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Based on record review and staff interview, the facility did not have a communication plan as part of their emergency preparedness plan in accordance with the requirements of 42 CFR 485.625(c). This deficiency has the potential to affect all patients, outpatients, and an undetermined number of staff and visitors.

Findings include:

On 09/20/2022 at 3:05 PM, record review revealed that the facility did not have an updated written emergency communication plan. The plan did not include specific instructions on how the automatic communication was to be initiated and a complete list of who was to be contacted in an emergency. The plan also did not include a means for sharing information about patient and facility needs.

This deficient practice was confirmed by Staff L, Staff M, and Staff N at the time of discovery.

Based on observation and interview, the facility did not provide means of egress in accordance with the requirements of NFPA 101, 2012 edition, Sections 19.2.1, 7.2.1.5.1, and 7.2.1.5.12. This deficient practice could affect an undetermined number of inpatients, outpatients, staff and visitors.

Findings include:

On 09/21/2022 at 11:24 AM, observation in Stairwell 1, a means of egress from the basement, as well as first floor Main Lobby, Waiting Room, and Exam Room Suites revealed a marked exit to the exterior and Door #7 which included a panic bar and a door alarm, but the door did not open upon operation.

This deficient practice was confirmed by Staff L and Staff M at the time of discovery.

Based on observation and interview, the facility did not maintain doors in rated walls to be self-closing doors or automatic closing devices complying with NFPA 101, 2012 edition, Sections 19.2.2.2.7, 7.2.1.8, 8.3.3.3, and 8.5.4.4. This deficient practices could affect all inpatients, outpatients, and an undetermined number of staff and visitors.

Findings include:

1. On 09/20/2022 at 3:39 PM, observation in the Kitchen Dish Room in the Basement revealed a door within a rated wall that was equipped with a self-closing device, but the door did not fully close after three attempts.

2. On 09/21/2022 at 10:51 AM, observation in the Soiled Utility Room across from Patient Room 116 revealed a door within a rated wall that was equipped with a self-closing device, but the door did not fully close after three attempts.

3. On 09/21/2022 at 11:08 AM, observation in the Office that was formerly a Gift Shop and adjacent to the first floor Conference Room revealed a door that was equipped with a hold open device, but the door did not fully close after three attempts.

These deficient practices were confirmed by Staff L and Staff M at the time of discovery.

Based on observation and interview, the facility did not protect a hazardous area in accordance with the requirements of NFPA 101, 2012 edition, Sections 19.3.2.1, 19.3.2.1.3, 19.3.2.5, and 8.7.1.3. This deficient practice could affect an undetermined number of inpatients, staff and visitors.

Findings include:

On 09/21/2022 at 9:53 AM, observation in the Ambulance Garage revealed the double doors leading from the 2 hour rated Garage to the Emergency Department Suite did not positively latch after three attempts.

This deficient practice was confirmed by Staff L and Staff M at the time of discovery.

Based on observation and interview, the facility did not provide a fire alarm system in accordance with the requirements of NFPA 101, 2012 edition, Sections 19.3.4 and 9.6; NFPA 72, 2010 edition, Sections 1.2.1 and 10.5.2; as well as NFPA 70, 2011 edition, Section 400.8. This deficiency has the potential to affect all inpatients, outpatients, and an undetermined number of staff and visitors.

Findings include:

On 09/20/2022 at 9:45 AM, observation in the Basement Floor Telecom Room revealed a fire alarm dialer sub-panel on temporary wiring. The wiring to the sub-panel was plugged into an outlet. Manual intervention renders this power source unreliable and not a means of permanent wiring.

This deficient practice was confirmed by Staff L and Staff M at the time of discovery.

Based on record review and interview, the facility did not provide a complete policy addressing when the fire alarm system is out of service in accordance with the requirements of NFPA 101, 2012 Edition, Section 9.6.1.6 and Federal Register Vol. 81, No. 86, page 26886. This deficiency has the potential to affect all inpatients, outpatients, and an undetermined number of staff and visitors.

