HospitalInspections.org

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Based on observation, record review and interview the facility failed to ensure room under a stairwell utilized as an exit egress was free from prohibited storage per NFPA 101: 7.2.2.5.3 as referenced NFPA 101: 19.2.2.3. This failed practice placed occupants in 3 of 7 smoke compartments at risk for delay in egress and/or exposure to a smoke/fire environment. Findings:

Observation on 12/13/19 at 9:10 am revealed an enclosed area (1602A) located under the exit stairwell (1017). Further review revealed the area was storage for cardboard boxes, plastic tools, plastic bags and other combustible material.

Review of the facility's Life Safety Plan, dated 2019, revealed the exit stairwell (1017) was protected by a 2-hour fire barrier.

During an interview on 12/13/19 at 9:10 am, the Director of Facilities was not able to confirm the separation rating between the enclosed area and the stairwell. The facility did not have a process to ensure the separation between the enclosed area and stairwell was maintained without integrity loss.

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Based on observation, record review and interview the facility failed to ensure exit signage was displayed in accordance with NFPA 101: 7.10 as referenced by NFPA 101: 19.2.10.1. Specifically, the facility failed to ensure exit signs were either installed in required locations per NFPA 101: 7.10.1.2 or free from visual obstructions per NFPA 101: 7.10.1.8. This failed practice placed occupants and patients (based on a census of 4) in 4 out of 5 smoke compartment, accessible by patients, at risk for delay in exit egress during an emergency event. Findings:

Observations on 12/13/19, revealed the exit corridor (1014) had informational signage hanging from the ceiling that extended the width of the corridor. Further observation revealed when heading southwest from cross corridors 1014A, the informational signage obstructed the exit signage located at the cross corridor doors 1014B.

Observation on 12/13/19, revealed no visual exit signage at the intersection of corridor 1035 and corridor 1033 (near nurse's station 1921). Specifically, no visual exit sign was observed in the southwest and northwest egress direction.

Observation on 12/13/19, revealed no visual exit signage in corridor 1039 when heading both northwest and southeast. Corridor 1039 housed inpatient rooms.

Observation on 12/13/19, revealed no visual exit signage in corridor 1002 when heading northeast.

Review of the facility's Life Safety Plan, dated 2019, revealed corridors 1002, 1014, 1033, 1035 and 1039 were constructed as exit egress corridors and lead to exit discharges.

During random interviews on 12/13/19, the Director of Facilities stated the ceiling suspended informational signage obstructed required exit signage and further stated the lack of exit signs in identified areas required exit signage for directional egress.

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Based on observation and interview, the facility failed to ensure hazardous areas were protected and free from penetrations in accordance with NFPA: Chapter 8 as referenced by NFPA 101: 19.3.2 in 2 of 5 smoke compartments accessible by patients. This failed practice placed occupants and patients at risk for exposure to a smoke and/or fire environment. Findings:

Observation on 12/12/19 at 2:55 pm, revealed two unprotected penetrations located in the common wall between the main electrical room (1504) and generator room (1502).

Review of the facility's Life Safety Plan, dated 2019, revealed the electrical room (1504) and generator room (1502) were identified as hazardous areas separated by a 2-hour fire barrier.

Observation on 12/13/19 at 8.15 am, revealed an unprotected penetration located in the common wall between an equipment room (1511) and main mechanical room (1505A).

Review of the facility's Life Safety Plan, dated 2019, revealed the equipment room (1511) and main mechanical room (1505A) were identified as hazardous areas separated by a 1-hour smoke barrier.

Observation on 12/13/19 at 9:15 am, revealed an unprotected penetration located in the medical gas supply room (1617). Specifically, a 3-inch pipe was passed through the wall with an observable unprotected gap around pipe.

Review of the facility's Life Safety Plan, dated 2019, revealed the medical gas supply room (1617) was protected by a 1-hour fire/smoke barrier and identified as a hazardous room.

