HospitalInspections.org

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Based on the observation of all doors opening onto the corridor on 6/24/2015, the facility failed to maintain corridor door that resisted the passage of smoke. Findings include:

1. Door to ER registration had a ¼" hole above hardware set which would allow the passage of smoke.
2. Door to Endoscopy had two (2) ¼" holes at latch set which would allow the passage of smoke.
3. Door to Ultrasound had four (4) ¼" holes around latch set that would not resist the passage of smoke.
4. Doors to Resident Rooms 105 and 106 hitting end of bed when attempt was made to close resident room doors.

This deficiency impacted 1 of 6 smoke compartments.
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2000 NFPA 101, 19.3.6.3.1* Corridor Doors. Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
CMS 2786R (02/2013) - There is no impediment to the closing of the doors.
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Based on the observation of exit lights throughout the facility on 6/24/2015, the facility failed to maintain exit signs with continuous illumination. Findings include:

1. Exit sign inside the mobile MRI trailer did not illuminate when test button was activated.
2. At IT building the illuminated exit sign would turn off when test switch was activated.

This deficiency impacted 2 of 4 smoke compartments.
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2000 NFPA 101, 7.10.1.4 Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
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The facility failed to provide readily accessible exit access. Findings include:

1. The door to Oxygen Tank Storage Room located at loading dock had a hasp and pad lock being used to lock the door.
2. The door into Janitor Chemical Storage Room located at loading dock had a hasp and pad lock being used to lock the door.

This deficiency impacted 1 of 4 smoke compartments.
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2000 NFPA 101, 7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
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The facility failed to maintain continuous lighting for means of egress. Findings include:

1. Emergency light inside the mobile MRI trailer did not illuminate when test button was pressed.
2. At IT building, the Emergency light did not illuminate when test button was pressed.
3. No emergency light provided inside the medical records space located off the back of the hospital

This deficiency impacted 3 of 4 smoke compartments.
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2000 NFPA 101, 7.8.1.1* Illumination of means of egress shall be provided in accordance with Section 7.8 for every building and structure where required in Chapters 11 through 42. For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, aisles, corridors, ramps, escalators, walkways, and exit passageways leading to a public way.
2000 NFPA 101, 7.8.1.2 Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use. Artificial lighting shall be employed at such locations and for such periods of time as required to maintain the illumination to the minimum criteria values herein specified.
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The facility failed to conduct fire drills per code. Findings include:

Third Quarter and Second Shift had no fire drills conducted.

This deficiency impacted 4 of 4 smoke compartments.
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2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 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. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
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Based on the observation on 6/24/2015, the facility failed to maintain the fire sprinkler system. Findings include:

1. At the Maintenance Shop, there was lumber stored on top of the sprinkler piping and wire hanging from the sprinkler piping.
2. At the Mechanical Room, at the ER/OR entrance, the doors to the mechanical room had been removed exposing the sprinkler lines to outside elements. Surveyor noted that the sprinkler lines could not be maintained at the required forty degrees as required by code.

This deficiency impacted 1 of 4 smoke compartments.
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1998 NFPA 25, 2-2.2* Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
1998 NFPA 25, 2-2.5 Buildings. Annually, prior to the onset of freezing weather, buildings with wet pipe systems shall be inspected to verify that windows, skylights, doors, ventilators, other openings and closures, blind spaces, unused attics, stair towers, roof houses, and low spaces under buildings do not expose water-filled sprinkler piping to freezing and to verify that adequate heat [minimum 40°F (4.4°C)] is available.
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Based on the observation of the facilities designated smoking area on 6/24/2015, the facility failed to maintain smoking area.

The designated smoking areas for employees and family smoking were not provided with noncombustible ashtrays.
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NFPA 101, 19.7.
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The facility failed to provide a readily accessible means of egress pathway at all times.
Findings include:

1. This surveyor noted that upon entering the facility on June 24 at 9:45 A.M; located in the corridor outside the kitchen and dining room carts and a serving steam table were stored in the corridor. Both carts and steam table were observed again at 3:00 P.M. still sitting in the corridor outside the kitchen.

