HospitalInspections.org

Based on observation and interview, the facility failed to provide the type of building construction as required.
Findings include:
On May 10, 2013 the building construction was inspected:
a. The exterior canopies are not of an allowed construction type, they do not have sprinkler coverage nor is it separated by a two-hour or greater vertically-aligned fire barrier wall.
b. The closet outside the CNO office, the entryway to the radiology dark room and the basement data room did not have fire sprinkler coverage; these areas were identified as non-compliant on the facilities prior annual fire sprinkler reports dated February 23, 2011 and June 28, 2012.
c. The OR suite scope room bathroom and storage closet, the CEO office closet, the CFO office closet, the elevator equipment room and the #22 electrical room did not have fire sprinkler protection.
d. The facility staff was unable to obtain access to the elevator pit during the survey to verify fire sprinkler coverage.
The staff acknowledged the findings when the deficiencies were identified.
Failure to provide the type of building construction as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 18 patients, 55 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 Section 19.1.6, 8.2.1.

Based on observation and interview, the facility failed to provide interior finish for corridors and exitways as required.
Findings include:
On May 9, 2013 the interior finish was inspected. A large wooden framing was built around a TV in the corridor by the radiology check-in; documentation was not available to show the flame spread rating of the wood and finish.
The staff acknowledged the findings when the deficiency was identified.
Failure to provide interior finish for corridors and exitways as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 18 patients, 55 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 Section 19.3.3.

Based on observation and interview, the facility failed to provide doors protecting corridor openings as required.
Findings include:
On May 10, 2013 the corridor doors were inspected:
a. The corridor door to the CT suite, the double corridor doors to the trauma room, the corridor door to the Ortho room and the Dutch type door to patient room 117 failed to positively latch into the doorframe when tested by facility staff.
b. The corridor door to the ECU Dining room, two of the kitchen corridor doors and the corridor door to the laboratory had wedges, kickstand doorstops or furniture propping the door in the open position.
c. The corridor door to patient rooms 102 and 112 had a gap exceeding 1/8-inch between the door and the doorframe; this office has accepted a gap of 1/8-inch or less to be considered smoke resistive for corridor door openings.
The staff acknowledged the findings when the deficiencies were identified.
Failure to provide doors protecting corridor openings as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 18 patients, 55 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 Section 19.3.6.3, 19.3.6.3.2, 19.3.6.3.3.

Based on observation and interview, the facility failed to provide enclosure of vertical openings as required.
Findings include:
On May 10, 2013 the vertical openings were inspected:
a. One of the two trash chutes had a container at the bottom that impeded the path of swing for the fire rated door preventing it from closing.
b. The first floor main stairwell door did not latch into the doorframe when tested by facility staff.
The staff acknowledged the findings when the deficiencies were identified.
Failure to provide enclosure of vertical openings as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 18 patients, 55 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 Section 19.3.1.1.

Based on observation and interview, the facility failed to provide automatic closing hold open devices as required.
Findings include:
On May 9, 2013 the automatic closing hold open devices were inspected. The automatic closing corridor door to the boiler room was held open by a magnetic device that did not have proper spot detectors installed on each side of the door.
The staff acknowledged the findings when the deficiency was identified.
Failure to provide automatic closing hold open devices as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 18 patients, 55 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 Section 19.2.2.2.6; 2002 NFPA 72 Section 5.14.6.

Based on observation and interview, the facility failed to provide smoke barriers as required.
Findings include:
On May 10, 2013 the smoke barrier was inspected. The ceiling above the smoke barrier was not maintained and the smoke barrier was not continuous from an outside wall to an outside wall and from a floor to a floor. The facility has twenty patient rooms capable of double occupancy, is licensed for twenty five beds and has two beds in the OR suite and four beds were observed in the ER suite; this thirty one patient bed capacity requires the first floor to have compliant smoke compartments.
The staff acknowledged the finding when the deficiency was identified.
Failure to provide smoke barriers as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 18 patients, 55 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 Section 19.3.7, 8.3.

