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Based upon observations made in the presence of the plant manager on 06-21-2021, it was determined that the facility did not continuously maintain the means of egress and exits to the public way at all times in accordance with NFPA 101: 19.2.1, 7.1.10.1

This deficiency affected all required fire door assemblies.

Findings include:
1-During the record review it was discovered that the facility did not test and maintain the annual inspections of fire doors in accordance with NFPA 80, NFPA 25

Based upon observations made in the presence of the plant manager on 06-21-2021, it was determined that the facility did not maintain the fire alarm system in accordance with NFPA 101 19.3.4.4, 9.6.5. And NFPA 72 Table 14.4.2.2

This deficiency affected all smoke dampers.

Findings include:
1-During the record review the facility failed to provide the testing documentation that the (Emergency control functions) smoke damper operations had been tested annually with the initiating device that activates the damper and not in accordance with NFPA 101 19.5.2.1, 19.3.4.4, 9.2 and NFPA 72 Table 14.4.2.2

Based upon observations made in the presence of the plant manager on 06-21-2021, it was determined that the facility did not maintain the fire resistance rating in accordance with NFPA 101 19.3.7., 8.5.3

The deficiency affected 1 of several fire/smoke compartments.

Findings include:
1-During the tour of the facility it was observed that the Fire barrier wall above the fire doors from the hospital waiting area into the physician clinic had unsealed penetrations and not in accordance with NFPA 101 19.3.7.3, 8.5.
2- During the tour of the facility it was observed that the Fire barrier wall above the fire doors at the corridor into the Behavioral Health Clinic had unsealed penetrations 2"x2" and not in accordance with NFPA 101 19.3.7.3, 8.5.
3-- During the tour of the facility it was observed that the Fire barrier wall above the fire doors at the corridor into the Physical Therapy gym had unsealed penetrations 2"x2" and not in accordance with NFPA 101 19.3.7.3, 8.5.
4-- During the tour of the facility it was observed that the Fire barrier walls in the server room had unsealed penetrations 2"x2" and not in accordance with NFPA 101 19.3.7.3, 8.5.

Based upon observations made in the presence of the plant manager on 06-21-2021, it was determined that the facility did not maintain electrical equipment in accordance with NFPA 101 19.5.1 and 9.1.2.

This deficiency affected 3 of several GFIC outlets.

Findings include
1-During the facility tour it was observed that the outlet in the Lab hand wash sink was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)
2- During the facility tour it was observed that the outlet in the radiology storage room was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)
3- During the facility tour it was observed that the 4 emergency circuit outlets in the Nursery was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)

Based upon observations made in the presence of the plant manager on 06-21-2021, it was determined that the facility did not install or maintain the buildings heating, ventilating and air conditioning systems in accordance with NFPA 101 19.5.2.1 and 9.2.

Findings include:
1-During the record review the facility failed to provide an itemized list of fire/ smoke damper locations and the tests that were performed. All inspections and testing shall be documented, indicating the location of the fire damper, date(s) of inspection, name of inspector, and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected in accordance with NFPA 80 19.3.4

Based upon observations made during the record review made in the presence of the plant manager on 06-21-2021, 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 19.7.1.2.

This deficiency affected all required fire drills.

Findings include:
During the record review of the facility it was discovered that the hospital has been conducting fire drills on two of the three shifts per quarter, by doing this they have conducted drills when the House keeping staff/department are not working a scheduled shift and cannot participate in the quarterly fire drills. The plant manager confirmed these findings. Fire drills shall be held at unexpected time under varying conditions at least quarterly on each shift in accordance with NFPA 101 19.7.1.2.

Based upon observations made during the record review made in the presence of the plant manager on 06-21-2021, it was determined that the facility did not maintain gas system in accordance with NFPA 99 5.1.14.2.3.

This deficiency affected the medical gas, vacuum system, WAGD, or support gas system.

Findings include:
During the record review the facility failed to provide documentation of the medical gas, vacuum, WAGD or support gas system is inspected annually and tested as part of a maintenance program and not in accordance with NFPA 99 5.1.14.2.1,5.1.14.2.2,5.1.15,5.2.14,5.3.13.4.2

Based upon observations made in the presence of the plant manager on 06-21-2021, it was determined that the facility did not test the Line Isolation Monitors in accordance with NFPA 99 6.3.4.1.4, 6.3.3.3.2

The deficiency affected 2 of 2 isolation monitor.

Findings include:
1-During the document review it was discovered that the line isolation monitors in the 2 operating rooms had not be tested. Line Isolation Monitors 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. And not in accordance with NFPA 99 6.3.4.1.4