Observation on 12/13/19 at 9:30 pm, revealed an unprotected penetration located in the common wall between a supply room (1608) and an exit corridor (1016).

Review of the facility's Life Safety Plan, dated 2019, revealed the supply room (1608) was identified as a hazardous area. Further review revealed the common wall was identified as a 1-hour fire barrier.

During random interviews on 12/12-13/19, the Director of Facilities acknowledged the findings at the time of their discovery.

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Based on observation, interview, and record review the facility failed to ensure:

(1) the central kitchen wet-chemical hood suppression system and exhaust was maintained in accordance with NFPA 17A as indicated by NFPA 96: 10.2.6 in reference to NFPA 101: 9.2.3. Specifically, the facility failed to ensure a suppression nozzle was orientated to protect the deep fat fryer;

(2) the central kitchen wet-chemical hood suppression system and exhaust was cleaned in accordance with NFPA 96: 11.6 as indicated by NFPA 96: 11.4 (referenced by NFPA 101: 9.2.3); and

(3) documentation was maintained in accordance with NFPA 96: 11.6.13 and 11.6.14.

These failed practices placed occupants in 1 of 7 smoke compartments at higher risk for exposure to a grease fire. Findings:

Kitchen Hood Suppression Nozzle:

Observation of the central kitchen, on 12/13/19 at 2:52 pm, revealed the kitchen utilized a deep fat fryer - Ansul R 102 Hood Suppression System. Further observation revealed the wet chemical kitchen hood suppression system nozzle, dedicated to protect the fryer, was directed to the area right of the deep fryer surface. As a result, the hood suppression nozzle was not correctly orientated in accordance with NFPA 17A.

During an interview on 12/13/19 at 2:52 pm, the Director of Facilities acknowledged the finding and stated the nozzle and fryer surface needed to be more centrally located.

Review of the Ansul "R-102 Restaurant Fire Suppression System Design, Installation, Recharge, and Maintenance Manual," dated 2014, revealed single nozzle protection of fryers shall "Nozzle tip ...aimed to the center of the cooking area."

Kitchen Hood Cleaning:

Record review of the facility's "Hood/Duct Fire Suppression System Inspection" report, dated 12/27/18, revealed the inspector documented "Needs to be professionally cleane[d]."

Record review of the facility's "Hood/Duct Fire Suppression System Inspection" report, dated 7/11/19, revealed the inspector documented "Needs to be professionally cleane[d]."

During random interviews on 12/12-13/19, the Director of Facilities stated he was unable to provide documentation of the last hood cleaning for the central kitchen wet-chemical hood suppression system and exhaust.

During a secondary follow-up interview on 12/18/19 at 2:00 pm, the Deputy Hospital Administrator (DHA) stated the facility found documentation of the kitchen hood suppression system and exhaust. The DHA provided a contractor "Estimate" for hood cleaning dated 7/20/18 and a payment slip that indicated the contractor was paid for services on 9/26/18. There was no documentation of a hood cleaning since 9/2018.

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Based on observation, record review and interview the facility failed to ensure the sprinkler system was installed in accordance with NFPA 13 as referenced by NFPA 101: 9.7 secondary to NFPA 101: 19.3.5. Specifically, the facility failed to ensure sprinkler heads were installed to: 1) prevent obstruction of spray patter, 2) prevent mechanical damage, and 3) protect fire rated walls at the penetration site of the sprinkler head. This failed practice placed occupants in 1 of 7 smoke compartments at risk for exposure to a smoke and/or fire environment due to an insufficient or delay in sprinkler extinguishment. Findings:

Observation of the Receiving Dock (1602), on 12/13/19 at 9:05 am revealed a side wall sprinkler located in the ceiling between two garage doors. Further review revealed the sprinkler was surround by multiple unistrut beams and conduit piping which resulted in the potential for obstructed spray pattern during activation per NFPA 13: 8.7.5.3.

