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Based on observation and interview, the facility failed to ensure compartmentation was maintained. Failure to maintain compartmentation has the potential to limit the facility ability to safeguard against the transfer of fires, smoke and dangerous gases beyond the compartment and hinders installed fire suppression system response, by allowing heat to bypass these features. This deficient practice affected patients, staff and visitors on the date(s) of the survey.

Findings include:

During the facility tour conducted on 10/29/19 from 9:00 - 10:30 AM, observation of the 3E Nourish - A1, revealed four (4) missing ceiling tiles from the suspended ceiling grid system.

Interview of the accompanying Facilities staff at approximately 9:30 AM on 10/29/19, established that the ceiling tiles had been removed due to an above the ceiling leak.

Actual NFPA standard:

19.1.1.3 Total Concept.
19.1.1.3.1 All health care facilities shall be designed, constructed, maintained, and operated to minimize the possibility of a fire emergency requiring the evacuation of occupants.

19.1.1.3.2 Because the safety of health care occupants cannot be ensured adequately by dependence on evacuation of the building, their protection from fire shall be provided by appropriate arrangement of facilities; adequate, trained staff; and development of operating and maintenance procedures composed of the following:
(1) Design, construction, and compartmentation
(2) Provision for detection, alarm, and extinguishment
(3) Fire prevention procedures and planning, training, and drilling programs for the isolation of fire, transfer of occupants to areas of refuge, or evacuation of the building.

Based on observation and interview, the facility failed to ensure the fire and smoke resistive properties of the structure were maintained. Failure to ensure penetrations are sealed and the fire protective coatings of steel support members are maintained, has the potential to allow smoke, fire and dangerous gases to pass between compartments and increase the risk of premature structural failure from exposing structural members to the increased heat during a fire. This deficient practice affected patients, staff and visitors on the date(s) of the survey.

Findings include:

During the facility tours conducted from October 28, to November 1, 2019 from 7:30 AM to 4:30 PM, the following observations of the fire protective properties were identified:

- Mechanical storage located in the OR suite identified as 218A, 218B, 2187C, revealed four (4) unsealed conduits that ranged in size from 1 inch to 2 inches in diameter, which passed into the ancillary space above the one-hour ceiling.
- In the data room identified as 3E Data C1, the intumescent putty was observed to have been removed from a 2 inch conduit that passed into the floor.
- In the data room identified as 3E Data B1, the fire alarm junction panel box cover was observed to have been removed and the approximately 2 inch conduit leaving the box and passing into the floor below was revealed to be unsealed.
- An above the ceiling inspection conducted of both sides of the cross-corridor fire barrier doors outside the CCU, revealed an approximately 2 inch unsealed conduit with data cabling passing through the rated assembly.
- Observation of the east basement ceiling revealed an approximately 2 inch unsealed conduit with cabling passing into the floor level above.
- Observati

Based on observation and interview, the facility failed to ensure means of egress were maintained in accordance with NFPA 101 and CMS Final Rule. Failure to limit corridor projections to 4 inches or less has the potential to hinder egress for visually impaired individuals during an emergency. This deficient practice affected patients, staff and visitors on the date(s) of the survey.

Findings include:

During the facility tour(s) conducted from 10/29 to 10/31/2019 from 8:00 AM - 3:30 PM, observation of corridor access revealed the following projections that exceeded four (4) inches from the wall:

- Outside rooms 3311-01 and 3311-02, a vitals monitor measured 5-1/2 inches from the wall at 70 inches from the floor.
- At the nurse's station on North 3E, a "Bedboard" measured 7 inches from the wall at 47 inches from the floor.
- Outside room 3209 a Bedboard measured 10 inches from the wall at 47 inches from the floor.
- In the Postpartum unit, all four (4) Bedboards measured 5 inches from the wall at 47 inches from the floor.
- Director of Lab Services reader board measured 5 inches from the wall at 65 inches from the floor.
- At the Heart Monitor Center, the patient monitor measured 5 inches from the wall at 65 inches from the floor.
- At 1 North, room 1917 Bedboard measured 6 inches from the wall at 47 inches from the floor.
- At the Labor/Delivery unit across from Electrical room 11, the Bedboard measured 5 inches from the wall at 47 inches from the floor.

Interview of the Engineering staff from 10/29 to 10/31/2019 and from 8:00 AM to 3:30 PM, established none of the staff was aware of the requirement to maintain four inches or less on projections into the corridor.