Based on observation and interview, the facility failed to provide hazardous areas as required
Findings include:
On May 10, 2013 the hazardous areas were inspected:
a. The corridor doors to the second floor medical records office, the basement dry storage room, the billing office the laundry room, the home health/central storage room, the ice room/storage room, the basement central storage room, the basement clean linen room, the maintenance shop and the PT gym had a wedge, kickstand door stop, bucket or magnetic hold open device holding the door in the open position.
b. The corridor doors to the basement housekeeping utility room, clean linen storage by the pharmacy and the third floor mechanical room did not have self closing devices on the doors.
c. The interior walls of the bio hazard room by patient room 120 were not smoke resistive and the basement telephone/storage room walls, ceiling and corridor door was not smoke resistive.
d. The corridor door to the soiled utility room by patient room 116 did not positively latch into the doorframe when tested by facility staff.
e. The movable shelves of patient records by the radiology staff area and the copy/workstation behind the main reception desk were not separated from the corridor; these two areas exceeded 50 square feet in area and had excessive loading of combustible materials which will consider the areas hazardous areas and shall be separated from the corridor.
The staff acknowledged the findings when the deficiencies were identified.
Failure to provide hazardous areas as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 18 patients, 55 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 Section 19.3.2.1.

Based on observation and interview, the facility failed to provide not less than two remotely located exits as required.
Findings include:
On May 10, 2013 the remoteness of exits was inspected. Exits from the basement corridor were not maintained; based on conversations with facility staff it was determined the PT Gym in the basement was used by inpatients of the hospital. Using rough measurements of plans from the facility the overall diagonal distance of the basement measured 254-feet. The minimum distance between the exits should be 85-feet; the measured distance between the basement stairway by the PT Gym and the only other compliant exit from the basement corridor was 64-feet. The " exit " through the PT Gym is not compliant because the exit cannot pass through a treatment area and the corridor to the PT Gym only measured 40-inches in clear width. The " exit " towards the maintenance shop/boiler area is not separated from the hazardous areas is not compliant for an exit.
The staff acknowledged the findings when the deficiency was identified.
Failure to provide not less than two remotely located exits as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 18 patients, 55 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 Section 19.2.4.1.

Based on observation and interview, the facility failed to provide travel distance to exits as required.
Findings include:
On May 10, 2013 the travel distance to exits was inspected. The travel distance within the OR suite from the OR recovery room to an exit access corridor door was 64-feet; this travel distance exceeds the maximum 50-feet allowed for travel distance for two intervening rooms.
The staff acknowledged the findings when the deficiency was identified.
Failure to provide travel distance to exits as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 4 patients, 4 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 Section 19.2.6.2.1.

Based on observation and interview, the facility failed to provide readily accessible exit access as required.
Findings include:
On May 10, 2013 the exit access was inspected. Exit access doors were not readily accessible, this occurred at the following doors:
a. The door to the walk-in freezer had a slide bolt hasp which was not operable from the egress side of the door.
b. The egress door from the OR suite locker room had a thumb turn latch which was mounted above the maximum allowed height for a releasing device.
c. The second floor medical records office had two releasing actions from the egress side of the corridor door.
The staff acknowledged the findings when the deficiencies were identified.
Failure to provide readily accessible exit access as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 1 patient, 20 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 Section 19.2.1.

