HospitalInspections.org

Based on random observation it was determined the hospital failed to maintain all corridor doors to close and latch without impediment.

Findings include:

1. During tour of the hospital on 01/09/12 at approximately 10:15 a.m., the following corridor doors were obstructed to close or failed to latch:

a. St. Joseph campus cafeteria corridor doors were observed to be held open with a hook at the top of the doors. Also, these doors were observed not to have any positive latching mechanism installed.

b. St. Joseph campus gift shop corridor door was observed to be held open with a "drop down" device attached to the bottom of the door.

Based on observation it was determined the hospital failed to maintain all vertical openings to be enclosed with construction having a fire resistance rating of at least one (1) hour.

Findings include:

1. On 01/10/12 at approximately 11:00 a.m., the St. Joseph campus fire exit door to stairwell identified as stair FS-1 was observed to have an inoperable latch.

Based on observation it was determined the hospital failed to maintain all exits readily accessible.

Findings include:

1. On 01/09/12 during the time frame of 10:15 a.m. and 11:45 a.m. the following equipment was observed to be stored unattended in the St. Joseph campus 2nd floor patient care unit corridors obstructing the egress paths:

a. Three (3) blood pressure machines (on charge).
b. Two (2) computers on wheels (on charge).

NFPA (National Fire Protection Association) 13, Standard for the Installation of Sprinkler Systems
1-6 Level of Protection.
1-6.1
A building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas.

NFPA 25 - Standard for the Inspection, Testing, and Maintenance of Water-based Protection Systems
2-2 Inspection.
2-2.1 Sprinklers.
2-2.1.1*
Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

This Standard is not met as evidenced by:

Based on observation it was determined the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) 13 and 25.

Findings include:

1. On 01/11/12 at approximately 10:00 a.m., a tour of the central sterile decontamination area was conducted. At this time, eight (8) sprinkler heads located in the following areas were observed to be corroded.

a. Central sterile decontamination area (7)
b. Area behind autoclave (1).

2. On 01/11/12 at approximately 10:00 a.m., an enclosed storage room in the central sterile decontamination area (near cart wash station) was observed not to have sprinkler coverage.

NFPA (National Fire Protection Association) 101 Life Safety Code 2000 edition

1-7 ENFORCEMENT
1-7.1 Administration and Enforcement.
This Code shall be administered and enforced by the authority having jurisdiction designated by the governing authority.

10.3 CONTENTS AND FURNISHINGS
10.3.5*
Furnishings or decorations of an explosive or highly flammable character shall not be used.

19.7.5.4
Combustible decorations shall be prohibited in any health care occupancy unless they are flame-retardant.

This Standard is not met as evidenced by:

Based on observation and staff interview it was determined the hospital failed to maintain all decorations not to be of a highly flammable character.

Findings include:

1. On 01/10/12 at approximately 1:00 p.m., an open flame device (an unsecured candle holder with burning candle) was observed on a table in the Saint Joseph campus waiting area (near coffee shop).

2. On this same date and time, an interview with the plant operations manager confirmed that the candle was burning.

Based on review of facility documentation and staff interview it was determined the hospital failed to maintain the medical gas system in accordance with National Fire Protection Association (NFPA) 99, Chapter 4.

Findings include:

1. On 01/04/12 at approximately 10:00 a.m., a medical gas system inspection report prepared by Northeast Medical Consulting Incorporated and dated 12/05/11 and 12/07/11 was reviewed. This report indicated the following deficiencies were found during the medical gas inspection for Memorial campus:

I) Sources
A) Oxygen (Medical Office Building)
1. A main valve is required to be installed and labeled with "Gas", "Area Secured", and "Do not close except in emergency".
2. A gas specific demand check should be installed on the master pressure switch and main gauge.
B) Oxygen (Medical Office Building-Sleep Lab).
1.The electrical outlets and switches are required to be at a minimum elevation of 5 feet.
C) Nitrous Oxide (Surgery)
1. A "No Smoking" sign is required to be posted.
2. The electrical outlets and switches are required to be a minimum elevation of 5 feet.

D) Nitrogen (Surgery)
1. A "No Smoking" sign is required to be posted.
2. The electrical outlets and switches are required to be a minimum elevation of 5 feet.

