HospitalInspections.org

Based on observation it was determined the facility failed to maintain the smoke/fire resistive rating of corridor walls.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.1, "Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5 (See also 19.2.5.9) (See all Exceptions) Section 19.3.6.2 "Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour." (See all Exceptions}.

Findings Include:

On August 11, 2014, the surveyor, accompanied by the Director of Maintenance, observed penetrations in the corridor wall located by Endoscopy.

During the exit conference on August 11, 2014, the above findings were again acknowledged by the Interim CEO and the Director of Maintenance.

Corridor walls must remain smoke tight/fire resistive to prevent smoke and heat from entering resident rooms. Smoke/heat will cause harm to the patients.

Based on observation it was determined the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On August 11, 2014 the surveyor, accompanied by the Director of Maintenance, observed the following corridor door would not tightly close when tested.

1. Lab Directors office door tested three of three times and will not positively latch.

During the exit conference on August 11, 2014, the above findings were again acknowledged by the Interim CEO and the Director of Maintenance.

In time of a fire failing to protect patients from heat and smoke could cause harm to the patients.

Based on observation it was determined the facility failed to fill penetrations in the smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of at least ½ hour." (1 Hour New) Chapter 8, Section 8.3.6. "Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:"
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
(a) It shall be made on either side of the smoke barrier.
(b) It shall be made by an approved device that is designed for the specific purpose.

Findings include:

On August 11, 2014, the surveyor, accompanied by the Director of Maintenance, observed unsealed penetrations in the smoke barrier/s, located at:

1. The general service hall to the Hospital, to include the three hour doors were wedged in the open position with impediments.

During the exit conference on August 11, 2014, the above findings were again acknowledged by the Interim CEO and the Director of Maintenance.

Failing to fill holes in smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility, which will cause harm to patients.

Based on observation it was determined the facility failed to maintain self closing doors in a smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than I hour. (1/2 hour for existing) Section 8.3.4.1, " Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

Findings include:

On August 11, 2014, the surveyor, accompanied by the Director of Maintenance, observed the astragal was removed from the corridor smoke/fire doors within the ER corridor. When closed there was a gap between the doors of approximately 1/4 inch.

During the exit conference on August 11, 2014, the above findings were again acknowledged by the Interim CEO and the Director of Maintenance.

This installation will allow smoke to contaminate smoke zones not directly effected by the fire, which will cause harm to patients.

Based on observation it was determined the facility did not maintain the integrity, smoke resistance, of doors in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.2.1 requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls and doors must be able to resist the passage of smoke. NFPA 80 "Fire Doors and Fire Windows" Chapter 2, Section 2-3.1.7 "The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. +/- 1/16 in for steel doors and shall not exceed 1/8 in. for wood doors.

Findings include:

On August 11, 2014, the surveyor, accompanied by the Director of Maintenance, observed the following hazardous area doors:

1. Next to infection control office, no door closing device.
2. Door to the kitchen with a closing device wedged open with an impediment.
3. Kitchen door to the corridor, no closing device.
4. Frozen section room contain flammables, door tested three of three times and will not positively latch.
5. OR janitors closet by the lab contains chemicals, no door closing device. (no sprinkler)
6. Respiratory therapy, one of two doors have no closing device.
7. Clean utility storage, door tested three of three times, will not positively latch.
8. Med Surge storage/electrical room, no door closing device.
9. CT storage room with combustibles, wedged open with an impediment.
10. ER soiled linen room, wedged open.
11. New ER med room with the pixies machine, door and door closing device removed.
12. Endoscopy door to the corridor, sprung open and will not close and positively latch.
13. OR electrical room, no door closing device and wedged open with an impediment.
14. OR storage room, door closing device disconnected.
15. IT, doors have no latching device.

During the exit conference on August 11, 2014, the above findings were again acknowledged by the Interim CEO and the Director of Maintenance.

Failing to prevent heat and smoke from spreading into the exit corridor will cause harm to patients.

Based on record review it was determined the facility failed to document the annual testing of battery back up emergency lighting.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.2.9.1, "Emergency lighting shall be provided in accordance with Section 7.9". Section 7.9.3 " Periodic Testing of Emergency Lighting Equipment" " A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction."

Findings include:

On August 11, 2014, the surveyor accompanied by the Director of Maintenance reviewed the monthly battery documentation. The ninty minute testing was not provided to the surveyor. annual testing were provided to the surveyor.