Based on observation and interview the facility failed to provide emergency electrical systems for illumination as required.
Findings include:
a. On May 10, 2013 the available documentation for emergency electrical systems was reviewed. The battery powered emergency lighting was not being tested for the required duration at the required intervals. Documentation provided showed one check mark each month for battery powered emergency light testing; upon interviewing facility maintenance staff there was no discussion of 30-second monthly testing or 90-minute annual testing of each fixture only that when they tested the fixtures they would press the test button for about ten seconds and if they all worked they placed a check mark on the form.
b. On May 10, 2013 the emergency electrical systems was inspected. The panel schedules indicating which breakers controlled the exterior emergency egress lighting were not able to be located. Upon interviewing facility maintenance staff, requesting which breakers controlled emergency exterior egress lighting, no breakers or panel schedules were identified. Based on this it could not be determined if exterior egress lighting had an emergency electrical systems illumination power supply and the exterior fixtures did not have battery packs.
The staff acknowledged the finding when the deficiencies were identified.
Failure to provide emergency electrical systems for illumination as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 18 patients, 55 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 Section 19.2.9.1.

Based on observation and interview, the facility failed to provide exit and directional signs as required.
Findings include:
On May 10, 2013 the exit directional signage was inspected:
a. The exit sign above the double doors from the ED to the main lobby had a left chevron exposed but path of travel to an exit was straight through the doors.
b. The basement corridor towards the PT Gym there were no exit signs displayed to indicate travel to an exit.
c. The door to the basement stairway had no signage to show this was the only exit from that side of the basement.
The staff acknowledged the findings when the deficiencies were identified.
Failure to provide exit and directional signs as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 4 patients, 12 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 Section 19.1.2.

Based on observation and interview, the facility failed to provide written plans for evacuation in the event of an emergency as required.
Findings include:
On May 10, 2013 the available documentation for plan for evacuation was reviewed. The four page fire safety plan was last revised February of 2006; this policy was not readily available and the four pages were found while searching multiple binders. Upon interviewing staff about the contents of the policy to include the Fire Squad described on page three there was mixed response but staff did not convey they were periodically instructed and kept informed with respect to their duties under the plan. This policy shall include all required components for a Health Care Occupancy.
The staff acknowledged the findings when the deficiencies were identified.
Failure to provide written plans for evacuation in the event of an emergency as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 18 patients, 55 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 Section 19.7.1.1.

Based on observation and interview, the facility failed to provide fire drills as required
Findings include:
On May 10, 2013 the available documentation for fire drills was reviewed. Documentation was not provided to show any fire drills had been conducted in the past twelve months. NFPA requires fire drills be conducted quarterly on each shift and the facility ' s fire drill policy dated 02/2006 indicates fire drilling at least one time every month on both day and night shift, but no records were available to show any fire drills within the past twelve months.
The staff acknowledged the finding when the deficiency was identified.
Failure to provide fire drills as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 18 patients, 55 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 section 19.7.1.2

Based on observation and interview, the facility failed to provide the fire alarm system as required.
Findings include:
a. On May 10, 2013 the fire alarm system was inspected:
1. The minimum audible and visual notification was not provided in staff sleeping rooms. During fire alarm testing, the five sleeping rooms had sound levels well below 75 dBA at the pillow level:
? The OR sleeping room measured 65 dBA.
? The ED sleeping room measured 61 dBA.
? The EMT staff sleeping room measured 62 dBA.
? The two nurse sleep area rooms each measured 56 dBA.
2. The wall mounted audible and visual notification appliance in the maintenance corridor was listed for ceiling use; use of this appliance on the wall is not in accordance with the manufacturer ' s listing.
3. The OR room did not have a fire alarm appliance to provide automatic occupant notification.
4. The location of the circuit breaker for the fire alarm control unit was not marked within the control unit.
b. On May 10, 2013 the available documentation for the fire alarm system was reviewed. Smoke dampers were not being tested annually. A smoke damper was observed in the open position above the corridor by X-ray two.
The staff acknowledged the finding when the deficiencies were identified.
Failure to provide the fire alarm system as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 18 patients, 55 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 Section 19.3.4.1, 9.6.1.4; 1999 NFPA 72.