E) Medical Air (X-ray Back Room - North Wing Back-up)
1. A second dryer with isolation valves is required to be installed.
2. A dew point monitor is required to be installed and wired to the master alarm panels.
3. A carbon monoxide monitor is required to be installed and wired to the master alarm panels.
4. A local audible and visual signal for the lag compressor in use should be installed and wired to the master alarm panels.
5. The dryers should have isolation valves installed for service.
6. A master pressure switch with a gas specific demand check is required to be installed immediately downstream of the main valve and wired to the master alarm panels.
7. A main guage with a gas specific demand check should be installed immediately downstream of the main valve.
8. A pressure relief valve is required to be installed on the compressor and receiver.
9. The medical air system should be labeled.
10. An intake filter should be installed.
11. Duplex line-pressure regulators should be installed with isolation valves.
12. A liquid ring separator flooded sensor should be installed on each compressor and connected to a local alarm.

F) Vacuum (X-ray Back Room - North Wing Back-up)
1. A gas specific demand check should be installed on the master low vacuum switch.
2. A local audible and visual signal for the lag pump in use should be installed, function, and wired to the master alarm panels.

G) Vaccum (Medical Office Building - Primary-Nash) In Use
1.The source/main valve is required to be labeled with "Gas". Area Served", and "Do not close except in emergency". The label must be color coded.
2. A drip leg should be installed on the exhaust piping at any dip or loop that can trap condensation.

H) Vacuum (Medical Office Building - Back-up Squire Cogswell) Not in use.
1. The lag alarm is required to be wired to the master alarm panel.
2. The source piping is required to be labeled with color coded directional tape.
3. The source/main valve is required to be labeled with "Gas", "Area Served", and "Do not close except in emergency". This label must be color coded.
4. A drip leg should be installed on the exhaust piping at any dip or loop that can trap condensation.

II Alarms
A) Area Alarms
1. One (1) pressure switch is required to be adjusted to be plus or minus 20% of line pressure.

III Zone Valves
1. Six (6) gauges should be installed downstream of zone valves.
2. One (1) medical air and one (1) oxygen valve leak externally when closed and are required to be repaired.
3. One (1) gauge is inaccurate or broken and is required to be replaced.

IV Contamination Testing
A) Dew Point
1. The dew point of medical air was below the maximum of 39 degrees Fahrenheit.

2. On 01/05/12 at approximately 9:15 a.m., an interview with the engineer manager revealed that the aforementioned deficiencies cited on the medical gas system inspection report dated 12//05/11 and 12/07/11 have not been corrected as of this date 01/05/12.

3. On 01/09/12 at approximately 11:00 a.m., a medical gas system inspection report prepared by Northeast Medical Consulting Incorporated and dated 09/08/11 was reviewed. This report indicated the following deficiencies were found during the medical gas inspection for St. Joseph campus:

I) Source Equipment
A) Medical Air ("A" Building Penthouse)
1. A drain should be available in the room.
2. A gas specific demand check should be installed on the mastwer pressure switch and main gauge.
B) Vacuum ( Penthouse "A" Building) Back-up
1. A gas specific demand check should be installed on the main gauge.

II) Alarms
A) Master Alarms
1. The points listed on page 2 of report should be added at the Engineering master alarm panel for the oxygen system. Page 2 list - Main liquid low, Reserve in use, Reserve low pressure, Low line pressure, High line pressure, and Reserve liquid low.
B) Area Alarms
1. One (1) pressure switch is upstream of the valves and is required to be downstream of the zone valves.

III) Zone Valves
1. 550-564 is missing the vacuum zone valve.
2. The piping is exposed in 251-254-262-263-2E North Cardiac Cath and 255-253 South 2E and requires correction by shielding the piping with a protective cover.
3. 37 gauges should be installed downstream of zone valves.
4. The gauges for 550-564 are currently upstream of the valves and are required to be downstream of valves.
5. One (1) valve box is missing the list of rooms controlled and it is required to be posted.
6. One (1) valve box has an incorrect or outdated list of rooms controlled and it is required to be updated.

IV) Patient Terminal Outlets
1. Nine (9) wall vacuum inlets have flow below the minimum of 3.0 scfm and require correction. Use a vacuum solution to clean the piping and rebuild the inlets to increase flow.
2. Four (4) outlets are missing the "Gas" and "Use No Oil" labels and are required to have it posted on the outlet.
3. Five (5) outlets leak due to worn o-rings and require correction.

V) Contamination Testing
A) Dew Point
1. The dew point of the medical air was below the maximum of 39 degrees Fahrenheit.

4. On 01/10/12 at approximately 1:15 p.m., an interview with the engineer manager revealed that the aforementioned deficiencies cited on the medical gas system inspection report dated 09//08/11 have not been corrected as of this date 01/10/12.