During the exit conference on August 11, 2014, the above findings were again acknowledged by the Interim CEO and the Director of Maintenance.

Failing to test and maintain emergency lighting units will cause harm to the patients.

Based on interview of staff members it was determined the facility does not follow the written Fire plan or train employees in life safety procedures and devices.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.7.1.2 Fire exit drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions."

Findings Include:

On August 11, 2014, the surveyor, accompanied by the Director of Maintenance, interviewed a staff employee of four years, and three employees in the lab. The employees do not know the fire procedures as written in the facilities Fire plan. During the Fire drills between the hours of 9 PM and 6 AM, the facility does not use a coded announcement and only does an oral fire drill.

During the exit conference on August 11, 2014, the above findings were again acknowledged by the Interim CEO and the Director of Maintenance.

Failure to train and drill the staff on fire procedures could result in harm to the patients.

Based on record review, and observation it was determined the facility did not inspect, test and maintain the automatic sprinkler system in accordance with the requirements of the Life Safety Code.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.5.1. "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing , and Maintenance of Water-Based Fire Protection Systems." NFPA 25, Water Based Extinguishment Systems, requires monthly, quarterly and annual testing of automatic sprinkler systems.

Section 9.7." Section 9.7.1.1 "Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, Chapter 3, Section 3-2.7.2, "Escutcheon Plates used with a recessed or flushed sprinkler shall be part of a listed sprinkler assembly."

Findings include:

On August 11, 2014, the surveyor, accompanied by the Director of Maintenance, reviewed the sprinkler quarterly and annual records which indicated the automatic sprinkler system quarterly inspector test flow times were not documented. The annual inspector test was documented.
The following escutcheon plates are missing:

1. Lab, one of six.
2. Lab break room, one of one.
3. Old Board room, one of three.

During the exit conference on August 11, 2014, the above findings were again acknowledged by the Interim CEO and the Director of Maintenance.

Failure to inspect, test, and maintain the sprinkler system could result in harm to the patients through the spread of smoke and fire.

Based on record review it was determined the facility failed to inspect and maintain the facilities fire dampers.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.2 Heating Ventilating and Air Conditioning Section 19.5.2.1 "Heating, ventilating, and air conditioning shall comply with the provisions of section 9.2 and shall be installed in accordance with the manufacture's specifications." Section 9.2.1 "Air Conditioning, Heating, Ventilating, Ductwork, and Related Equipment." "Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A," "Standard for Installation of Air Conditioning and Ventilating Systems...

NFPA 90A 1999 Edition Section 3-4.7 "Maintenance" "At least every four years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked and moving parts shall be lubricated as necessary."

Findings include:

On August 11, 2014, the surveyor, accompanied by the Director of Maintenance reviewed the Fire Protection and Life Safety records. The facility did not have documentation of fire damper inspection or maintenance. The Director of Maintenance stated the fire dampers were not inspected or maintained in the past four years.

During the exit conference on August 11, 2014, the above findings were again acknowledged by the Interim CEO and the Director of Maintenance.

Failing to inspect and maintain the facility fire dampers may cause harm to the patients.

Based on Record review it was determined the kitchen hood was not cleaned or inspected in accordance with NFPA 96.

NFPA 101 Life Safety Code, 2000 Edition, Chapter 19, Section 19.3.2.6, "Cooking Facilities." "Cooking facilities shall be protected in accordance with 9.2.3." Section 9.2.3, "Commercial Cooking Equipment" "Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.... Chapter 8, Section 8-3 "Cleaning" "Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person (s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1." Table 8-3.1, Exhaust System Inspection Schedule "Type or Volume of Cooking Frequency" "Systems serving moderate-volume cooking operations." Frequency is Semiannually"
Section 8-3.1.1 "Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified, and certified company or person (s) acceptable to the authority having jurisdiction in accordance with Section 8-3."
Section 8-3.1.2 "When a vent cleaning service is used, a certificate showing date of inspection or cleaning shall be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company. It shall also indicate areas not cleaned."

Findings Include:

On August 11, 2014, the surveyor accompanied by the Director of Maintenance reviewed the kitchen hood documentation. The last invoice was dated October 23, 2013. The facility was unable to provide documented evidence that the cooking hood and vents were inspected and cleaned in accordance with NFPA 96 for April 2014.

During the exit conference on August 11, 2014, the above findings were again acknowledged by the Interim CEO and the Director of Maintenance.