Based on observation and interview, the facility failed to provide a complete fire sprinkler system throughout as required.
Findings include:
On May 9 and 10, 2013 the coverage and spacing of fire sprinkler heads were inspected.
a. The Bio hazard room by patient room 120 only had partial fire sprinkler coverage due to the irregular shape of the room.
b. An alcove at the Radiology Desk, in the corridor by patient room 119, in the OR suite recovery room and in the central sterilizer room was not protected by the fire sprinkler system.
c. The Ortho room in the ER had one sidewall sprinkler head which was spaced over 11-feet from the sidewall.
d. The soiled utility room by patient room 116 had a sidewall head spaced 15.5-inches from the ceiling.
e. The third floor stairwell had a sidewall sprinkler head spaced 3-inches from the ceiling.
f. Multiple sidewall sprinkler heads in the corridor by ECU dining were closer than 4-inches from the ceiling.
g. The sidewall sprinkler head at the bottom of the stairwell was not installed under the first landing above the bottom of the shaft.
h. An ordinary temperature pendant sprinkler head was installed within 12-inches of a ceiling diffuser by radiology check in.
Sprinkler heads shall be spaced in accordance with their listing.
The staff acknowledged the findings when the deficiencies were identified.
Failure to provide a complete fire sprinkler system throughout as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 18 patients, 55 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 Section 19.3.5.

Based on observation and interview, the facility failed to provide supervised sprinkler system control valves as required.
Findings include:
On May 10, 2013 the fire sprinkler control valves were inspected. The control valve in the lobby of the nurses sleep area did not have electronic supervision of the valve. The unsupervised control valve was written as a deficiency on the February 23, 2011 annual fire sprinkler report.
The staff acknowledged the findings when the deficiency was identified.
Failure to provide supervised sprinkler system control valves as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 18 patients, 55 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 Section 19.3.5.1, 9.7.2.1.

Based on observation and interview, the facility failed to provide the sprinkler system as required.
Findings include:
a. On May 10, 2013 the fire sprinkler system was inspected.
1. The sprinkler head in the closet of patient room 115 had fallen below the drywall ceiling.
2. The cubical curtain in patient rooms 103, 109, 111, 113, 114, 115, 116, 119, 120, & 121was bunched up obstructing the nearby sidewall sprinkler head.
3. The fire sprinkler head was obstructed by a light fixture in the nursery converted to clean linen storage room.
4. The radiology storage closet and the kitchen storage room (#53) had storage too close to the pendant fire sprinkler.
5. The hanger on the pipe for a pendant sprinkler head in the second floor mechanical room did not have provisions to prevent upward movement of the pipe.
6. There were drop ceiling tiles missing in the nurse sleeping area lobby and the basement data room; missing ceiling tiles delaying fire sprinkler response listed to be installed below a smooth flat horizontal ceiling.
7. There were sprinkler heads closer than 6-feet from each other in the corridor by radiology check-in, in the CT room and in the x-ray room.
8. There was a loaded and damaged pendant fire sprinkler head in the corridor by the front desk lobby area.
9. The OR suite scope room shower was being used for storage and did not have fire sprinkler coverage.
10. There were quick response and standard response pendant sprinkler heads in the same sprinkler compartment in the corridor by the radiology check-in desk.
11. The escutcheon for the fire sprinkler head was missing in the basement phone/storage room.
b. On May 10, 2013 the available documentation for the fire sprinkler system was reviewed.
1. Documentation was not provided to show the 5-year hydrostatic testing of the standpipe had been completed; this was marked as deficient on the June 28, 2012 and December 6, 2012 fire sprinkler report.
2. Documentation was not provided to show the 5-year internal inspection of the fire sprinkler piping had been completed; this was marked as deficient on the December 6, 2012 fire sprinkler report.
The staff acknowledged the findings when the deficiencies were identified.
Failure to provide the sprinkler system as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 18 patients, 55 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 Section 19.3.5.1, 9.7.5, 1998 NFPA 25.

Based on observation and interview, the facility failed to provide fire extinguishers as required.
Findings include:
On May 10, 2013 the fire extinguishers were inspected. The fire extinguisher in the elevator equipment room was sitting on the floor.
The staff acknowledged the findings when the deficiency was identified.
Failure to provide fire extinguishers as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 2 patients, 4 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 Section 19.3.5.6.