Due to the extent and number of findings, this de

Based on record review and interview, the facility failed to ensure that relative humidity (RH) within operating rooms was maintained in accordance with NFPA 99 and ASHRAE 170. Failure to ensure RH in operating rooms is maintained within safe ranges prior to and during procedures, has the potential to increase patients to exposed risks of arc fires. This deficient practice affected all patients, staff and visitors in the OR suite on the dates of the survey.

Findings include:

During review of provided OR relative humidity logs conducted from 10/28/19 to 10/31/19, logs revealed the RH was documented as below 20 percent on 39 days, with 8 of those days having recorded RH levels below 10 percent, including the lowest recorded RH as 3.3 percent. This documentation was found to be a systemic condition with no further review deemed necessary.

When asked as to the written policy or procedure for what action would be taken when RH levels dropped below 20 percent, the Engineering Director stated there was not a written policy for procedures when RH dropped below 20 percent, but the practice was to notify the OR at the time RH levels were discovered out of range. Further asked if there was any follow-up documented for what the OR did prior to, or during operations for monitoring RH levels, he stated he was unaware of any follow-up documented, but his staff had installed humidistat's in the OR's for nursing staff to monitor.

Actual NFPA standard:

NFPA 99
Chapter 9 Heating, Ventilation, and Air Conditioning (HVAC)

9.3 General.
9.3.1 Heating, Cooling, Ventilating, and Process Systems.
9.3.1.1 Heating, cooling, ventilating, and process systems serving spaces or providing health care functions covered by this code or listed within ASHRAE 170, Ventilation of Health Care Facilities, sha

Based on observation and interview, the facility failed to ensure Alcohol-Based Hand Rub (ABHR) dispensers were installed in accordance with NFPA 101. Failure to ensure ABHR dispensers are installed away from ignition sources such as electrical switches or outlets, has the potential to increase the risk of fires in the facility by exposing those ignition sources to flammable liquids. This deficient practice affected patients, staff and visitors on the date(s) of the survey.

Findings include:
During the facility tour conducted on 10/30/19 from 11:00 AM - 2:00 PM, observation of installed ABHR dispensers revealed the following:

- In Exam Room 23 of the Emergency Department (ED), an ABHR dispenser was installed over a light switch.
- At the Decon entrance off the ambulance loading bay, an ABHR dispenser was installed over the entrance badge reader.
- At the ED reception area, an ABHR dispenser was installed over an outlet.
- Observation of Trauma room 17 revealed an ABHR dispenser installed over a light switch.

At approximately 11:45 AM, Facilities Engineering staff was asked about ABHR installations over the proximity of ignition sources. Staff responded that they knew of keeping the clearance to electrical installations and that these installations were not observed prior to the date of the survey.

Further observation of the refills used for the dispenser revealed they housed a foaming product of approximately 60 percent ethyl-alcohol base.

Actual NFPA standard:

NFPA 101

19.3.2.6% Alcohol-Based Hand-Rub Dispensers. Alcohol-based hand-rub dispensers shall be protected in accordance with 8.7.3.1, unless all of the following conditions are met:
(1) Where dispensers are installed

Based on record review and interview, the facility failed to ensure that fire alarm systems were maintained in accordance with NFPA 72. Failure to perform sensitivity testing for fire alarm smoke detection systems, has the potential to hinder system response during a fire event. This deficient practice affected patients, staff and visitors on the date(s) of the survey.

Findings include:

During review of provided fire alarm inspection records conducted on 10/29/19 from 1:00 - 3:30 PM, no records were available demonstrating a sensitivity testing had been performed on the fire alarm smoke detection system. Interview of the Facilities Engineering staff present at the time of review of the provided inspection records, stated he was not aware the addressable fire alarm system was required to have sensitivity testing documentation provided.

Actual NFPA standard:

NFPA 72
Chapter 14 Inspection, Testing, and Maintenance
14.4.5.3.1
Sensitivity shall be checked within 1 year after installation.
14.4.5.3.2
Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3.
14.4.5.3.3 After the second required calibration test, if sensitivity tests indicate that the device has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years.
14.4.5.5.3 Records shall be kept by the building owner specifying which detectors have been tested.
14.4.5.5.4 Within 5 years, each detector shall have been tested.

Based on record review and interview, the facility failed to ensure fire suppression systems were maintained in accordance with NFPA 25. Failure to maintain sprinkler pendants free of obstructions and replace or test dry system pendants at least every ten years, has the potential to hinder system performance during a fire event. This deficient practice affected patients, staff and visitors on the date(s) of the survey.