Failing to inspect and clean the kitchen hood and vents will allow a build-up of grease and provide fuel for a fire. A fire in the kitchen may cause harm to patients and staff.

Based on Observation it was determined the facility failed to separate empty and full medical gas cylinders, and keep the oxygen bottles free of combustible materials.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.2.4. "Medical gas storage and administration areas shall be protected in Accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99, Chapter 4, Section 4-3.5.2.2 (a) (2) "If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

Chapter 8, Section 8-3.1.11 "Storage Requirements" Section 8-3.1.11.2 "Storage of nonflammable gases less than 3000 cubic. feet.." (a) "Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. (c) "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by: (c) (2) A minimum distance of 5 ft. if the entire storage location is protected by an automatic sprinkler system..."

Findings include:

On August 11, 2014 the surveyor, accompanied by the Director of Maintenance observed the soiled utility room, ten E O2 bottles were not marked FULL/EMPTY, the bottles were next to an electrical outlet and combustibles, and the door would not positively latch.
The recovery/post op has one E O2 bottle stored by combustibles, and the OR storage room has one E O 2 bottle stored by electrical and combustibles.

During the exit conference on August 11, 2014, the above findings were again acknowledged by the Interim CEO and the Director of Maintenance.

In an emergency, patients could be harmed if an empty medical gas cylinder was mistakenly taken from the storage area.
Leaking oxygen could penetrate combustible materials and create an extreme fire hazard, which could cause harm to the patients. In an emergency, patients could be harmed if an empty medical gas cylinder was mistakenly taken from the storage area.

Based on record review and observation it was determined the facility failed to allow access to the electrical equipment/panel; failed to provide a guard on the light bulbs; failed to provide receptacle face plates; and failed to test and document the monthly testing of the Line Isolation Monitor tests/Isolated Electrical Panels.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1., Section 9.1.2 "Electrical wiring and equipment shall be in accordance with NFPA 70 National Electrical Code." NEC, 1999, ARTICLE 110, SECTION 110-26 Spaces About Electrical Equipment. "Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons." Table 110-26(a) Working Space Minimum of three (3) feet in all directions.

( NO STORAGE ALLOWED IN THE WORKING SPACE)

NFPA 70 National Electrical Code." NEC, 1999, Article 110, Section 110-27 (b) Prevent Physical Damage. " In locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage

" NEC, 1999, Article 410, Section 410-56 (e) Position of Receptacle Faces. "3. After installation, receptacle faces shall be flush with or project from faceplate of insulating material and shall project a minimum of 0.015 in. From metal faceplate. Faceplate shall be installed so as to completely cover the opening and seat against the mounting surface."

NFPA 101, Life Safety Code, 2000 Edition, Maintenance and Testing (See 4.6.12) "Maintenance and Testing "Section 4.6.12.1, "Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction."

"NFPA 99 1999 Edition, Health Care Facilities Section 3-3.3.4.2 The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following: (b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch (see 3-3.2.2.3(f)) 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."

Findings include:

On August 11, 2014, the surveyor, accompanied by the Director of Maintenance, observed storage in front of the electrical panel (s) located in Med Surg storage/electrical room, storage of cleaning carts in front of electrical panels.

The following electrical items were observed:

1. No documentation of OR one and two Isolated Electrical Panel testing.
2. Infection control office, no light cover.
3. Respiratory therapy, electrical room, two of two lights no covers.
4. Nursing suite office, microwave plugged into a power strip.
5. Med Surg storage closet, one light no cover.
6. Physicians lounge, refrigerator plugged into a power strip.
7. OR corridor, 110, face plate broken.
8. IT office, two refrigerators and one microwave plugged into a power strip.

During the exit conference on August 11, 2014, the above findings were again acknowledged by the Interim CEO and the Director of Maintenance.

Blocking of access to electrical panels or equipment may delay personnel from controlling an emergency situation. Patients will be harmed if a fire should start because of a delay.
Failure to keep light guards on the light could cause accidental damage or possibly a fire, which could cause harm to the patients.
Failing to repair broken receptacles and face plates may contribute to starting a fire by allowing the electrical wiring to short when an electrical appliance is plugged in or removed from the receptacle. A fire in the facility may cause harm to the patients.
Failing to test and maintain documentation on the Line Isolation Tests/Isolated Electrical Panels could cause harm to the patients in an emergency or power outage.

