HospitalInspections.org

Based on observations made during a tour of the facility and interviews with the facility maintenance staff, staff failed to demonstrate familiar knowledge of fire procedures, key phrases, and the fire plan. This can cause confusion during an actual event that would require staff to act and safeguard the residents and other building occupants.

The findings included:

During a facility tour on 3/8/17 at 1:15 p.m., Facility Maintenance Staff A did not have a key to unlock the third floor stairwell doors. Facility Maintenance Staff A said not all staff members have a key to the exit doors. Facility Maintenance Staff A asked other staff members for their keys, and they did not have exit door keys.

On 3/9/17 at 4:35 p.m. during the exit conference, Facility Maintenance Staff A acknowledged this finding.

Based on observations made during a life safety tour on 3/9/17 and facility maintenance staff interview, the facility failed to ensure all penetrations of sensitive partitions, i.e., fire walls and smoke walls, were properly protected with fire stop Underwriters Laboratory (UL) design schedules in accordance with NFPA 101 8.3.5.1. This would allow fire, smoke, and toxic gases to migrate from one compartment to another thereby increasing the size of the affected area.

The findings included:

1. During a tour of the facility on 3/9/17 at 1:45 p.m. with Facility Maintenance Staff A, it was observed that a two-inch metal conduit passing through the fire/smoke barrier above the ceiling tile was not properly protected for a one-hour fire wall. This was located above the double doors leading into the 3 East wing.

2. During a tour of the facility on 3/9/17 at 1:55 p.m. with Facility Maintenance Staff A, it was observed that a flex conduit and blue cables passing through the fire/smoke barrier above the ceiling tile was not properly protected for a one-hour fire wall. This was located above the double doors near room 2-177.

Breaches and penetrations of all fire/smoke barrier walls must be appropriately repaired and the walls brought back to their original fire-rated integrity. These penetrations must be resealed with a UL approved design and approved fire-rated caulking or compound on both sides of each penetration.

3. On 3/9/17 at 4:35 p.m. during the exit conference, Facility Maintenance Staff A acknowledged this finding.

Based on observation and facility maintenance staff and kitchen staff interviews, the use of commercial cooking equipment was not in accordance with NFPA 96. If the equipment is not maintained as required, there is a potential for an increased fire hazard.

The findings included:

During a tour of the kitchen at 10:50 a.m. on 3/8/17, the caulking in the seams inside the hood system was falling out or missing. This was discussed with the Kitchen Manager and Facility Maintenance Staff A.

On 3/9/17 at 4:35 p.m. during the exit conference, Facility Maintenance Staff A acknowledged this finding.

NFPA 96 (2011 edition) 5.1.4

Based on facility records and facility maintenance staff interviews, the facility failed to ensure smoke/fire dampers were inspected and tested as required. This could allow fire/smoke to breach adjacent smoke compartments and endanger occupants of the building.

The findings included:

In the fire smoke dampers report dated 2/20/14 through 2/25/14, dampers #36, #37, #38, #40, and #41 were disabled (locked open on purpose). On 3/8/17 at 10:35 a.m., Facility Maintenance Staff A had no knowledge why these dampers were disabled and locked in the open position.

On 3/9/17 at 4:35 p.m. during the exit conference, Facility Maintenance Staff A acknowledged this finding.

NFPA 101 (2012 edition) 19.3.7.3, 8.6.7.1(1)

Based on observation and facility maintenance staff and local county emergency management staff interviews, the facility failed to annually submit a written, comprehensive emergency management plan for emergency care during an internal or external disaster or emergency. The comprehensive emergency management plan shall be reviewed and updated annually. The hospital shall test the implementation of the emergency management plan semiannually, either in response to a disaster or an emergency or in a planned drill, and shall evaluate and document the hospital's performance to the hospital's safety committee.

The findings included:

1. The facility failed to submit a comprehensive emergency management plan annually. During a review of the facility's documents on 3/9/17 at 11:15 a.m., the comprehensive emergency management plan was expired as of February, 2016. The facility did submit a plan to the county Emergency Management on December 30, 2016.

These findings were confirmed by the county Emergency Management Coordinator on 3/10/17 at 10:15 a.m.

2. During document review, the facility was unable to produce documentation for the internal or external disaster exercise.

Facility Maintenance Staff A said he was unsure if the facility conducted either exercise.

3. On 3/9/17 at 4:35 p.m. during the exit conference, Facility Maintenance Staff A acknowledged this finding.

Based on observation of fire drill documentation on 3/8/17 and facility maintenance staff interview, the facility did not perform their responsibilities for protection of visitors, patients, or staff for conducting quarterly fire drills as required.

The findings included:

During the fire drill record review on 3/8/17 at 2:40 p.m.,it was determined that the facility had not been conducting the required fire drills under varied conditions.

The records reviewed revealed that most of the fire drills were conducted on the same day for each shift.

Below are the dates provided by the facility for 2016 fire drills:

3/23/16 @ 1:00 p.m., 3/24/16 @ 630 p.m., 3/25/16 @ 5:30 a.m.
5/24/16 @ 2:00 a.m., 5/25/16 @ 2:00 p.m.
6/2/16 @ 5:00 a.m., 6/2/16 @ 6:30 p.m., 6/3/16 @ 11:10 a.m.
9/29/16 @ 3:00 a.m., 9/29/16 @ 3:01 p.m., 9/29/16 @ 5:00 p.m.

On 3/9/17 at 4:35 p.m. during the exit conference, Facility Maintenance Staff A acknowledged this finding.

19.7.1.6 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.

Based on observation and facility maintenance staff interviews, the facility failed to maintain electrical equipment and wiring in accordance with NFPA 70, The National Electric Code (N.E.C.) and NFPA 99 Health Care Facilities Code to provide a facility free from electrical hazards. Failure to maintain electrical devices, equipment, and wiring in accordance with the applicable standards can result in the hazards of electric shock, electrocution, energized equipment, and fire resulting from electric sources.

The findings included:

During a tour of the facility's geriatric unit on 3/9/17 at 1:25 p.m. with Facility Maintenance Staff A, it was observed that the power cords of the beds had been modified by shortening them. This resulted in a two-foot power cord to provide the electrical connection to the wall outlet.

In an interview on 3/9/17 at 1:25 p.m., Facility Maintenance Staff A said he had "modified the power bed cords just enough to plug in and have the bed raise up or down." This supported the visual observation that the cords to all the hospital beds in this unit had been shortened.

On 3/9/17 at 4:35 p.m. during the exit conference, Facility Maintenance Staff A acknowledged this finding.