Findings Include:

On 09/20/2022 at 10:50 AM, record review revealed the fire alarm outage policy titled "Fire Watch Check List" within the 2022 Interim Life Safety Plan documents did not have continuous rounds, did not have dedicated staff conducting the fire watch, and did not identify how fire watch personnel should respond when a fire is observed given the fire alarm system is non-functional. The Code Red noted in the facility plan would not work when the fire alarm system is non-functional.

This deficient practice was confirmed by Staff L, Staff M, and Staff N at the time of discovery.

Based on observation and interview, the facility did not provide an automatic sprinkler system in accordance with NFPA 101, 2012 edition, Sections 19.3.5.3, 19.1.6.1, and 9.7.1.1, as well as NFPA 13, 2010 edition, Sections 6.2.7, 8.15.7.1, and 9.1.1.7. These deficiencies has the potential to affect an undetermined number of inpatients, out-patients,staff and visitors.

Findings include:

1. On 09/20/2022 at 9:41 AM, observation in the Basement Facility Manager Office revealed that 1 inch diameter blue fiber piping was draped over sprinkler piping, thereby using the sprinkler piping for support.

2. On 09/20/2022 at 9:48 AM, observation in the Basement Floor Telecom Room revealed that (4) low voltage wiring was hanging on a pendant sprinkler, thereby using the sprinkler for support and blocking the sprinkler head from working properly.

3. On 09/21/2022 at 10:01 AM, observation in the Emergency Department Supply Room revealed the sprinkler head cover plate, an escutcheon plate, was not in place, thereby not completing the sprinkler assembly listing.

4. On 09/21/2022 at 10:34 AM, observation in the closet adjacent to Patient Room 122 revealed the sprinkler head cover plate, an escutcheon plate, was missing, thereby not completing the sprinkler assembly listing.

5. On 09/21/2022 at 2:30 PM, observation at the Employee Entrance revealed a combustible canopy attached to the hospital building without sprinkler coverage. The hospital building is a Type II (000) construction type which requires the facility to be fully sprinkler protected throughout to NFPA 13. The roof canopy has a combustible canvas covering with an approximate ground coverage area of 34 feet in length by 8 feet in width. The canopy has seven (7) plastic combustible walls panels each of approximate size of 7 feet by 7 feet in area. The ceiling of the canopy also has plastic combustible eggcrate shaped ceiling panels also covering an area approximately of 34 feet in length by 8 feet in width. The canopy is not a free-standing structure and also serves as patient protection when accessing MRI trailer services.

6. On 09/21/2022 at 2:44 PM, observation in the EVS Breakroom revealed the sprinkler head cover plate, an escutcheon plate, was not in place, thereby not completing the sprinkler assembly listing.

These deficient practices were confirmed by Staff L and Staff M at the time of discovery.

Based on observation and staff interview, the facility did not maintain corridor doors in accordance with NFPA 101, 2012 edition, Section 19.3.6.3 and 19.3.6.3.11. This deficient practice could affect 8 inpatients, as well as an undetermined number of staff and visitors.

Findings include:

On 09/21/2022 at 10:57 AM, observation in the Chapel revealed that the door to the corridor did not fully close after three attempts.

This deficient practice was confirmed by Staff L and Staff M at the time of discovery.

Based on observation and interview, the facility did not maintain smoke barrier walls in accordance with the requirements of NFPA 101, 2012 edition, Sections 19.3.7.3, 19.3.7.6, 8.5.2, and 8.5.6. These deficiencies has the potential to affect an undetermined number of
inpatients, out-patients,staff and visitors.

Findings include:

1. On 09/21/2022 at 12:02 PM, observation above the ceiling at the 2 hour smoke/fire barrier wall between the 1962 building and 1982 addition adjacent to the Kalmar 1 Waiting Room revealed a 3" inch diameter penetration that was not properly fire stopped according to an approved method.