Based on observation it was determined the facility failed to maintain the smoke/fire resistive rating of corridor walls.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.1, "Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5 (See also 19.2.5.9) (See all Exceptions) Section 19.3.6.2 "Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour." (See all Exceptions}.

Findings Include:

On August 11, 2014, the surveyor, accompanied by the Director of Maintenance, observed penetrations in the corridor wall located by Endoscopy.

During the exit conference on August 11, 2014, the above findings were again acknowledged by the Interim CEO and the Director of Maintenance.

Corridor walls must remain smoke tight/fire resistive to prevent smoke and heat from entering resident rooms. Smoke/heat will cause harm to the patients.

Based on observation it was determined the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On August 11, 2014 the surveyor, accompanied by the Director of Maintenance, observed the following corridor door would not tightly close when tested.

1. Lab Directors office door tested three of three times and will not positively latch.

During the exit conference on August 11, 2014, the above findings were again acknowledged by the Interim CEO and the Director of Maintenance.

In time of a fire failing to protect patients from heat and smoke could cause harm to the patients.

Based on observation it was determined the facility failed to fill penetrations in the smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of at least ½ hour." (1 Hour New) Chapter 8, Section 8.3.6. "Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:"
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
(a) It shall be made on either side of the smoke barrier.
(b) It shall be made by an approved device that is designed for the specific purpose.

Findings include:

On August 11, 2014, the surveyor, accompanied by the Director of Maintenance, observed unsealed penetrations in the smoke barrier/s, located at:

1. The general service hall to the Hospital, to include the three hour doors were wedged in the open position with impediments.

During the exit conference on August 11, 2014, the above findings were again acknowledged by the Interim CEO and the Director of Maintenance.

Failing to fill holes in smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility, which will cause harm to patients.

Based on observation it was determined the facility failed to maintain self closing doors in a smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than I hour. (1/2 hour for existing) Section 8.3.4.1, " Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

Findings include:

On August 11, 2014, the surveyor, accompanied by the Director of Maintenance, observed the astragal was removed from the corridor smoke/fire doors within the ER corridor. When closed there was a gap between the doors of approximately 1/4 inch.

During the exit conference on August 11, 2014, the above findings were again acknowledged by the Interim CEO and the Director of Maintenance.

This installation will allow smoke to contaminate smoke zones not directly effected by the fire, which will cause harm to patients.

Based on observation it was determined the facility did not maintain the integrity, smoke resistance, of doors in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.2.1 requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls and doors must be able to resist the passage of smoke. NFPA 80 "Fire Doors and Fire Windows" Chapter 2, Section 2-3.1.7 "The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. +/- 1/16 in for steel doors and shall not exceed 1/8 in. for wood doors.

Findings include:

On August 11, 2014, the surveyor, accompanied by the Director of Maintenance, observed the following hazardous area doors:

1. Next to infection control office, no door closing device.
2. Door to the kitchen with a closing device wedged open with an impediment.
3. Kitchen door to the corridor, no closing device.
4. Frozen section room contain flammables, door tested three of three times and will not positively latch.
5. OR janitors closet by the lab contains chemicals, no door closing device. (no sprinkler)
6. Respiratory therapy, one of two doors have no closing device.
7. Clean utility storage, door tested three of three times, will not positively latch.
8. Med Surge storage/electrical room, no door closing device.
9. CT storage room with combustibles, wedged open with an impediment.
10. ER soiled linen room, wedged open.
11. New ER med room with the pixies machine, door and door closing device removed.
12. Endoscopy door to the corridor, sprung open and will not close and positively latch.
13. OR electrical room, no door closing device and wedged open with an impediment.
14. OR storage room, door closing device disconnected.
15. IT, doors have no latching device.

During the exit conference on August 11, 2014, the above findings were again acknowledged by the Interim CEO and the Director of Maintenance.

Failing to prevent heat and smoke from spreading into the exit corridor will cause harm to patients.

Based on record review it was determined the facility failed to document the annual testing of battery back up emergency lighting.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.2.9.1, "Emergency lighting shall be provided in accordance with Section 7.9". Section 7.9.3 " Periodic Testing of Emergency Lighting Equipment" " A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction."

Findings include:

On August 11, 2014, the surveyor accompanied by the Director of Maintenance reviewed the monthly battery documentation. The ninty minute testing was not provided to the surveyor. annual testing were provided to the surveyor.