2. This surveyor noted that upon entering the facility on June 24 at 9:45 A.M; located in the main corridor outside Material Management, a hospital bed was sitting in the corridor. At 3:00 P.M; the bed was observed again at 3:00 P.M. still sitting in the corridor outside Materials Management.

3. This surveyor noted that upon entering the facility on June 24 at 9:45 A.M; located in the main corridor leading to Imaging a portable x-ray machine, a patient lift, and carts were sitting in the corridor. At 3:00 P.M. the portable x-ray machine, patient lift, and carts were observed again still sitting in the corridor leading to Imaging.

This deficiency impacted 1 of 4 smoke compartments.
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2000 NFPA 101, 7.1.10.1* Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
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Based on the observation on 6/24/2015, the facility failed to maintain the area free of flammable materials around the bulk oxygen storage and securing the secondary oxygen storage tanks. Findings include:

1. This surveyor noted leaves and grass inside the bulk oxygen storage enclosure.
2. The secondary gas storage manifold system had tanks that were not secured individually as required by code.

This deficiency impacted 4 of 4 smoke compartments.
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1999 NFPA 99 4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement). Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials [see also 4-3.1.1.2(a)7]
1999 NFPA 99, 4-3.1.1.1 and 4-5.1.1.1 Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.
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1. Based on the observation on 06/24/2015, the facility failed to maintain generator notification components.

The facility failed to provide an annunciator panel for the emergency generator powering the OR/ER. Without the annunciator panel, the facility was not able to readily observe generator status.

2. Based on the observation of the oxygen storage area on 6/24/2015, the facility failed to maintain the storage space per code. Findings include:

In the oxygen storage area at the loading dock the Oxygen Storage Room had a HVAC unit inside the room mounted below the five (5 ') foot minimum mounting height as stated in the code.

3. The facility failed to have installed a generator in accordance with NFPA 99, Standard for Health Care Facilities, for a health care occupancy that normally uses life-support devices

The natural gas generator used to provide power for the OR and ER was observed not to have on-site fuel, for a minimum of 96 hours of operation. Or have a letter from the natural gas supplier stating that the natural gas is 100% reliable. Per CMS, the following is required in the letter from the natural gas supplier:
a. A statement of 100% reliability of the natural gas delivery.
b. A brief description that supports the statement regarding the reliability.
c. A statement that there is no probability of interruption of the natural gas.
d. A brief description that supports the statement regarding no probability of interruption.
e. The signature of technical personnel from the natural gas vendor.

This deficiency impacted 1 of 4 smoke compartments.
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NFPA 99, 1999, 3-4.1.1.15 + Alarm Annunciator. A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows: (a) Individual visual signals shall indicate the following: 1. When the emergency or auxiliary power source is operating to supply power to load 2. When the battery charger is malfunctioning (b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following: 1. Low lubricating oil pressure 2. Low water temperature (below those required in 3-4.1.1.9) 3. Excessive water temperature 4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply 5. Overcrank (failed to start) 6. Overspeed Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]
1999 NFPA 99, 4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement). 4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.
1999 NFPA 99, 12-3.3.1 If electrical life support equipment is required, the essential electrical distribution system shall conform to a Type 1 system as described in Chapter 3.
1999 NFPA 99, 3-4.1.1.13 Fuel Supply. The fuel supply for the generator set shall comply with 3-1.1 and 3-4.2 of NFPA 110, Standard for Emergency and Standby Power Systems.
1999 NFPA 110, 3-1.1 The following energy sources shall be permitted for use for the emergency power supply (EPS):
(a) * Liquid petroleum products at atmospheric pressure
(b) Liquefied petroleum gas (liquid or vapor withdrawal)
(c) Natural or synthetic gas
Exception: For Level 1 installations in locations where the probability of interruption of off-site fuel supplies is high (e.g., due to earthquake, flood damage, or a demonstrated utility unreliability), on-site storage of an alternate energy source sufficient to allow full output of the emergency power supply system (EPSS) to be delivered for the class specified shall be required, with provision for automatic transfer from the primary energy source to the alternate energy source.
3-1.2* The performance of a Level 1 EPSS in seismic risk areas shall be based on the EPS equipment operating a minimum of 96 hours without refueling if the need for an EPS persists for this period of time
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Based on the observation of all doors opening onto the corridor on 6/24/2015, the facility failed to maintain corridor door that resisted the passage of smoke. Findings include:

1. Door to ER registration had a ¼" hole above hardware set which would allow the passage of smoke.
2. Door to Endoscopy had two (2) ¼" holes at latch set which would allow the passage of smoke.
3. Door to Ultrasound had four (4) ¼" holes around latch set that would not resist the passage of smoke.
4. Doors to Resident Rooms 105 and 106 hitting end of bed when attempt was made to close resident room doors.