Based on observation and interview, the facility failed to provide smoking regulations as required.
Findings include:
On May 10, 2013 the available documentation for the smoking regulations was reviewed. No documentation was provided to show the facility had smoking regulations.
The staff acknowledged the findings when the deficiency was identified.
Failure to provide smoking regulations as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 18 patients, 55 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 Section 19.7.4.

Based on observation and interview, the facility failed to provide building service equipment as required.
Findings include:
a. On May 10, 2013 the available documentation for the maintenance of the fusible link fire dampers was reviewed. No documentation was provided to show six-year maintenance of the fusible link fire dampers.
b. On May 10, 2013 the facility ' s hydronic heating system was discussed with facility maintenance staff, after there were many portable heaters found throughout the facility. Maintenance staff indicated the majority of the hydronic heating system had been shut down due the age and overall decay of the system. Based on this the facility does not appear to have a permanent and reliable heating system.
Failure to provide building service equipment as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 18 patients, 55 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 Section 19.5.2.1, 9.2, 9.2.1; 1999 NFPA 90A Section 3-4.7.

Based on observation and interview, the facility failed to provide commercial cooking equipment as required.
Findings include:
On May 10, 2013 the commercial kitchen hood system was inspected:
a. The rooftop exhaust fan neither discharged upwards nor 40-inches above the rooftop.
b. The construction of the exhaust fan housing did not appear to be carbon steel or stainless steel.
c. The appliances under the kitchen hood were not under the hood by 6-inches.
d. The kitchen hood and ductwork were loaded with grease or other foreign material; it was not cleaned to bare metal.
e. The construction of the kitchen hood did not appear to be stainless steel or carbon steel.
f. Access panels for the kitchen hood ductwork were not located during the survey.
The staff acknowledged the findings when the deficiencies were identified.
Failure to provide commercial cooking equipment as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 18 patients, 55 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 Section 19.3.2.6, 9.3.2; NFPA 96.

Based on observation and interview, the facility failed to prohibit portable space heaters as required.
Findings include:
On May 10, 2013 the portable heaters were inspected:
a. Portable heaters were in patient rooms 114, 119 and 121.
b. Portable heaters were in the maintenance shop, the basement PT Gym, the business and billing office; no documentation was provided to show these portable heaters had heating elements which do not exceed 212-degress Fahrenheit.
The staff acknowledged the findings when the deficiencies were identified.
Failure to prohibit portable space heaters as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 18 patients, 55 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 Section 19.1.2.

Based on observation and interview, the facility failed to provide the means of egress free of all obstructions or impediments as required.
Findings include:
On May 9 and May10, 2013 the corridors were inspected:
a. Wheelchairs stored in a corridor alcove obstructed egress from the OR suite locker room.
b. The main patient corridors were obstructed by a patient bed, food cart, recliner, housekeeping cart, nourishment cart, a floor fan and a flat 2 ' x4 ' rolling cart with floor buffer machine; these item ' s locations were observed on May 9, 2013 around 1202 and again in the same locations May 9, 2013 around 1254.
c. A wheel chair stored in the ER vestibule blocked the breakaway feature of horizontal sliding door.
The staff acknowledged the findings when the deficiencies were identified.
Failure to provide the means of egress free of all obstructions or impediments as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 18 patients, 55 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 Section 7.1.10.

Based on observation and interview, the facility failed to prohibit non-flame-retardant decorations as required.
Findings include:
On May 10, 2013 the corridor decorations were inspected:
a. Combustible decorations were on or around the door to patient rooms 111, 112, 113, 114, 115, 116, 118 & 119.
b. Combustible decorations were in the first floor corridor and the basement corridor; to include papers on cork bulletin boards.
Documentation was not provided to show the decorations were flame-retardant.
The staff acknowledged the findings when the deficiencies were identified.
Failure to prohibit non-flame-retardant decorations as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 18 patients, 55 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 Section 19.7.5.4.