NFPA (National Fire Protection Association) 110 - Standard for Emergency and Standby Power Systems
5-3 Lighting.
5-3.1
The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

This Standard is not met as evidenced by:

Based on observation and staff interview it was determined the hospital failed to maintain the facility generator in accordance with National Fire Protection Association (NFPA) 110.

Findings include:

1. On 01/05/12 at approximately 1:30 p.m., the Memorial Campus generator transfer switch rooms were observed not to have any emergency battery-powered lighting. An interview with the engineering manager on this same date and time confirmed that the generator transfer switch rooms were not equipped with emergency battery-powered lighting.

Based on random observation it was determined the hospital failed to maintain all electrical wiring in accordance with National Fire Protection Association (NFPA) 70.

Findings include:

1. On 01/09/12 at approximately 11:00 a.m., one (1) electrical power strip (relocatable power tap) was observed to be in use in the corridor on the St. Joseph campus 2nd floor patient care unit. Also, at this time an extension cord was observed to be in use for a computer on wheels.

2. On 01/11/12 at approximately 9:00 a.m., three (3) extension cords were observed in use for computers on wheels in the St. Joseph campus post anesthesia care unit (PACU).

Reference:

Underwriters Laboratories (UL) Directory Guide: Relocatable Power Taps Use and Installation
Relocatable power taps have not been investigated and are not intended for use with general patient care areas or critical patient care areas of health care facilities as defined in Article 517 of ANSI/NFPA 70, "National Electrical Code".

NFPA 70 National Electrical Code- 2002 Edition Article 517 Health Care Facilities
517.2 Definitions

Health Care Facilities. Buildings or portions of buildings that contain, but are not limited to, occupancies such as hospitals; nursing homes; limited care; supervisory care; clinics; medical and dental offices; and ambulatory care, whether permanent or movable.

Patient Care Area: Any portion of a health care facility wherein patients are intended to be examined or treated. Areas of a health care facility in which patient care is administered are classified as general care areas or critical care areas, either of which may be classified as a wet location. The governing body of the facility designates these areas in accordance with the type of patient care anticipated and with the following definitions of the area classification. FPN: Business offices, corridors, lounges, day rooms, dining rooms, or similar areas typically are not classified as patient care areas.

Based on random observation it was determined the hospital failed to maintain all corridor doors to close and latch without impediment.

Findings include:

1. During tour of the hospital on 01/09/12 at approximately 10:15 a.m., the following corridor doors were obstructed to close or failed to latch:

a. St. Joseph campus cafeteria corridor doors were observed to be held open with a hook at the top of the doors. Also, these doors were observed not to have any positive latching mechanism installed.

b. St. Joseph campus gift shop corridor door was observed to be held open with a "drop down" device attached to the bottom of the door.

Based on observation it was determined the hospital failed to maintain all vertical openings to be enclosed with construction having a fire resistance rating of at least one (1) hour.

Findings include:

1. On 01/10/12 at approximately 11:00 a.m., the St. Joseph campus fire exit door to stairwell identified as stair FS-1 was observed to have an inoperable latch.

Based on observation it was determined the hospital failed to maintain all exits readily accessible.

Findings include:

1. On 01/09/12 during the time frame of 10:15 a.m. and 11:45 a.m. the following equipment was observed to be stored unattended in the St. Joseph campus 2nd floor patient care unit corridors obstructing the egress paths:

a. Three (3) blood pressure machines (on charge).
b. Two (2) computers on wheels (on charge).

NFPA (National Fire Protection Association) 13, Standard for the Installation of Sprinkler Systems
1-6 Level of Protection.
1-6.1
A building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas.

NFPA 25 - Standard for the Inspection, Testing, and Maintenance of Water-based Protection Systems
2-2 Inspection.
2-2.1 Sprinklers.
2-2.1.1*
Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

This Standard is not met as evidenced by:

Based on observation it was determined the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) 13 and 25.

Findings include:

1. On 01/11/12 at approximately 10:00 a.m., a tour of the central sterile decontamination area was conducted. At this time, eight (8) sprinkler heads located in the following areas were observed to be corroded.

a. Central sterile decontamination area (7)
b. Area behind autoclave (1).

2. On 01/11/12 at approximately 10:00 a.m., an enclosed storage room in the central sterile decontamination area (near cart wash station) was observed not to have sprinkler coverage.

NFPA (National Fire Protection Association) 101 Life Safety Code 2000 edition

1-7 ENFORCEMENT
1-7.1 Administration and Enforcement.
This Code shall be administered and enforced by the authority having jurisdiction designated by the governing authority.

10.3 CONTENTS AND FURNISHINGS
10.3.5*
Furnishings or decorations of an explosive or highly flammable character shall not be used.

19.7.5.4
Combustible decorations shall be prohibited in any health care occupancy unless they are flame-retardant.

This Standard is not met as evidenced by:

Based on observation and staff interview it was determined the hospital failed to maintain all decorations not to be of a highly flammable character.

Findings include:

1. On 01/10/12 at approximately 1:00 p.m., an open flame device (an unsecured candle holder with burning candle) was observed on a table in the Saint Joseph campus waiting area (near coffee shop).

2. On this same date and time, an interview with the plant operations manager confirmed that the candle was burning.

Based on review of facility documentation and staff interview it was determined the hospital failed to maintain the medical gas system in accordance with National Fire Protection Association (NFPA) 99, Chapter 4.

Findings include:

1. On 01/04/12 at approximately 10:00 a.m., a medical gas system inspection report prepared by Northeast Medical Consulting Incorporated and dated 12/05/11 and 12/07/11 was reviewed. This report indicated the following deficiencies were found during the medical gas inspection for Memorial campus:

I) Sources
A) Oxygen (Medical Office Building)
1. A main valve is required to be installed and labeled with "Gas", "Area Secured", and "Do not close except in emergency".
2. A gas specific demand check should be installed on the master pressure switch and main gauge.
B) Oxygen (Medical Office Building-Sleep Lab).
1.The electrical outlets and switches are required to be at a minimum elevation of 5 feet.
C) Nitrous Oxide (Surgery)
1. A "No Smoking" sign is required to be posted.
2. The electrical outlets and switches are required to be a minimum elevation of 5 feet.

D) Nitrogen (Surgery)
1. A "No Smoking" sign is required to be posted.
2. The electrical outlets and switches are required to be a minimum elevation of 5 feet.

E) Medical Air (X-ray Back Room - North Wing Back-up)
1. A second dryer with isolation valves is required to be installed.
2. A dew point monitor is required to be installed and wired to the master alarm panels.
3. A carbon monoxide monitor is required to be installed and wired to the master alarm panels.
4. A local audible and visual signal for the lag compressor in use should be installed and wired to the master alarm panels.
5. The dryers should have isolation valves installed for service.
6. A master pressure switch with a gas specific demand check is required to be installed immediately downstream of the main valve and wired to the master alarm panels.
7. A main guage with a gas specific demand check should be installed immediately downstream of the main valve.
8. A pressure relief valve is required to be installed on the compressor and receiver.
9. The medical air system should be labeled.
10. An intake filter should be installed.
11. Duplex line-pressure regulators should be installed with isolation valves.
12. A liquid ring separator flooded sensor should be installed on each compressor and connected to a local alarm.

F) Vacuum (X-ray Back Room - North Wing Back-up)
1. A gas specific demand check should be installed on the master low vacuum switch.
2. A local audible and visual signal for the lag pump in use should be installed, function, and wired to the master alarm panels.

G) Vaccum (Medical Office Building - Primary-Nash) In Use
1.The source/main valve is required to be labeled with "Gas". Area Served", and "Do not close except in emergency". The label must be color coded.
2. A drip leg should be installed on the exhaust piping at any dip or loop that can trap condensation.

H) Vacuum (Medical Office Building - Back-up Squire Cogswell) Not in use.
1. The lag alarm is required to be wired to the master alarm panel.
2. The source piping is required to be labeled with color coded directional tape.
3. The source/main valve is required to be labeled with "Gas", "Area Served", and "Do not close except in emergency". This label must be color coded.
4. A drip leg should be installed on the exhaust piping at any dip or loop that can trap condensation.

II Alarms
A) Area Alarms
1. One (1) pressure switch is required to be adjusted to be plus or minus 20% of line pressure.

III Zone Valves
1. Six (6) gauges should be installed downstream of zone valves.
2. One (1) medical air and one (1) oxygen valve leak externally when closed and are required to be repaired.
3. One (1) gauge is inaccurate or broken and is required to be replaced.

IV Contamination Testing
A) Dew Point
1. The dew point of medical air was below the maximum of 39 degrees Fahrenheit.

2. On 01/05/12 at approximately 9:15 a.m., an interview with the engineer manager revealed that the aforementioned deficiencies cited on the medical gas system inspection report dated 12//05/11 and 12/07/11 have not been corrected as of this date 01/05/12.

3. On 01/09/12 at approximately 11:00 a.m., a medical gas system inspection report prepared by Northeast Medical Consulting Incorporated and dated 09/08/11 was reviewed. This report indicated the following deficiencies were found during the medical gas inspection for St. Joseph campus:

I) Source Equipment
A) Medical Air ("A" Building Penthouse)
1. A drain should be available in the room.
2. A gas specific demand check should be installed on the mastwer pressure switch and main gauge.
B) Vacuum ( Penthouse "A" Building) Back-up
1. A gas specific demand check should be installed on the main gauge.

II) Alarms
A) Master Alarms
1. The points listed on page 2 of report should be added at the Engineering master alarm panel for the oxygen system. Page 2 list - Main liquid low, Reserve in use, Reserve low pressure, Low line pressure, High line pressure, and Reserve liquid low.
B) Area Alarms
1. One (1) pressure switch is upstream of the valves and is required to be downstream of the zone valves.

III) Zone Valves
1. 550-564 is missing the vacuum zone valve.
2. The piping is exposed in 251-254-262-263-2E North Cardiac Cath and 255-253 South 2E and requires correction by shielding the piping with a protective cover.
3. 37 gauges should be installed downstream of zone valves.
4. The gauges for 550-564 are currently upstream of the valves and are required to be downstream of valves.
5. One (1) valve box is missing the list of rooms controlled and it is required to be posted.
6. One (1) valve box has an incorrect or outdated list of rooms controlled and it is required to be updated.

IV) Patient Terminal Outlets
1. Nine (9) wall vacuum inlets have flow below the minimum of 3.0 scfm and require correction. Use a vacuum solution to clean the piping and rebuild the inlets to increase flow.
2. Four (4) outlets are missing the "Gas" and "Use No Oil" labels and are required to have it posted on the outlet.
3. Five (5) outlets leak due to worn o-rings and require correction.

V) Contamination Testing
A) Dew Point
1. The dew point of the medical air was below the maximum of 39 degrees Fahrenheit.

4. On 01/10/12 at approximately 1:15 p.m., an interview with the engineer manager revealed that the aforementioned deficiencies cited on the medical gas system inspection report dated 09//08/11 have not been corrected as of this date 01/10/12.

NFPA (National Fire Protection Association) 110 - Standard for Emergency and Standby Power Systems
5-3 Lighting.
5-3.1
The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

This Standard is not met as evidenced by:

Based on observation and staff interview it was determined the hospital failed to maintain the facility generator in accordance with National Fire Protection Association (NFPA) 110.

Findings include:

1. On 01/05/12 at approximately 1:30 p.m., the Memorial Campus generator transfer switch rooms were observed not to have any emergency battery-powered lighting. An interview with the engineering manager on this same date and time confirmed that the generator transfer switch rooms were not equipped with emergency battery-powered lighting.

Based on random observation it was determined the hospital failed to maintain all electrical wiring in accordance with National Fire Protection Association (NFPA) 70.

Findings include:

1. On 01/09/12 at approximately 11:00 a.m., one (1) electrical power strip (relocatable power tap) was observed to be in use in the corridor on the St. Joseph campus 2nd floor patient care unit. Also, at this time an extension cord was observed to be in use for a computer on wheels.

2. On 01/11/12 at approximately 9:00 a.m., three (3) extension cords were observed in use for computers on wheels in the St. Joseph campus post anesthesia care unit (PACU).

Reference:

Underwriters Laboratories (UL) Directory Guide: Relocatable Power Taps Use and Installation
Relocatable power taps have not been investigated and are not intended for use with general patient care areas or critical patient care areas of health care facilities as defined in Article 517 of ANSI/NFPA 70, "National Electrical Code".

NFPA 70 National Electrical Code- 2002 Edition Article 517 Health Care Facilities
517.2 Definitions

Health Care Facilities. Buildings or portions of buildings that contain, but are not limited to, occupancies such as hospitals; nursing homes; limited care; supervisory care; clinics; medical and dental offices; and ambulatory care, whether permanent or movable.

Patient Care Area: Any portion of a health care facility wherein patients are intended to be examined or treated. Areas of a health care facility in which patient care is administered are classified as general care areas or critical care areas, either of which may be classified as a wet location. The governing body of the facility designates these areas in accordance with the type of patient care anticipated and with the following definitions of the area classification. FPN: Business offices, corridors, lounges, day rooms, dining rooms, or similar areas typically are not classified as patient care areas.