2. On 09/21/2022 at 12:04 PM, observation above the ceiling at the 2 hour smoke/fire barrier wall between the 1962 building and 1982 addition adjacent to the Kalmar 1 Waiting Room revealed a 1/2 inch diameter penetration on the 1962 building side of the wall that was not properly fire stopped according to an approved method.

3. On 09/21/2022 at 2:16 PM, observation above the ceiling at the 1 hour smoke/fire barrier wall adjacent to the Rehab/Cardio Outpatient Soiled Linen Room revealed (2) 1/2 inch diameter penetrations that was not properly fire stopped according to an approved method.

These deficient practices were confirmed by Staff L and Staff M at the time of discovery.

Based on observation and staff interview, the facility did not ensure the electrical wiring and equipment met the requirements of NFPA 101, 2012 Edition, Sections 19.5.1.1, and 9.1.2, as well as NFPA 70, edition 2011, Articles 110.8, 210.8(B), 314.17, and 314.20. These deficiencies has the potential to affect an undetermined number of inpatients, out-patients,staff and visitors.

Findings Include:

1. On 09/21/2022 at 11:36 AM, observation in the Exam Room 9 in the Emergency Department revealed an electrical receptacle was located approximately 4 feet from the sink and 18 inches above the floor. The facility was not able to confirm that ground-fault circuit-interrupter (GFCI) protection was provided within 6 feet from the sink.

2. On 09/21/2022 at 11:40 AM, observation in the Kalmar 1 Exam Room 2 revealed an electrical receptacle was located approximately 2 feet from the sink. The facility was not able to confirm that ground-fault circuit-interrupter (GFCI) protection was provided within 6 feet from the sink.

3. On 09/21/2022 at 11:43 AM, observation in the Kalmar 1 Exam Room 4 revealed an electrical receptacle was located approximately 2 feet from the sink. The facility was not able to confirm that ground-fault circuit-interrupter (GFCI) protection was provided within 6 feet from the sink.

4. On 09/21/2022 at 12:06 PM, observation above the ceiling at the 2 hour smoke/fire barrier wall between the 1962 building and 1982 addition adjacent to the Kalmar 1 Waiting Room revealed a 4 x 4 inch junction box on the 1962 building side of the wall did not have a cover leaving the raceway system open.

5. On 09/21/2022 at 1:51 PM, observation in Kalmar 2 Exam Room 5 revealed a flexible cord multi-outlet strip device (power strip) connected to an extension cord, (temporary power tap), was used as a substitute for permanent, fixed wiring and powering a personal refrigerator.

6. On 09/21/2022 at 3:01 PM, observation in the Mammography Room revealed an electrical receptacle was located approximately 3 feet from the sink. The facility was not able to confirm that ground-fault circuit-interrupter (GFCI) protection was provided within 6 feet from the sink.

These deficient practices were confirmed by Staff L and Staff M at the time of discovery.

Based on observation and interview, the facility did not store oxygen cylinders in accordance with the requirements of NFPA 101, 2012 edition, Sections 19.3.2.4 and 8.7. as well as NFPA 99, 2012 edition, Sections 11.3.3, 11.3.3.4, and 11.6.5.2. These deficiencies has the potential to affect an undetermined number of inpatients, out-patients,staff and visitors.

Findings include:

1. On 09/21/2022 at 10:28 AM, observation in the enclosed Hall Room between the Patient Rooms revealed (1) Type "D" sized oxygen cylinder was not stored securely chained or in a rack. (7) Type "E" oxygen cylinders were securely stored within the same room.

2. On 09/21/2022 at 2:31 PM, observation in the Work Room outside of the OR, renamed the Equipment Storage Room, revealed (1) Type "E" sized oxygen cylinder was not stored securely chained or in a rack.

These deficient practices were confirmed by Staff L and Staff M at the time of discovery.