During the exit conference on August 11, 2014, the above findings were again acknowledged by the Interim CEO and the Director of Maintenance.

Failing to test and maintain emergency lighting units will cause harm to the patients.

Based on interview of staff members it was determined the facility does not follow the written Fire plan or train employees in life safety procedures and devices.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.7.1.2 Fire exit drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions."

Findings Include:

On August 11, 2014, the surveyor, accompanied by the Director of Maintenance, interviewed a staff employee of four years, and three employees in the lab. The employees do not know the fire procedures as written in the facilities Fire plan. During the Fire drills between the hours of 9 PM and 6 AM, the facility does not use a coded announcement and only does an oral fire drill.

During the exit conference on August 11, 2014, the above findings were again acknowledged by the Interim CEO and the Director of Maintenance.

Failure to train and drill the staff on fire procedures could result in harm to the patients.

Based on record review, and observation it was determined the facility did not inspect, test and maintain the automatic sprinkler system in accordance with the requirements of the Life Safety Code.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.5.1. "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing , and Maintenance of Water-Based Fire Protection Systems." NFPA 25, Water Based Extinguishment Systems, requires monthly, quarterly and annual testing of automatic sprinkler systems.

Section 9.7." Section 9.7.1.1 "Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, Chapter 3, Section 3-2.7.2, "Escutcheon Plates used with a recessed or flushed sprinkler shall be part of a listed sprinkler assembly."

Findings include:

On August 11, 2014, the surveyor, accompanied by the Director of Maintenance, reviewed the sprinkler quarterly and annual records which indicated the automatic sprinkler system quarterly inspector test flow times were not documented. The annual inspector test was documented.
The following escutcheon plates are missing:

1. Lab, one of six.
2. Lab break room, one of one.
3. Old Board room, one of three.

During the exit conference on August 11, 2014, the above findings were again acknowledged by the Interim CEO and the Director of Maintenance.

Failure to inspect, test, and maintain the sprinkler system could result in harm to the patients through the spread of smoke and fire.

Based on record review it was determined the facility failed to inspect and maintain the facilities fire dampers.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.2 Heating Ventilating and Air Conditioning Section 19.5.2.1 "Heating, ventilating, and air conditioning shall comply with the provisions of section 9.2 and shall be installed in accordance with the manufacture's specifications." Section 9.2.1 "Air Conditioning, Heating, Ventilating, Ductwork, and Related Equipment." "Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A," "Standard for Installation of Air Conditioning and Ventilating Systems...

NFPA 90A 1999 Edition Section 3-4.7 "Maintenance" "At least every four years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked and moving parts shall be lubricated as necessary."

Findings include:

On August 11, 2014, the surveyor, accompanied by the Director of Maintenance reviewed the Fire Protection and Life Safety records. The facility did not have documentation of fire damper inspection or maintenance. The Director of Maintenance stated the fire dampers were not inspected or maintained in the past four years.

During the exit conference on August 11, 2014, the above findings were again acknowledged by the Interim CEO and the Director of Maintenance.

Failing to inspect and maintain the facility fire dampers may cause harm to the patients.

Based on Record review it was determined the kitchen hood was not cleaned or inspected in accordance with NFPA 96.

NFPA 101 Life Safety Code, 2000 Edition, Chapter 19, Section 19.3.2.6, "Cooking Facilities." "Cooking facilities shall be protected in accordance with 9.2.3." Section 9.2.3, "Commercial Cooking Equipment" "Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.... Chapter 8, Section 8-3 "Cleaning" "Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person (s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1." Table 8-3.1, Exhaust System Inspection Schedule "Type or Volume of Cooking Frequency" "Systems serving moderate-volume cooking operations." Frequency is Semiannually"
Section 8-3.1.1 "Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified, and certified company or person (s) acceptable to the authority having jurisdiction in accordance with Section 8-3."
Section 8-3.1.2 "When a vent cleaning service is used, a certificate showing date of inspection or cleaning shall be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company. It shall also indicate areas not cleaned."

Findings Include:

On August 11, 2014, the surveyor accompanied by the Director of Maintenance reviewed the kitchen hood documentation. The last invoice was dated October 23, 2013. The facility was unable to provide documented evidence that the cooking hood and vents were inspected and cleaned in accordance with NFPA 96 for April 2014.

During the exit conference on August 11, 2014, the above findings were again acknowledged by the Interim CEO and the Director of Maintenance.