Based on observation and interview, the facility failed to provide loose hanging films and fabrics as required.
Findings include:
On May 10, 2013 the loose hanging fabrics/films were inspected. The loose hanging fabric in the ER break room, the OR suite scope room, the OR suite locker room, the head nurses office and the loose hanging film in the kitchen by walk-in freezer and in main floor business office had no tags to show flame spread of the fabric/film; documentation was not provided to show flame-retardant properties.
The staff acknowledged the findings when the deficiencies were identified.
Failure to provide loose hanging films and fabrics as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 18 patients, 55 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 Section 19.7.5.

Based on observation and interview, the facility failed to prohibit large capacity mobile trash/linen containers as required.
Findings include:
On May 9, 2013 the large capacity mobile trash/linen containers were inspected:
a. A trash can with a capacity greater than 32-gallons was in the corridor doorway to the dishwasher section of the kitchen; this trashcan prohibited the corridor door form closing.
b. An unattended mobile trash container greater than 32-gallons was located in the first floor corridor; this container was observed 1252 and again in the same spot at 1347.
The staff acknowledged the findings when the deficiencies were identified.
Failure to prohibit large capacity mobile trash/linen containers as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 18 patients, 55 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 Section 19.7.5.5.

Based on observation and interview, the facility failed to provide medical gas administration and storage as required.
Findings include:
On May 10, 2013 the medical gas storage was inspected. There was an unsecured E tank of O2 in patient room 109.
The staff acknowledged the findings when the deficiencies were identified.
Failure to provide medical gas administration and storage locations as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 6 patients, 12 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 Section 19.3.2.4; 1999 NFPA 99 Section 4-3.5.2.1(b)(27).

Based on observation and interview, the facility failed to provide piped medical gas systems as required.
Findings include:
On May 10, 2013 the piped medical gas system was inspected:
a. The area alarm panels for the OR suite were not at a nurse ' s station or a location that appeared to provide responsible surveillance; the panels were just in the corridor of the OR suite.
b. A threaded joint in the O2 manifold room had a galvanized plug in the female adaptor.
c. The light switch in the O2 manifold room was less than 5-feet above the floor.
d. A low voltage power line was suspended over the bulk O2 tank.
The staff acknowledged the findings when the deficiencies were identified.
Failure to provide piped medical gas systems as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 18 patients, 55 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 Section 19.3.2.4; 1999 NFPA 99 Section 4-3.1.2.2(c)(2), 4-3.1.2.8(a)(1), 4-3.1.1.2(a)(4); 1996 NFPA 50 Section 2-1.1.

Based on observation and interview, the facility failed to provide the anesthetizing location(s) as required.
Findings include:
a. On May 10, 2013 the OR anesthetizing location was inspected. A smoke control feature for the OR was not able to be located or tested.
b. On May 10, 2013 the available documentation for OR humidity was reviewed. No documentation was provided to show humidity levels were being maintained at or above 35% at a minimum.
The staff acknowledged the findings when the deficiencies were identified.
Failure to provide the anesthetizing location(s) as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 4 patients, 8 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 Section 19.3.2.3; 1999 NFPA 99 Section 5-4.1.3, 5-4.1.1.

Based on observation and interview, the facility failed to provide construction materials as required.
Findings include:
On May 10, 2013 interior walls and partitions were inspected. Interior walls and partitions were of wood stud construction in the maintenance corridor, the respiratory therapy room and the basement central storage room.
The staff acknowledged the findings when the deficiencies were identified.
Failure to provide construction materials as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 18 patients, 55 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 Section 19.1.6.3.

