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Based on observation, it was determined the facility failed to maintain the special locking exit door located on the first floor called the SIM lab unit of the hospital.

NFPA 101 Life Safety Court, 2012, Chapter 19, Section, 19.2.2.2.4 "Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side." Exception No. 2 "Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path. Section 7.2.1.6.1 "Special Locking Arrangements" " (c) An irreversible process shall release the lock within 15 to 30 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbs nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only."

Findings include:

On August 30, 2017, the surveyor accompanied by the Maintenance Supervisor and Facilities Maintenance observed the SIM lab exit door had an alarm on the exit door. The exit door was tested manually by pushing the panic bar by the maintenance staff. The exit door would not open on the alarm. The exit door had no sign mounted next or adjacent to the exit door stating "Push until alarm sounds the door will open within 15 to 30 seconds." The door was tested a few times but would not open or sound on alarm within 15/30 seconds.

During the exit conference on August 30, 2017, the above findings were again acknowledged by Chief Operations officer, Facilities/Services Director, Maintenance Supervisor and Facilities Maintenance.

Failing to provide manual release of the exit doors will cause harm to patients and staff in an emergency

Based on record review with the Facilities /Services Director, it was determined the facility had no documentation of testing of the multiple battery backup emergency lights located throughout the hospital.

NFPA 101, Life Safety Code, 2012, 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" " Section 7.9.3.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows: (1) Functional Testing shall be conducted monthly with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds except as otherwise permitted by 7.9.3.1.1.(2) The Test interval shall be permitted to be extended beyond 30 days with the approval of authority having jurisdiction.(3) Functional testing shall be conducted annually for a minimum of 1/1/2 hours if the emergency lighting system is battery powered. (4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1 (1) and (3). (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction."

Findings include:

On August 29, 2017, the surveyor accompanied by the Facilities /Services Director reviewed the documentation of the hospital battery backup emergency lighting units. The facility had no documentation to indicate all the battery backup emergency lighting units located throughout the entire hospital in 2016 were tested for the monthly thirty second test to include January of 2017. The Annual 90 minute (1/1/2 hour) test was also missing for 2016. No documentation was provided during the survey or exit to indicate it had been completed.

During the exit conference on August 30, 2017 the above findings were again acknowledged by Chief Operations Officer, Facilities/Services Director, Maintenance Supervisor and Facilities Maintenance.

Failing to test and document all the battery backup emergency lighting units in the hospital could cause harm to the patients in an emergency power outage.

Based on observation, it was determined the the facility failed to assure that all parts of the facility, the E-4 and E-5 electrical rooms were provided sprinkler system coverage.

NFPA 101 Life Safety Code, 2012, 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." ." Chapter 9, 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 Section 8.15.10 Electrical equipment Section 8.15.10.1 "Unless the requirements of 8.15.10.3 are met, sprinkler protection shall be required in electrical equipment rooms."

Section 8.15.10.3 "Sprinklers shall not be required in electrical equipment rooms where all of the following conditions are met:

1. The room is dedicated to electrical equipment only.
2. Only dry pipe electrical equipment is used
3. Equipment is installed in a 2 hour fire rated enclosure including protection for penetrations.
4. No combustibles storage is permitted to be stored in the room."

Findings include:

On August 30, 2017, the surveyor, accompanied by the Maintenance Supervisor and Facilities Maintenance staff observed the ceiling areas of the E-4 and E-5 electrical rooms. The Maintenance Supervisor, Facilities Maintenance staff and surveyor could not see at the time of the survey if sprinklers were installed in the electrical rooms. There was no documentation provided to the surveyor on site that the electrical rooms were of two hour rated construction.

During the exit conference on August 30, 2017, the above findings were again acknowledged by Chief Operations officer, Facilities/Services Director, Maintenance Supervisor and Facilities Maintenance.

Failing to provide sprinkler coverage in storage areas by blocking the sprinkler heads could result in harm to the patients in time of a fire.

Based on record review and interview with the Facilities /Services Director, it was determined the facility failed to test the electric fire pump Monthly for 10 minutes for March, April, September and November of 2016, in accordance with the National Fire Protection Association (NFPA 25) Water Based Fire Protection Systems NFPA 2011 Edition.