Failing to inspect and clean the kitchen hood and vents will allow a build-up of grease and provide fuel for a fire. A fire in the kitchen may cause harm to patients and staff.

Based on Observation it was determined the facility failed to separate empty and full medical gas cylinders, and keep the oxygen bottles free of combustible materials.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.2.4. "Medical gas storage and administration areas shall be protected in Accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99, Chapter 4, Section 4-3.5.2.2 (a) (2) "If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

Chapter 8, Section 8-3.1.11 "Storage Requirements" Section 8-3.1.11.2 "Storage of nonflammable gases less than 3000 cubic. feet.." (a) "Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. (c) "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by: (c) (2) A minimum distance of 5 ft. if the entire storage location is protected by an automatic sprinkler system..."

Findings include:

On August 11, 2014 the surveyor, accompanied by the Director of Maintenance observed the soiled utility room, ten E O2 bottles were not marked FULL/EMPTY, the bottles were next to an electrical outlet and combustibles, and the door would not positively latch.
The recovery/post op has one E O2 bottle stored by combustibles, and the OR storage room has one E O 2 bottle stored by electrical and combustibles.

During the exit conference on August 11, 2014, the above findings were again acknowledged by the Interim CEO and the Director of Maintenance.

In an emergency, patients could be harmed if an empty medical gas cylinder was mistakenly taken from the storage area.
Leaking oxygen could penetrate combustible materials and create an extreme fire hazard, which could cause harm to the patients. In an emergency, patients could be harmed if an empty medical gas cylinder was mistakenly taken from the storage area.

Based on record review and observation it was determined the facility failed to allow access to the electrical equipment/panel; failed to provide a guard on the light bulbs; failed to provide receptacle face plates; and failed to test and document the monthly testing of the Line Isolation Monitor tests/Isolated Electrical Panels.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1., Section 9.1.2 "Electrical wiring and equipment shall be in accordance with NFPA 70 National Electrical Code." NEC, 1999, ARTICLE 110, SECTION 110-26 Spaces About Electrical Equipment. "Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons." Table 110-26(a) Working Space Minimum of three (3) feet in all directions.

( NO STORAGE ALLOWED IN THE WORKING SPACE)

NFPA 70 National Electrical Code." NEC, 1999, Article 110, Section 110-27 (b) Prevent Physical Damage. " In locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage

" NEC, 1999, Article 410, Section 410-56 (e) Position of Receptacle Faces. "3. After installation, receptacle faces shall be flush with or project from faceplate of insulating material and shall project a minimum of 0.015 in. From metal faceplate. Faceplate shall be installed so as to completely cover the opening and seat against the mounting surface."

NFPA 101, Life Safety Code, 2000 Edition, Maintenance and Testing (See 4.6.12) "Maintenance and Testing "Section 4.6.12.1, "Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction."

"NFPA 99 1999 Edition, Health Care Facilities Section 3-3.3.4.2 The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following: (b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch (see 3-3.2.2.3(f)) 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."

Findings include:

On August 11, 2014, the surveyor, accompanied by the Director of Maintenance, observed storage in front of the electrical panel (s) located in Med Surg storage/electrical room, storage of cleaning carts in front of electrical panels.

The following electrical items were observed:

1. No documentation of OR one and two Isolated Electrical Panel testing.
2. Infection control office, no light cover.
3. Respiratory therapy, electrical room, two of two lights no covers.
4. Nursing suite office, microwave plugged into a power strip.
5. Med Surg storage closet, one light no cover.
6. Physicians lounge, refrigerator plugged into a power strip.
7. OR corridor, 110, face plate broken.
8. IT office, two refrigerators and one microwave plugged into a power strip.

During the exit conference on August 11, 2014, the above findings were again acknowledged by the Interim CEO and the Director of Maintenance.

Blocking of access to electrical panels or equipment may delay personnel from controlling an emergency situation. Patients will be harmed if a fire should start because of a delay.
Failure to keep light guards on the light could cause accidental damage or possibly a fire, which could cause harm to the patients.
Failing to repair broken receptacles and face plates may contribute to starting a fire by allowing the electrical wiring to short when an electrical appliance is plugged in or removed from the receptacle. A fire in the facility may cause harm to the patients.
Failing to test and maintain documentation on the Line Isolation Tests/Isolated Electrical Panels could cause harm to the patients in an emergency or power outage.