Review of the facility's Life Safety Plan, dated 2019, revealed the Receiving Dock (1602) was identified as a hazardous area.

Observation of the Special Waste Holding room (1618), on 12/13/19 at 9:20 am, revealed a side wall sprinkler head located under the garage door track. This sprinkler head was designed to protect coverage in the event the garage door is open during activation. Further review revealed the sprinkler head did not contain protective barrier cage or guard in accordance with NFPA 13: 6.2.8.

Review of the facility's Life Safety Plan, dated 2019, revealed the Special Waste Holding room (1618) was identified as a hazardous area.

Observation of an exit stairwell #1, on 12/13/19 at 11:15 am, revealed a sprinkler head located at the top of the stairwell was missing an escutcheon plate in accordance with NFPA 13: 6.2.7.

Review of the facility's Life Safety Plan, dated 2019, revealed the exit Stairwell #1 was a designated exit egress path.

During random interviews on 12/13/19, the Director of Facilities acknowledged the findings at the time of their discovery.

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Based on record review, observation, and interview the facility failed to ensure a corridor was separated from two treatment area (dental clinic and eye clinic) by a partition that prevented the passage of smoke in accordance with NFPA 101: 19.3.6.2 as referenced by NFPA 101: 19.3.6.1. This failed practice placed occupants in 1 out of 7 smoke compartments at risk for exposure to a smoke environment. Findings:

Vision Clinic:

Review of the facility's Life Safety Plan, dated 2019, revealed the common wall between the eye clinic corridor (2013A) and the eye clinic reception desk (2207) was identified as a smoke partition.

Observation on 12/13/19, revealed the eye clinic reception desk opened to a lobby (2001) which connected to another exit corridor (2005). Further observation revealed the common wall between the eye clinic corridor (2013A) and the eye clinic reception desk (2207) had two large openings without any protection to prevent the passage of smoke. The two openings extended the length of the wall and were approximately 24" in height. No barrier was observed to separate the eye clinic corridor with the lobby/exit corridor.

During an interview on 12/13/19, Eye Clinic Staff #1 stated the openings were cut out after the facility had been built to open up the eye clinic display room and treatment area. Eye Clinic Staff #1 further stated the eye clinic felt small in size and opening the walls provided a more visually appealing environment.

The Director of Facilities acknowledged the finding at the time of discovery.

Dental Clinic:

Random observations from 12/11-13/19, revealed an opening located at the dental reception desk that allowed the dental reception staff to interact with patients. The opening from dental reception desk (2101) and waiting area lobby (2001) was protected by an automatic roller door that activated with the facility's fire alarm system. Further random observations from 12/11-13/19, revealed a printer support arm and various office supplies and supplies holders were located atop a black and yellow 2" strip taped across the counter. During the random observations, it was revealed the taped strip was the indicator for the drop zone of the automatic roller door. A total of 7 random observations during 12/11-13/19, revealed this drop zone was impeded by office supplies and the printer arm.

Review of the facility's Life Safety Plan, dated 2019, revealed the opening to the dental reception area was identified as a smoke partition.

During an interview on 12/13/19, the Director of Facilities stated nothing should have been on the yellow and black strip or impede the dropping action of roller door.

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Based on observation and interview the facility failed to ensure a patient room entry door closed in a manner that prevented the passage of smoke in accordance with NFPA 101: 19.3.6.3. This failed practice placed one patient (based on a census of 4) at risk for exposure to a smoked and/or fire environment. Findings:

Observation on 12/13/19 at 11:02 am, revealed the door connecting patient room 1915A to the exit corridor did not close in manner to prevent the passage of smoke. Further observation revealed the door was equipped with an automatic closing device and a bristle-like guard was installed across the bottom of the door. When tested the bristle-like guard prevented the door from closing resulting in several inches between the frame and the door.