This deficiency impacted 1 of 6 smoke compartments.
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2000 NFPA 101, 19.3.6.3.1* Corridor Doors. Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
CMS 2786R (02/2013) - There is no impediment to the closing of the doors.
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Based on the observation of exit lights throughout the facility on 6/24/2015, the facility failed to maintain exit signs with continuous illumination. Findings include:

1. Exit sign inside the mobile MRI trailer did not illuminate when test button was activated.
2. At IT building the illuminated exit sign would turn off when test switch was activated.

This deficiency impacted 2 of 4 smoke compartments.
_________________

2000 NFPA 101, 7.10.1.4 Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
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The facility failed to provide readily accessible exit access. Findings include:

1. The door to Oxygen Tank Storage Room located at loading dock had a hasp and pad lock being used to lock the door.
2. The door into Janitor Chemical Storage Room located at loading dock had a hasp and pad lock being used to lock the door.

This deficiency impacted 1 of 4 smoke compartments.
______________

2000 NFPA 101, 7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
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The facility failed to maintain continuous lighting for means of egress. Findings include:

1. Emergency light inside the mobile MRI trailer did not illuminate when test button was pressed.
2. At IT building, the Emergency light did not illuminate when test button was pressed.
3. No emergency light provided inside the medical records space located off the back of the hospital

This deficiency impacted 3 of 4 smoke compartments.
_____________________

2000 NFPA 101, 7.8.1.1* Illumination of means of egress shall be provided in accordance with Section 7.8 for every building and structure where required in Chapters 11 through 42. For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, aisles, corridors, ramps, escalators, walkways, and exit passageways leading to a public way.
2000 NFPA 101, 7.8.1.2 Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use. Artificial lighting shall be employed at such locations and for such periods of time as required to maintain the illumination to the minimum criteria values herein specified.
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The facility failed to conduct fire drills per code. Findings include:

Third Quarter and Second Shift had no fire drills conducted.

This deficiency impacted 4 of 4 smoke compartments.
__________________

2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 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. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
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Based on the observation on 6/24/2015, the facility failed to maintain the fire sprinkler system. Findings include:

1. At the Maintenance Shop, there was lumber stored on top of the sprinkler piping and wire hanging from the sprinkler piping.
2. At the Mechanical Room, at the ER/OR entrance, the doors to the mechanical room had been removed exposing the sprinkler lines to outside elements. Surveyor noted that the sprinkler lines could not be maintained at the required forty degrees as required by code.

This deficiency impacted 1 of 4 smoke compartments.
_____________

1998 NFPA 25, 2-2.2* Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
1998 NFPA 25, 2-2.5 Buildings. Annually, prior to the onset of freezing weather, buildings with wet pipe systems shall be inspected to verify that windows, skylights, doors, ventilators, other openings and closures, blind spaces, unused attics, stair towers, roof houses, and low spaces under buildings do not expose water-filled sprinkler piping to freezing and to verify that adequate heat [minimum 40°F (4.4°C)] is available.
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Based on the observation of the facilities designated smoking area on 6/24/2015, the facility failed to maintain smoking area.

The designated smoking areas for employees and family smoking were not provided with noncombustible ashtrays.
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NFPA 101, 19.7.
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The facility failed to provide a readily accessible means of egress pathway at all times.
Findings include:

1. This surveyor noted that upon entering the facility on June 24 at 9:45 A.M; located in the corridor outside the kitchen and dining room carts and a serving steam table were stored in the corridor. Both carts and steam table were observed again at 3:00 P.M. still sitting in the corridor outside the kitchen.

