant manager on 7/12/2016 it was determined that the facility life support equipment shall have a Type I Essential Electric System for hospitals and inpatient hospices with life support in accordance with NFPA 99 3.4.2.2; 3.4.2.1.4.

This deficiency affected 1 of 1 generator.

Findings include:

During the tour of the facility and staff interview it was determined that the facility generator was lacking the required control panel located outside the generator room that annunciates the following and has a battery back up;

(a) Individual visual signals shall indicate the
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. over crank (failed to start)
6. over speed
In accordance with NFPA 99 16-3.3.2, 3-4.1.1.4(a); NFPA 110 3-5.5.6.

Based upon observations made in the presence of the plant manager on 07/12/2016, it was determined that the facility did not maintain electrical equipment in accordance with NFPA 101 19.5.1 and 9.1.2.

The deficiency effected 2 of 2 line isolation monitors in the operating suites.

Findings include:

During the tour of the operating rooms it was found that 2 of 2 line isolation monitors in O.R. suites 1 and 2 had carts stored in front of them and were not in compliance with the following codes. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical code 9.1.2, electrical panels shall have 36 inches of clear space in front of them at all times.

Based upon record review and staff interview made in the presence of the plant manager on 07/12/2016, it was determined that the facility did not have in place a fire watch policy for the disruption of the fire sprinkler system in accordance with NFPA 101 9.7.6.1.

This deficiency affected 1 of several facility policies.

Findings include:

During record review it was determined the facilities fire watch policy did not contain instructions to notify the authorities having jurisdiction, local fire and state health departments, in case the fire sprinkler system is out of service for more than 4 hours in any 24 hour period.