During an interview, on 12/13/19 at 11:02 am, the Director of Facilities stated the bristle-like guard caused the door to meet too much resistance and failed to close completely to prevent the passage of smoke and/or fire.

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Based on observation, record review, and interview the facility failed to ensure a smoke barrier was free from an unprotected penetration. This failed practice placed occupants in 2 of 7 smoke compartments at risk for exposure to a smoke and/or fire environment during egress via exit corridors. Findings:

Observation on 12/13/19 at 1:00 pm, revealed an 18-inch by 1-inch opening in the smoke barrier located above the cross corridor doors (1014B).

Review of the facility's Life Safety Plan, dated 2019, revealed the wall where the cross corridor doors (1014B) was identified as a 1-hour smoke barrier.

During an interview on 12/13/19 at 1:00 pm, the Director of Facilities acknowledged the finding at the time of discovery.

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Based on record review and interview, the facility failed to ensure fire drills were conducted under varied conditions in accordance with NFPA 101: 19.7.1.6. This failed practice placed all occupants and patients (based on a census of 4) at risk for delay in emergency response to a fire/smoke emergency. Findings:

Record review of the facility's fire drills for 2019, revealed each fire drill was initiated by utilizing the pull station. Further review revealed the last three third shift (12:00 am - 7:00 am) fire drills were conducted at similar times: 9/28/19 - 5:12 am; 9/25/19 - 6:30 am; and 9/18/19 - 5:12 am.

During an interview on 12/13/19, the Director of Facilities stated the fire drills were not varied in conditions of testing and needed to be changed to reflect different mechanisms and times of activation.

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Based on record review and interview, the facility failed to ensure the medical gas warning system was maintained in accordance to NFPA 99 as referenced by NFPA 101: 4.6.12 and NFPA 101: 19.3.2.4. Specifically, the facility failed to ensure a local alarm for the medical air lag compressor was maintained in accordance with NFPA 99: 5.1.9.5.4. This failed practice placed all patients (based on census of 4) at risk for not receiving medical gas services in a timely and safe manner. Findings:

Record review of the facility's annual medical gas system inspection report, dated 11/15/19, revealed the inspector found the local alarm for the medical air lag compressor "in Use Audible did not sound at the Source Equipment." The finding was documented as required to be addressed.

During an interview on 12/13/19, the Director of Facilities stated he was unaware of any infractions related to the medical gas system inspection completed on 11/15/19. When presented with the medical gas inspection report, the Director of Facilities further stated the issue had not been reviewed or fixed at the time of survey.

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Based on record review, interview and observation, the facility failed to ensure the generator sets were maintained in accordance with NFPA 99 and NFPA 110 as referenced at NFPA 101: 9.1.3. These failed practices placed all non-patient occupants and patients (based on a census of 4) at risk for loss or delay in emergency power. Findings:

Monthly Generator Testing:

Record review, from 12/11-13/19, of the facility's monthly generator test log revealed a load test was conducted on 9/24/19 followed by a test conducted on 10/12/19. The test were completed at an 18 day interval which fell outside the testing frequency requirements referenced at NFPA 99: 6.4.4.1.1.4(A).

Written Schedule for Maintenance and Operational Testing:

Review of the facility's life safety documentation, from 12/11-13/19, revealed no written schedule for routine maintenance and operational testing of the generator system had been established in accordance with NFPA 110: 8.3.3.

During an interview on 12/12/19 at 9:00 am, the Director of Facilities stated he was unable to provide a written schedule for routine maintenance and operational testing of the generator system.

High Mortality Parts:

Observations during the facility tour on 12/11-13/19, revealed no identified high mortality parts secured on the premises for the generator sets.

Record review, from 12/11-13/19, of the facility's life safety code documents revealed no evidence of high mortality parts identified by experience in accordance with NFPA 110: 8.2.4. In addition, review of the facility's Life Safety Assessment, dated 10/8/19, revealed no review and/or assessment of generator requirements.