NFPA 101 Life Safety Code, 2012, 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, 1998 Edition Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems." NFPA 25, Chapter 5, Section 5-3.2.1 "A weekly test of electric motor driven pump assemblies shall be conducted without flowing water. This test shall be conducted by starting the pump automatically. The pump shall run a minimum of 10 minutes."

NFPA 101 Life Safety Code, 2012, 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, 1998 Edition Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems." NFPA 25, 2011 Edition Water Based Fire Protection Systems Handbook. Chapter 8, Section 8.3.1.2 " Electric motor driven fire pumps shall be operated monthly." Section 8.3.2.3, "The electric pump shall run a minimum of 10 minutes."

Findings include:

On August 29, 2017, the surveyor, accompanied by the Facilities /Services Director reviewed the fire pump test records. The facility failed to test the electric fire pump monthly for 10 minutes for March, April, September and November of 2016. No documentation was provided during the survey or exit indicating it was completed in accordance with the National Fire Protection Association (NFPA 25) Water Based Fire Protection Systems NFPA 2011 Edition.

During the exit conference on August 30, 2017, the above findings were again acknowledged by Chief Operations Officer, Facilities/Services Director, Maintenance Supervisor and Facilities Maintenance.

Failure to conduct the fire pump tests at the proper operating time could allow the fire pump to fail during a fire emergency. This could cause harm to the patients in time of a fire emergency.

Based on observation, it was determined the facility failed to maintain the corridor doors to be self or automatic closing due to door stops or door wedges observed under the corridor doors holding the doors in an open position.

NFPA 101 Life Safety Code, 2012, Chapter 19 Existing, Section 19.3.2 1 "Doors to hazardous areas shall be self closing or automatic closing in accordance with 19.2.2.4. Section 19.2.2.4 Any door required to be self closing shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. Section 7.2.1.8.2 The required manual fire alarm system and the systems required by 7.2.1.8.2. shall be arranged to initiate the closing action of all such doors throughout the entire facility."

Findings include:

On August 29, 2017, the surveyor accompanied by the Maintenance Supervisor and Facilities Maintenance observed the following self-closing or automatic closing doors had door stops or door wedges under the corridor doors to hold the corridor doors in an open position. The corridor doors were on self or automatic closing devices.

1. 3rd floor NCC work Room office
2. 1st floor ICU rooms five and eight.

During the exit conference on August 30, 2017, the above findings were again acknowledged by Chief Operations Officer, Facilities/Services Director, Maintenance Supervisor and Facilities Maintenance.

Failing to keep self-closing or automatic closing doors closed by allowing door chalks or door wedges will allow smoke and heat to spread during a fire throughout the facility, which could cause harm to the patients.

Based on observation, it was determined the facility failed to fill penetrations in two of 21 smoke barriers in the entire hospital.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire resistance rating of at least ½ hour." Chapter 8, Section 8.5.6.2 "Penetrations for cables cable trays, conduits, pipes, tubes, vents wires and similar items to accommodate electrical, plumbing and communications systems that pass through a wall, floor or /ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof /ceiling of a smoke barrier assembly shall be protected by a system or material capable of restricting the transfer of smoke."

Findings include:

On August 29, 2017, the surveyor, accompanied by the Maintenance Supervisor and Facilities Maintenance
observed unsealed penetrations in the smoke barriers in the following locations:

1. Smoke barrier # 13 on the 2nd floor.
2. Smoke barrier #11 1st floor by room 119

During the exit conference on August 30, 2017, the above findings were again acknowledged by Chief Operations Officer, Facilities/Services Director, Maintenance Supervisor and Facilities Maintenance.

Failing seal the penetrations, holes and openings in the smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility, which could cause harm to the patients in times of a fire.

Based on review of NFPA Life Safety Code and observation, it was determined the facility:

1.) failed to provide a protective guards on two light ballasts located in the SIM lab unit of the hospital.

2. did not allow access to electrical equipment panels in three locations in the hospital.

Findings include:

1. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1." Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70, 2011 Edition, 'National Electrical Code.' " NEC, 2011, 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...."

On August 30, 2017, the surveyor, accompanied by the Maintenance Supervisor and Facilities Maintenance observed exposed light bulbs in two light ballasts in the SIM lab unit. There was no protective guards on the exposed light bulbs.

