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Based on observation, the facility failed to maintain the fire/Smoke doors in operational condition. Fire/Smoke doors which do not close completely can allow fire, heat, smoke, toxic fumes to penetrate an area which is to be protected endangering all persons within the 2 compartments.

The findings include:

During facility tour with the Director of Maintenance at about 1:45 PM on 6/16/2015, it was found that fire/smoke doors outside the kitchen in the hallway hallway, the engine room, the lab hallway door to the ice machine (no hardware on door), the emergency room admittance door and the cross-over hallway door all had problems properly closing. The Fire/Smoke doors are not in accordance with NFPA 101, 19.2.2.2.6 and 7.2.1 NFPA 101 Life Safety Code (2006) 19.2.2.2

Based on document review and staff interview, the facility failed to maintain proper testing and proper documentation for the emergency lighting. Testing of the emergency light helps to ensure emergency lighting in emergency conditions. Failure of emergency lighting may endanger all of the occupants within the facility.

The findings include:

During the document review with the Maintenance Director on 6/16/2015 at 11:30 AM, it was found that the monthly testing of the emergency lights were not being performed consistently and there was no documentation of the annual test. During interview with the maintenance director at that time, it was stated that he had just taken over the position and was not aware of the requirement. Emergency lights must be tested for 30 seconds monthly and 90 minutes annually. Documentation of the tests must be maintained. NFPA 101- 7.9 and 19.2.9.1

Based on document review with maintenance staff, the facility failed to conduct and document the required annual Internal/External disaster drills. These drills increase the knowledge of staff of the action to take in an emergency situation.

The findings include:

During the document review with maintenance staff at 11:00 AM on 6/16/2015, it was found that the annual Internal and External drills had not been done. "Each organizational entity shall implement two or more (Internal & External) specific responses of the emergency operations plan during each year". According to CMS (Centers for Medicare and Medicaid Services), drills must be separated by 4 to 7 months. NFPA 99 Chapter 12 & 17.3.12

Based on observation, the facility failed to utilize an audible alarm appliance in the on-call sleeping room area which could negatively affect those within the room during an emergency situation.

The findings:

During the facility tour with the Director of Maintenance at 2:40 PM on 6/16/2015, the on-call sleeping areas were found not provided with an audible alarm appliance in the following locations: 1) Anesthesia sleep room 2) Radiology sleep room. NFPA 72

7.4.4 Sleeping Areas. 7.4.4.1* Where audible appliances are installed to provide signals for sleeping areas, they shall have a sound level of at least 15 dB above the average ambient sound level or 5 dB above the maximum sound level having a duration of at least 60 seconds or a sound level of at least 75 dBA, whichever is greater, measured at the pillow level in the occupiable area, using the A-weighted scale (dBA).

Based on document review and interview with the Director of Maintenance, it was noted that the facility failed to maintain documentation on the annual testing of receptacles and the exercise of the main breaker. Not testing receptacles could lead to faulty outlets and a possible shock or fire hazard. Also, not exercising the main breaker could lead to a situation where it could malfunction affecting all persons with in the facility.

The findings include:

During document review with the Director of Maintenance at 11:10 am on 6/16/2015, it was found that the proper documentation for maintenance and testing was not being kept per NFPA 101 for the testing of receptacles on an annual basis.

During document review with the Director of Maintenance at 11:15 AM on 6/16/2015, it was found that the proper documentation for maintenance and testing was not being kept in accordance with NFPA 70, National Electrical Code. 9.1.2 for the exercise of the Main and Feeder Breaker.

During interview with the director of maintenance at 11:15 AM on 6/16/2015, it was stated that due to recently taking the position there was a time delay in accomplishing the needed electrical requirements. It was also stated that these items would be corrected immediately.