2. This surveyor noted that upon entering the facility on June 24 at 9:45 A.M; located in the main corridor outside Material Management, a hospital bed was sitting in the corridor. At 3:00 P.M; the bed was observed again at 3:00 P.M. still sitting in the corridor outside Materials Management.

3. This surveyor noted that upon entering the facility on June 24 at 9:45 A.M; located in the main corridor leading to Imaging a portable x-ray machine, a patient lift, and carts were sitting in the corridor. At 3:00 P.M. the portable x-ray machine, patient lift, and carts were observed again still sitting in the corridor leading to Imaging.

This deficiency impacted 1 of 4 smoke compartments.
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2000 NFPA 101, 7.1.10.1* Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
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Based on the observation on 6/24/2015, the facility failed to maintain the area free of flammable materials around the bulk oxygen storage and securing the secondary oxygen storage tanks. Findings include:

1. This surveyor noted leaves and grass inside the bulk oxygen storage enclosure.
2. The secondary gas storage manifold system had tanks that were not secured individually as required by code.

This deficiency impacted 4 of 4 smoke compartments.
___________________

1999 NFPA 99 4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement). Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials [see also 4-3.1.1.2(a)7]
1999 NFPA 99, 4-3.1.1.1 and 4-5.1.1.1 Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.
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1. Based on the observation on 06/24/2015, the facility failed to maintain generator notification components.

The facility failed to provide an annunciator panel for the emergency generator powering the OR/ER. Without the annunciator panel, the facility was not able to readily observe generator status.

2. Based on the observation of the oxygen storage area on 6/24/2015, the facility failed to maintain the storage space per code. Findings include:

In the oxygen storage area at the loading dock the Oxygen Storage Room had a HVAC unit inside the room mounted below the five (5 ') foot minimum mounting height as stated in the code.

3. The facility failed to have installed a generator in accordance with NFPA 99, Standard for Health Care Facilities, for a health care occupancy that normally uses life-support devices

The natural gas generator used to provide power for the OR and ER was observed not to have on-site fuel, for a minimum of 96 hours of operation. Or have a letter from the natural gas supplier stating that the natural gas is 100% reliable. Per CMS, the following is required in the letter from the natural gas supplier:
a. A statement of 100% reliability of the natural gas delivery.
b. A brief description that supports the statement regarding the reliability.
c. A statement that there is no probability of interruption of the natural gas.
d. A brief description that supports the statement regarding no probability of interruption.
e. The signature of technical personnel from the natural gas vendor.

This deficiency impacted 1 of 4 smoke compartments.
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NFPA 99, 1999, 3-4.1.1.15 + Alarm Annunciator. A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows: (a) Individual visual signals shall indicate the following: 1. When the emergency or auxiliary power source is operating to supply power to load 2. When the battery charger is malfunctioning (b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following: 1. Low lubricating oil pressure 2. Low water temperature (below those required in 3-4.1.1.9) 3. Excessive water temperature 4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply 5. Overcrank (failed to start) 6. Overspeed Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]
1999 NFPA 99, 4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement). 4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.
1999 NFPA 99, 12-3.3.1 If electrical life support equipment is required, the essential electrical distribution system shall conform to a Type 1 system as described in Chapter 3.
1999 NFPA 99, 3-4.1.1.13 Fuel Supply. The fuel supply for the generator set shall comply with 3-1.1 and 3-4.2 of NFPA 110, Standard for Emergency and Standby Power Systems.
1999 NFPA 110, 3-1.1 The following energy sources shall be permitted for use for the emergency power supply (EPS):
(a) * Liquid petroleum products at atmospheric pressure
(b) Liquefied petroleum gas (liquid or vapor withdrawal)
(c) Natural or synthetic gas
Exception: For Level 1 installations in locations where the probability of interruption of off-site fuel supplies is high (e.g., due to earthquake, flood damage, or a demonstrated utility unreliability), on-site storage of an alternate energy source sufficient to allow full output of the emergency power supply system (EPSS) to be delivered for the class specified shall be required, with provision for automatic transfer from the primary energy source to the alternate energy source.
3-1.2* The performance of a Level 1 EPSS in seismic risk areas shall be based on the EPS equipment operating a minimum of 96 hours without refueling if the need for an EPS persists for this period of time
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