Findings include:

1) During review of the provided maintenance and inspection records conducted on 10/28/19 from 1:00 - 3:00 PM, records indicated the installation of a dry system. When asked at approximately 2:00 PM as to the protection area(s) of the dry system, Facility Engineering staff stated there were two (2) dry pendants installed in 2000 to protect the underside of the interstitial space of a rooftop Heating Ventilation and Air Conditioning (HVAC) unit and he was not aware of any UL testing or replacement having been performed on these pendants.

2) During the facility tour conducted on 10/31/19 from 9:30 AM - 12:00 PM, inspection of the off-site Internal Medicine Clinic revealed one (1) sprinkler pendant in the Clean Laundry closet with a protective construction cap installed and absent the sprinkler escutcheon and a storage closet abutting the exam rooms with a storage shelf approximately 13 inches from the bottom of the deflector.

Actual NFPA standard:

NFPA 25

5.2% Inspection.
5.2.1 Sprinklers.
5.2.1.2% The minimum clearance required by the installation standard shall be maintained below all sprinkler deflectors.

5.3.1.1.1.6% Dry sprinklers that have been in service for 10 years shall be replaced or representative samples shall be tested and then retested at 10-year intervals.

NFPA 13

8.5.6% Clearance to

Based on observation, the facility failed to ensure portable fire extinguishers were maintained in accordance with NFPA 10. Failure to install fire extinguishers at the appropriate height, has the potential to result in damage(s) to the extinguisher and/or hinder staff response during a fire event. This deficient practice affected patients, staff and visitors on the date(s) of the survey.

Findings include:

During the facility tour(s) conducted from October 29 to November 1, 2019 from 7:30 AM to 4:30 PM, observation of the installed portable fire extinguishers revealed the following:

- In the 3E Mechanical B-1, the fire extinguisher was revealed to be unmounted and sitting on the floor.
- In the first floor Engineering command center, the fire extinguisher height measured 61-1/2 inches when measured from the floor to the top of the extinguisher.
- In the lower basement level, four (4) fire extinguishers were revealed to be mounted above 60 inches from the floor to the top of the extinguisher: the Paint shop was mounted at 61-1/2 inches to the top; two (2) at the boiler room were at 61-1/2 inches to the top; one (1) at the chiller was at 61-1/2 inches to the top of the extinguisher.
- In the lower basement tunnel area, two extinguishers were observed to be mounted at 61-1/2 inches to the top of the extinguisher.
- In the main Kitchen, the ABC type extinguisher was revealed to be mounted at 63-1/2 inches to the top of the extinguisher.

Actual NFPA standard:

NFPA 10
6.1.3.8 Installation Height.
6.1.3.8.1 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor.

6.1.3.8.2 Fire extinguishers having a gross

Based on observation and operational testing, the facility failed to ensure patient room doors that enter the corridor would close and latch. Failure to provide positive latching arrangements on patient room doors that enter the corridor, has the potential to allow fire, smoke and dangerous gases to pass between compartments and hinder the safe egress of patients during a fire event. This deficient practice affected patients, staff and visitors on the date(s) of the survey.

Findings include:

During the facility tour conducted on 10/29/2019 from 8:30 - 10:00 AM, observation and operational testing of patient rooms 3112, 3027 and 3011 revealed the door was unable to close and positively latch, keeping the door shut when activated.

Actual NFPA standard:

19.3.6.3% Corridor Doors.
19.3.6.3.5% Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply:
(1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.
(2) Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7.

Based on observation, the facility failed to ensure that protected openings in smoke barrier walls were maintained free of obstructions to ensure compartmentation. Blocking the openings of self-closing rolling fire doors, has the potential to allow fire, smoke and dangerous gases to pass between compartments during a fire. This deficient practice affected patients, staff and visitors on the date(s) of the survey.

Findings include:

During the facility tour conducted on 10/31/19 from 8:30 - 10:00 AM, observation of the Heart Center Lobby revealed a drop-down rolling fire door installed at the rated 2-hour barrier of the main entrance to the center. Further observation revealed two (2) computer monitors, a payment/card reader and a pen holder, were placed in the opening and would further obstruct the automatic closing features of this fire door.

Actual NFPA standard:

8.3.3 Fire Doors and Windows.
8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code.

NFPA 80
Chapter 5 Care and Maintenance

5.2.13 Prevention of Door Blockage.
5.2.13.1 Door openings and the surrounding areas shall be kept clear of anything that could obstruct or interfere with the free operation of the door.

Based on observation, the facility failed to ensure safe electrical installations in accordance with NFPA 101, NFPA 70 and UL 1363. Failure to ensure electrical appliances and installations are maintained as part of listed, approved assemblies, has the potential to expose patients to the increased risks of electrical shock and/or arc fires. This deficient practice affected patients, staff and visitors on the date(s) of the survey.

Findings include:

During the facility tour(s) conducted on 10/29 and 10/30/2019 from 8:00 AM - 3:30 PM, observation of installed electrical installations revealed the following:

- In the ED and Lab upper mezzanine, an approximately four inch by four inch square electrical junction box was observed to be missing the cover and exposing the live electrical parts.
- At the Nurse's Lead Resource Center, a coffee maker was observed to be using a 3-1 extension cord to supply power, substituting the direct wiring of the facility.
- At the AM Monitoring Studio, a relocatable power tap (RPT) was observed be used to supply power to a microwave.
- In the East Basement, an approximately four inch by four inch square electrical junction box was observed to be missing the cover and exposing the live electrical parts.
- In the East Basement data storage room, a 2-gang outlet box was observed to be missing one of the two outlets and exposing the live electrical parts.
- At the Nursing Admin station, a power supply bank was observed connected in series (daisy-chained) into a RPT.
- At Housekeeping "Lost and Found", a RPT was observed being used to supply power to a microwave.
- At the ED breakroom, a direct-wire electrical wall clock was observed to be missing from the wall, leaving the expo

Based on record review conducted on 10/31/19 from 9:30 - 11:00 AM, records provided for the OB Gyn clinic and Internal Medicine clinic, indicated fire drills were not conducted on all shifts quarterly. Failure to conduct quarterly fire drills for staff in Ambulatory Health Care clinics has the potential to hinder staff preparedness during fire events. This deficient practice affected patients, staff and visitors in those outpatient locations on the date(s) of the survey.

Findings include:

During review of documentation for facility response to fires, drill records provided for the OB Gyn clinic and the Internal Medicine clinic revealed the OB Gyn clinic had only conducted 1 of 4 required fire drills in the past year and the Internal Medicine clinic conducted 3 of 4 in the past year.

Actual NFPA standard:

Chapter 3 Definitions

3.3.188.1% Ambulatory Health Care Occupancy. An occupancy used to provide services or treatment simultaneously to four or more patients that provides, on an outpatient basis, one or more of the following: (1) treatment for patients that renders the patients incapable of taking action for self-preservation under emergency conditions without the assistance
of others; (2) anesthesia that renders the patients incapable of taking action for self-preservation under emergency conditions without the assistance of others; (3) emergency or
urgent care for patients who, due to the nature of their injury or illness, are incapable of taking action for self-preservation under emergency conditions without the assistance of others.

21.7% Operating Features.
21.7.1 Evacuation and Relocation Plan and Fire Drills.

21.7.1.4% Fire drills in ambulatory health care facilities shall include the transmission of a fire alarm signal and simulation of emergency f

Based on record review, observation and interview, the facility failed to ensure electrical receptacles were inspected and tested in accordance with NFPA 99. Failure to test receptacles, whether fixed or portable, on a routine basis, has the potential to expose patients, staff and visitors to electrical shock and/or arc fires. This deficient practice affected patients, staff and visitors in the OR suite on the date(s) of the survey.

Findings include:

1) During review of provided maintenance and inspection records conducted on 10/28/19 from 1:00 - 4:30 PM, records did not indicate inspection and testing had been conducted on flexible cord power outlets (power strips) used to supply power to Patient Care Related Electrical Equipment (PCREE) in the OR's.

2) During the facility tour conducted on 10/30/19 from 8:30 - 9:30 AM, observation of portable, multiple plug outlets installed in CVOR 2 and C-section OR1 revealed the following:

- CVOR 2 was observed to have (2), power strips in use for PCREE. Further observation of these power strips revealed one (1) was a standard UL 1363 and one (1) was a UL 1363A. No biomed testing identification was observed tagged on either power strip.
- C-section OR1 was observed to have a non-UL 1363A power strip in use to supply power to PCREE equipment that did not have any biomed identification indicating testing of the equipment was performed. Further observation revealed it was not secured to a cart.

Interview of Facilities Engineering staff present at the time of the observation, revealed he was not aware of any testing of these portable outlet connections being conducted.

Actual NFPA standard:

6.3.2.2.8 Wet Procedure Locations.
6.3.2.2.8.1% Wet procedure locations shall be provided with special protection against

Based on record review and observation, the facility failed to ensure relocatable power taps (RPTs) used for patient care related equipment (PCREE), meet the standards of UL 1363A or UL 60601-1. Failure to use approved and listed RPTs with PCREE, has the potential to expose patients to electrical shock and arc hazards. This deficient practice affected patients undergoing surgery and staff on the date(s) of the survey.

Findings include:

1) During an inspection of the OR suite and the Labor/Delivery suite conducted on 10/30/19 from approximately 8:30 - 10:00 AM, observation of CVOR 2 and C-Section OR 1 revealed the following:

- CVOR 2 was observed to have (2), RPT's in use for PCREE, only one of which was determined to be in accordance with UL 1363A requirements. Further observation revealed no identification biomed testing had been performed.
- C-section OR1 was observed to have a UL 1363 RPT in use to supply power to PCREE equipment that did not have any biomed identification indicating testing of the equipment was performed. Further observation revealed it was not secured to a cart.

Interview of Facilities Engineering staff present at the time of these observations established he was unaware of any testing performed for the RPT's located in either OR.

Actual NFPA standard:

NFPA 99

10.2.3.6 Multiple Outlet Connection. Two or more power receptacles supplied by a flexible cord shall be permitted to be used to supply power to plug-connected components of a movable equipment assembly that is rack-, table-, pedestal-, or cartmounted, provided that all of the following conditions are met:
(1) The receptacles are permanently attached to the equipment assembly.
(2)%The sum of the ampacity of all appliances connected to the outlets does not exc

Based on observation and interview, the facility failed to ensure oxygen cylinder storage was in compliance with NFPA 99. Failure to provide segregation of full and empty cylinders in storage and ensure adequate ventilation of those spaces, has the potential to inadvertently use the incorrect cylinder during an emergency requiring supplemental oxygen, as well as increase the risks of explosion and fire due to excess build-up of medical gases in confined spaces. This deficient practice affected patients, staff and visitors on the date(s) of the survey.

Findings include:

During the facility tour conducted on 10/30/19 from 1:30 - 3:45 PM, observation of stored medical gas locations revealed the following:

- Observation of the Respiratory Therapy storage located off the south ED entrance at approximately 2:00 PM, the storage was revealed to have one (1) carbon monoxide cylinder which was identified as "Empty", intermixed with one (1) cylinder identified as full. Asked at the location how the facility staff determined which cylinder was empty and which was full, the Facility Engineer present stated that if the plastic protective cap was missing from the cylinder valve connection, the cylinder would be "Empty".

- Observation of the main Oxygen storage location on the east side of the main level, established two (2) areas housing the principal storage of medical gas cylinders. The first location, or the primary storage location for "K" cylinders, was observed to have no ventilation for the space, either static or mechanical and four (4) "K" cylinders of oxygen, along with nitrogen, carbon dioxide and medical air.

Asked about the missing ventilation, Facilities Engineering staff present at the time of this observation stated they had not been aware of the missing ventilation in this st

Based on record review and interview, the facility failed to ensure that Category 1 piped-in medical gas systems were maintained in accordance with NFPA 99. Failure to ensure repairs are conducted on deficiencies revealed during annual servicing of equipment, has the potential to hinder system performance and result in patient injury or death. This deficient practice affected those patients, staff and visitors exposed to the areas found defective and needing repair during the annual inspection.

Findings include:

During review of the provided annual med gas inspection and subsequent repair records conducted on 10/29/19 from 2:00 - 3:30 PM, records documented seven (7) identified deficiencies reported on the annual med gas inspection performed on 6/14/19 that had not been repaired as of the date of the survey. Those items identified as having not been corrected were as follows:

a. Specialty procedures had changed use and were no longer in compliance as noted on page 3 of the report.
b. Med gas room on 1st floor alarm is not in compliance for two (2) items as noted on page 3 of the report.
c. The ED master alarm panel is not in compliance as noted on page 3 of the report.
d. The thermostat in the med gas storage room is not in compliance as noted on page 3 of the report.
e. Zone valves are indicated as not installed in compliance as noted on page 4 of the report.

Interview of the Facilities Engineering Supervisor on 10/29/19 at approximately 3:00 PM, established he was not aware all deficiencies identified on the annual report had not been corrected.

Actual NFPA standard:

11.6.2.5 Oxygen equipment that is defective shall not be used until one of the following tasks has been performed:
(1) It has been repaired by competent in-house person