Receptacle Testing in Patient Care Areas.
NFPA 99 4.3.3.2
A permanent record shall be kept of the results of each of the tests.
(a) The physical integrity of each receptacle shall be con-firmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz)

Based on observation, the facility failed to maintain the fire/Smoke doors in operational condition. Fire/Smoke doors which do not close completely can allow fire, heat, smoke, toxic fumes to penetrate an area which is to be protected endangering all persons within the 2 compartments.

The findings include:

During facility tour with the Director of Maintenance at about 1:45 PM on 6/16/2015, it was found that fire/smoke doors outside the kitchen in the hallway hallway, the engine room, the lab hallway door to the ice machine (no hardware on door), the emergency room admittance door and the cross-over hallway door all had problems properly closing. The Fire/Smoke doors are not in accordance with NFPA 101, 19.2.2.2.6 and 7.2.1 NFPA 101 Life Safety Code (2006) 19.2.2.2

Based on document review and staff interview, the facility failed to maintain proper testing and proper documentation for the emergency lighting. Testing of the emergency light helps to ensure emergency lighting in emergency conditions. Failure of emergency lighting may endanger all of the occupants within the facility.

The findings include:

During the document review with the Maintenance Director on 6/16/2015 at 11:30 AM, it was found that the monthly testing of the emergency lights were not being performed consistently and there was no documentation of the annual test. During interview with the maintenance director at that time, it was stated that he had just taken over the position and was not aware of the requirement. Emergency lights must be tested for 30 seconds monthly and 90 minutes annually. Documentation of the tests must be maintained. NFPA 101- 7.9 and 19.2.9.1

Based on document review with maintenance staff, the facility failed to conduct and document the required annual Internal/External disaster drills. These drills increase the knowledge of staff of the action to take in an emergency situation.

The findings include:

During the document review with maintenance staff at 11:00 AM on 6/16/2015, it was found that the annual Internal and External drills had not been done. "Each organizational entity shall implement two or more (Internal & External) specific responses of the emergency operations plan during each year". According to CMS (Centers for Medicare and Medicaid Services), drills must be separated by 4 to 7 months. NFPA 99 Chapter 12 & 17.3.12

Based on observation, the facility failed to utilize an audible alarm appliance in the on-call sleeping room area which could negatively affect those within the room during an emergency situation.

The findings:

During the facility tour with the Director of Maintenance at 2:40 PM on 6/16/2015, the on-call sleeping areas were found not provided with an audible alarm appliance in the following locations: 1) Anesthesia sleep room 2) Radiology sleep room. NFPA 72

7.4.4 Sleeping Areas. 7.4.4.1* Where audible appliances are installed to provide signals for sleeping areas, they shall have a sound level of at least 15 dB above the average ambient sound level or 5 dB above the maximum sound level having a duration of at least 60 seconds or a sound level of at least 75 dBA, whichever is greater, measured at the pillow level in the occupiable area, using the A-weighted scale (dBA).

Based on document review and interview with the Director of Maintenance, it was noted that the facility failed to maintain documentation on the annual testing of receptacles and the exercise of the main breaker. Not testing receptacles could lead to faulty outlets and a possible shock or fire hazard. Also, not exercising the main breaker could lead to a situation where it could malfunction affecting all persons with in the facility.

The findings include:

During document review with the Director of Maintenance at 11:10 am on 6/16/2015, it was found that the proper documentation for maintenance and testing was not being kept per NFPA 101 for the testing of receptacles on an annual basis.

During document review with the Director of Maintenance at 11:15 AM on 6/16/2015, it was found that the proper documentation for maintenance and testing was not being kept in accordance with NFPA 70, National Electrical Code. 9.1.2 for the exercise of the Main and Feeder Breaker.

During interview with the director of maintenance at 11:15 AM on 6/16/2015, it was stated that due to recently taking the position there was a time delay in accomplishing the needed electrical requirements. It was also stated that these items would be corrected immediately.

Receptacle Testing in Patient Care Areas.
NFPA 99 4.3.3.2
A permanent record shall be kept of the results of each of the tests.
(a) The physical integrity of each receptacle shall be con-firmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz)