HospitalInspections.org

Based on observation and staff interview it was determined the hospital failed to maintain all exhaust ventilation in accordance with NFPA (National Fire Protection Association) 90A.

Findings include:

1. On 07/13/11 at approximately 2:30 p.m., four (4) portable air conditioning units were observed in the lab area. At this time, the return air exhaust duct for the air conditioning units were observed to be attached to lay-in ceiling tiles. An interview with a manager of facilities engineering on this same date and time revealed that the air conditioning units were exhausting air into the concealed space above the lay-in-ceiling. This practice of exhausting air into the ceiling concealed space area is creating a return air plenum. At the time of this survey, there was no certification available to determine that the ceiling concealed space area meets the construction requirements for a return air plenum.

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

Findings include:

1. On 07/11/11 at approximately 2:00 p.m., a medical gas system inspection report prepared by Northeast Medical Consulting Incorporated and dated 02/03/11 was reviewed. This report indicated the following deficiencies were found during the medical gas inspection:

I) Sources
A) Nitrous Oxide
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.

B) Nitrogen
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.

C) Carbon Dioxide
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) Medical Air (6A64 Mechanical Room)
1. A gas specific demand check should be installed on the master pressure switch and main gauge.

E) Vacuum
1. A gas specific demand check should be installed on the master low vacuum switch.
2. A gas specific demand check should be installed on the main gauge.
3. A drip leg should be installed on the exhaust piping at any dip or loop that can trap condensation.

II Zone Valves
1. One (1) valve box is obstructed and inaccessible and requires correction.
2. One (1) valve box cover is broken and is required to be replaced.
3. One (1) gauge is inaccurate or broken and is required to be replaced.
4. Eleven (11) valves leaking during opening and closing of valves.

2. On 07/12/11 at approximately 3:15 p.m., an interview with the manager of facilities engineering revealed that the aforementioned deficiencies cited on the medical gas system inspection report dated 02/03/11 have not been corrected as of this date 07/12/11.

NFPA 70 - National Electrical Code
Chapter 5 - Special Occupancies
Article 517 - Health Care Facilities
517-20. Wet Locations
a. All receptacles and fixed equipment within the area of the wet location shall have ground-fault circuit-interrupter protection for personnel if interruption of power under fault conditions can be tolerated, or be served by an isolated power system if such interruption cannot be tolerated.

This Standard is not met as evidenced by:

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

Findings include:

1. On 07/12/11 at approximately 10:00 a.m., four (4) electrical receptacles near sinks in the dentistry room located on 7 west were observed not to be GFCI (ground fault circuit interrupter) receptacles.

Based on observation and staff interview it was determined the hospital failed to maintain all exhaust ventilation in accordance with NFPA (National Fire Protection Association) 90A.

Findings include:

1. On 07/13/11 at approximately 2:30 p.m., four (4) portable air conditioning units were observed in the lab area. At this time, the return air exhaust duct for the air conditioning units were observed to be attached to lay-in ceiling tiles. An interview with a manager of facilities engineering on this same date and time revealed that the air conditioning units were exhausting air into the concealed space above the lay-in-ceiling. This practice of exhausting air into the ceiling concealed space area is creating a return air plenum. At the time of this survey, there was no certification available to determine that the ceiling concealed space area meets the construction requirements for a return air plenum.

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

Findings include:

1. On 07/11/11 at approximately 2:00 p.m., a medical gas system inspection report prepared by Northeast Medical Consulting Incorporated and dated 02/03/11 was reviewed. This report indicated the following deficiencies were found during the medical gas inspection:

I) Sources
A) Nitrous Oxide
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.

B) Nitrogen
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.

C) Carbon Dioxide
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) Medical Air (6A64 Mechanical Room)
1. A gas specific demand check should be installed on the master pressure switch and main gauge.

E) Vacuum
1. A gas specific demand check should be installed on the master low vacuum switch.
2. A gas specific demand check should be installed on the main gauge.
3. A drip leg should be installed on the exhaust piping at any dip or loop that can trap condensation.

II Zone Valves
1. One (1) valve box is obstructed and inaccessible and requires correction.
2. One (1) valve box cover is broken and is required to be replaced.
3. One (1) gauge is inaccurate or broken and is required to be replaced.
4. Eleven (11) valves leaking during opening and closing of valves.

2. On 07/12/11 at approximately 3:15 p.m., an interview with the manager of facilities engineering revealed that the aforementioned deficiencies cited on the medical gas system inspection report dated 02/03/11 have not been corrected as of this date 07/12/11.

NFPA 70 - National Electrical Code
Chapter 5 - Special Occupancies
Article 517 - Health Care Facilities
517-20. Wet Locations
a. All receptacles and fixed equipment within the area of the wet location shall have ground-fault circuit-interrupter protection for personnel if interruption of power under fault conditions can be tolerated, or be served by an isolated power system if such interruption cannot be tolerated.

This Standard is not met as evidenced by:

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

Findings include:

1. On 07/12/11 at approximately 10:00 a.m., four (4) electrical receptacles near sinks in the dentistry room located on 7 west were observed not to be GFCI (ground fault circuit interrupter) receptacles.