During the exit conference on August 30, 2017, the above findings were again acknowledged by Chief Operations Officer, Facilities/Services Director, Maintenance Supervisor and Facilities Maintenance.

Failure to keep light guards on exposed light bulbs could cause accidental damage or possibly a fire, which could cause harm to the patients.

2. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.5.1.1 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, 2011 Edition, "National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction." NEC, 2011 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)"

On August 30, 2017, the surveyor accompanied by the Maintenance Supervisor and Facilities Maintenance observed electrical panels were blocked within three feet with miscellaneous items located in the following locations in the hospital.

1. First floor Med surge nurses station blocked with vital car machines.
2. Decon clean side blocked with ABC fire extinguishers, battery charger and IV pole.
3. South machine room blocked by construction drop boxes, panel EQ1HA.

During the exit conference on August 30, 2017, the above findings were again acknowledged by Chief Operations Officer, Facilities/Services Director, Maintenance Supervisor and Facilities Maintenance.

Blocking of access to electrical panels or equipment may delay personnel from controlling an emergency situation. Patients could be harmed if a fire should start because of a delay.

Based on observation and interview with staff, it was determined the facility failed to provide a written plan for the protection of all patients in time of a fire or emergency at the nurses stations in the tower floors. Theses were the first, third and fourth floors.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.7.1.1 "The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of a fire, for their evacuation to areas of refuge, and from the evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator's position or at the security center."

Findings include:

On August 29, 2017, the surveyor accompanied by the Maintenance Supervisor and Facilities Maintenance,
asked the nursing staff for the written fire/emergency policy manual at the nurse's stations. The written fire and emergency policy manual was not found or seen by the staff during the survey on the first, third and fourth floors.

During the exit conference on August 30, 2017, the above findings were again acknowledged by Chief Operations Officer, Facilities/Services Director, Maintenance Supervisor and Facilities Maintenance.

In time of an emergency, an emergency policy manual must be readily available for the staff. Patients could be harmed if the Staff is not trained or is unable to locate the emergency evacuation policy manual.

Based on observation, it was determined the facility allowed the use of extension cords and multi-outlet adapters to be used for appliances, and were not plugged directly into the wall receptacle outlets for all the appliances observed during the survey.

NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2 , "All Patient Care Areas," Sections 6.3.2.2..6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters."

Findings include:

On August 29, and August 30, 2017 the surveyor, accompanied by the Maintenance Supervisor and Facilities Maintenance observed the following:

1. Coding office, extension cord daisy chained together for office equipment.
2. Centralized scheduling extension cord connected into computer.
3. Gift shop managers office extension cord used for appliances.
4. Outpatient Registration extension cord in use for the computer
5. Med surge directors office refrigerator and printer plugged into a power strip

During the exit conference on August 30, 2017, the above findings were again acknowledged by Chief Operations Officer, Facilities/Services Director, Maintenance Supervisor and Facilities Maintenance.

The use of extension cords and multiple outlet adapters could create an overload of the electrical system, and could cause a fire or an electrical hazard. A fire could cause harm to the patients.

Based on observation, the facility failed to require nitrogen gas H tank cylinders and carbon dioxide cylinders be secured in a stand or cart in the main kitchen or the medical gas bottle storage room.

NFPA 101 Life Safety Code, 2012, 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 2012 Edition Chapter 11 Section 11.6.2.3 (11) "Free standing cylinders shall be properly chained or supported in a proper cylinder stand or cart."

Findings include:

On August 30, 2017, the surveyor accompanied by the Maintenance Supervisor and Facilities Maintenance observed nitrogen gas H tank cylinders and carbon dioxide cylinders in a stand or cart in the main kitchen, and the medical gas bottle storage room not secured in a rack or stand. Both locations observed had chains to secure the nitrogen and carbon dioxide cylinders, although the chains were not being used to secure the cylinders.

During the exit conference on August 30, 2017, the above findings were again acknowledged by Chief Operations Officer, Facilities/Services Director, Maintenance Supervisor and Facilities Maintenance.

Failing to secure compressed medical gas cylinders could cause harm to the patients and staff.