During an interview on 12/12/19 at 9:00 am, the Director of Facilities stated the facility did not have replacement parts identified by experience as high mortality items maintained in a secure location within the hospital.

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Based on observation and interview, the facility failed to ensure power strips, extension cords and power cords were used and maintained in a safe manner in accordance with NFPA 70 as referenced by NFPA 101: 9.1.2 and 19.5.1. This failed practice placed occupants and patients (based on a census of 4) in 4 out 5 smoke compartments accessible by patients at risk for exposure to a fire and/or smoke environment and increased risk for electrical fires. Findings:

Observation of Central Supply, on 12/12/19 at 4:31 pm, revealed an extension cord was supplying power to a power strip. Further observation revealed the power strip was powering a uninterruptible power source apparatus that provided electricity for two computer units.

Observation of room 1826, on 12/13/19 at 9:55 am, revealed an unmounted power strip was suspended midair. The suspension of the power strip caused tension on the power strip cord and cords of appliances being supplied electricity.

Observation of room 1827, on 12/13/19 at 10:30 am, revealed an unmounted power strip was suspended midair under the sink. The power strip supplied electricity to a large refrigerator, a microwave and coffee pot. Further review of the power strip revealed the warning label to read to use in "dry areas only."

Observation of room 1971, on 12/13/19 at 12:15 pm, revealed a 12-inch round device with multiple outlets atop a desk. The round multi-plug device was supplied electricity from a power strip.

Observation of the large conference room (command center room), on 12/13/19 at 12:18 pm, revealed three suspended power adapters supplying power to computer units. This suspended power adaptors weight caused strain to be applied to the bound power cords.

Observation of the medical staff office, on 12/13/19 at 1:39 pm, revealed a suspended power adapter supplying power to a computer unit that resulted in tension of the power cords wiring.

Observation of the social work office, on 12/13/19 at 2:00 pm, revealed a desk with a pre-installed linear multi-outlet strip with heavy gauge wiring. This multi-outlet strip was supplied electricity via secondary power strip.

Observation of the PBX area (1124A), on 12/13/19 at 2:15 pm, revealed a suspended power adapter supplying power to a computer unit that resulted in tension of the power cords wiring.

Observation of the central pharmacy, on 12/13/19 at 3:00 pm, revealed 3 of the 4 service windows (area where pharmacy staff engage with patients) had suspended power adapters that supplied power to computers which resulted in tension of the power cords wiring.

During random interviews on 12/12-13/19, the Director of Facilities acknowledged the findings at the time of their discovery.

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Based on observation, record review and interview, the facility failed to ensure all personnel concerned with the application and maintenance of medical gases and others who handled medical gases and the cylinders that contained the medical gases, were provided with training and education in accordance with NFPA 99: 11.5.2.1.1 as referenced by NFPA 101: 19.3.2.4. This failed practice placed all occupants at risk for exposure to an unsafe environment and increased risk of fire and/or smoke exposure. Findings:

Random observations from 12/11-13/19, revealed the facility used an oxygen cascade system to deliver oxygen to patient care areas via in-wall piped medical gas. Further observation revealed the facility utilized storage of oxygen cylinders.

Record review of the current maintenance staff list on 12/13/19, revealed the department had 16 employees as of 12/10/19.

During an interview on 12/13/19, the Director of Facilities stated that all maintenance staff had the ability to handle medical gas cylinders.

Record review of the most recent facility provided training entitled "The Safe Use of Oxygen and Cylinder Handling Safety Training Class," dated 3/18/19, revealed 7 of the 16 (Staff #s 1; 2; 3; 4; 5; 6; and 7) maintenance department employees attended.

During an interview on 12/13/19, the Director of Facilities stated the remaining 9 employees (Staff #s 8; 9; 10; 11; 12; 13; 14; 15; and 16), had not been provided the training at the time of survey.

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