Based on observation and interview, the facility failed to provide the essential electrical system as required.
Findings include:
On May 10, 2013 the essential electrical system was inspected:
a. The essential electrical system transfer switches were in the same room as the normal electrical service equipment was installed.
b. A remote manual stop station was not able to be located in the area of the exterior generator.
c. There were only two transfer switches for the three branches of the essential electrical system.
The staff acknowledged the findings when the deficiencies were identified.
Failure to provide the essential electrical system as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 18 patients, 55 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 Section 19.5.1, 9.1.3; 1999 NFPA 110 Section 5-2.2, 3-5.5.6; 1999 NPFA 99 Section 3-4.2.2.1.

a. Based on observation and interview, the facility failed to provide building service equipment as required.
Findings include:
On May 10, 2013 the building service equipment was inspected:
1. The exhaust ducts for the two Type II natural gas clothes dryers had screws holding the venting together and the exhaust ducts were not sealed properly.
2. There was not adequate make up air provided for the two Type II clothes dryers in the laundry room; the minimum size of the required free make up air source shall be one square inch of free air per 1000 Btu/hr plus any other fans or equipment in the area; one dryer was 142,560 Btu and the second was 180,000 Btu.
3. There were materials not necessary for the maintenance or operation of the elevator stored in the elevator machine room.
The staff acknowledged the findings when the deficiencies were identified.
Failure to provide building service equipment as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 1 patient, 6 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 Section 19.5.1, 19.5.3, 9.1.1, 9.4.2.2; 1999 NFPA 54 Section 6.4.3(b), 6.4.5(a), 6.4.4(b); 1993 ASME/ANSI A17.3 Section 8.6.4.8.2.
b. Based on observation and interview, the facility failed to prohibit dead-end corridors as required.
Findings include:
On May 10, 2013 dead-end corridors were inspected. The corridor towards the maintenance shop/boiler room extended 109-feet to a doorway that appeared to be a prior exit access vestibule, based on review of plans available at the facility; the vestibule is no longer separated from the boiler room, medical gas equipment and combustible storage are now also in the vestibule. The doorway had an illuminated exit sign directing egress through the doorway.
The staff acknowledged the findings when the deficiencies were identified.
Failure to prohibit dead-end corridors as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 1 patient, 12 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 Section 19.2.5.10.

Based on observation and interview, the facility failed to provide laboratory safety education as required.
Findings include:
On May 9, 2013 the available documentation for laboratory safety education was reviewed. No documentation was provided to show continuing safety education had been provided monthly in the past twelve months or that procedures had been annually reviewed.
The staff acknowledged the findings when the deficiencies were identified.
Failure to provide laboratory safety education as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 1 patient, 6 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 Section 19.3.2.2; 1999 NFPA 99 Section 10-2.1.4.2.

Based on observation and interview, the facility failed to provide procedures for laboratory emergencies as required.
Findings include:
On May 9, 2013 the available documentation for procedures for laboratory emergencies was reviewed:
a. No documentation was provided to show facility specific procedures for fire alarm activation, evacuation, equipment shutdown, provisions for control of emergencies that could occur in the laboratory including specific detailed plans for control operations by an emergency control group within the organization or a public fire department, chemical spills or for extinguishing clothing fires.
b. No documentation was provided to show laboratory specific fire exit drills were conducted at least quarterly in the past twelve months.
The staff acknowledged the findings when the deficiencies were identified.
Failure to provide procedures for laboratory emergencies as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 1 patient, 6 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 Section 19.3.2.2; 1999 NFPA 99 Section 10-2.1.3, 10-2.1.4.3.

Based on observation and interview, the facility failed to provide emergency electrical systems as required.
Findings include:
On May 9, 2013 the available documentation for emergency electrical systems was reviewed. Documentation was not provided to show:
a. The generator ran under load at 30% or greater of the rating plate at least monthly.
b. An annual load bank was conducted at the required minimum loads for the required minimum timeframes.
c. Main and feed circuit breakers between the emergency power supply and the transfer switch load terminals had been exercised every six-months, twelve-months or 24-months as applicable.
d. Transfer switches were exercised monthly.
The staff acknowledged the finding when the deficiencies were identified.
Failure to provide emergency lighting electrical systems as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 18 patients, 55 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 Section 19.2.9.1, 7.9.1.1, 7.9.2.3, 7.9.3; 1999 NFPA 110 Section 6-4.2, 6-4.2.2, 6-4.6, 6-3.5.

Based on observation and interview, the facility failed to provide three branches for the essential electrical system as required.
Findings include:
On May 10, 2013 the essential electrical system was inspected. The electrical panels for the essential electrical system did not have current or updated panel schedules nor was there a current one line available to provide verification of the three required branches of the essential electrical system.
The staff acknowledged the findings when the deficiencies were identified.
Failure to provide three branches for the essential electrical system as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 18 patients, 55 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 Section 19.3.2.3; 1999 NFPA 99 Section 3-4.2.2.1.

Based on observation and interview, the facility failed to provide electrical components as required.
Findings include:
On May 9 and May 10, 2013 electrical components were inspected:
a. There were extension cords or flexible cords utilized to provide permanent power to electrical equipment in the EMT staff sleeping room, to a power strip in the copier/workstation area, in the maintenance shop, in the ER sleeping room, in patient rooms 109, 116 and 120, in the head nurses office, in the basement dry storage room, in the PT Gym, to a ceiling mounted florescent light fixture in the basement telephone/storage room, to the battery back-up emergency lighting in the transfer switch room, to a wall lamp in the radiology dark room, there were three piggy backed power strips in the CNO office and a multi tap electrical adaptor in the PT Gym.
b. There were disconnecting means without current or legible identification within the breaker panels. This includes electrical breaker panels located in the OR suite, basement corridor breaker panels, PT Gym breaker panels, breaker panels in the telephone/storage room, breaker panels in the kitchen and breaker panels in electrical rooms.
c. There was a cord cap damaged by the mobile records shelves in the second floor medical records office smashing the cord cap between the shelves and a surface mounted receptacle. There was also a cord cap damaged by the blanket warmer in the corridor where the blanket warmer was smashing the cord cap against the wall receptacle.
d. There was flexible cord passing through a doorway in the PT Gym, another through a doorway between the laundry room and the clean linen room, another through a doorway between a patient room and the corridor and another through a wall pass-through between the decontamination room and the sterile room in the OR Suite.
e. There were flexible cables altered to TVs in patient rooms 114, 116, 117, 118, and 119 to reach a receptacle up near the ceiling; changing this cord voids the listing or labeling of the TV.
The staff acknowledged the findings when the deficiencies were identified.
Failure to provide electrical components as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 18 patients, 55 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 Section 19.5; 1999 NFPA 70 Section 400-8(1), 110-22, 110-12 (c), 400-8(2), 110-3(b).

Based on observation and interview, the facility failed to provide an approved fire watch system as required.
Findings include:
On May 10, 2013 the available documentation for an approved fire watch system was reviewed. No documentation was provided to show building evacuation or an approved fire watch system was available in the event the sprinkler system was out of service for more than four hours in a twenty-four hour period.
The staff acknowledged the findings when the deficiencies were identified.
Failure to provide an approved fire watch system as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 18 patients, 55 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 Section 19.3.5.1, 9.7.6.1.

Based on observation and interview, the facility failed to provide an approved fire watch system as required.
Findings include:
On May 10, 2013 the available documentation for an approved fire watch system was reviewed. No documentation was provided to show building evacuation or an approved fire watch system was available in the event the fire alarm system was out of service for more than four hours in a twenty-four hour period.
The staff acknowledged the findings when the deficiencies were identified.
Failure to provide an approved fire watch system as required increases the risk of death or injury due to fire.
The deficiency has the potential to affect 18 patients, 55 staff and an unknown number of visitors.
Ref: 2000 NFPA 101 Section 19.3.4.1, 9.6.1.8.