HospitalInspections.org

Based on observation and staff interviews, the facility failed to assure that the 2 hour wall separating the health care facility from the business occupancy is sealed, failing to provide the proper fire resistance rating. This affects 2 of the 4 smoke zones. The facility has a capacity of 25 in patients with a census of 10 at the time of survey.

Findings Include:

During the survey on 4-15-2010 between 9:15 A.M. and 3:45 P.M. the following is
observed:

The 2 hour wall separating healthcare from business occupancy has wiring passing through the wall in conduit sleeves that are not properly sealed as follows:
a. 3 conduit sleeves located above the ceiling tile level at the entrance to the surgery corridor are missing fire resistant sealant.
b. 1 conduit sleeve located above the ceiling tile level at the entrance to the clinic area from the main lobby.

Staff B was present and stated that recently some data or communication systems work had been performed by an outside contractor and that the conduit sleeves would be sealed immediately with a code compliant material. Surveyor confirmed that sealant had been properly applied at the time of the survey.

Based on observation and staff interview the facility failed to ensure proper separation of the gift shop from other spaces. This deficient practice would allow for the spread of smoke and fire to travel into the adjacent area, affecting 2 of 4 smoke zones. The facility has a capacity of 25 in patients with a census of 10 at the time of survey.

Findings Include:

During the survey on 4-15-2010 between 9:15 A.M. and 3:45 P.M. the following is observed:

The door between the main lobby area and gift shop was held open by a wooden wedge.

Staff B removed the wooden wedge at the time of the survey. Gift shop volunteers informed Staff B that the gift shop door was being wedged open because "customers could not tell if the gift shop was open with the door closed".

Based on observation and staff interview the facility failed to ensure proper separation of hazardous areas from other spaces. This deficient practice would allow for the spread of smoke and fire to travel into the adjacent area, affecting 1 of 4 smoke zones. The facility has a capacity of 25 in patients with a census of 10 at the time of survey.

Findings Include:

During the survey on 4-15-2010 between 9:15 A.M. and 3:45 P.M. the following is observed:

--1 The dirty housekeeping room door in the surgery area door did not latch. The latching mechanism and striking plate had both been taped over to prevent the door from latching.
--2 The surgical storage room door was held open by a wooden wedge.

Staff B removed the tape at the time of the survey allowing the door to latch and the wooden wedge. Later during the survey a housekeeper asked Staff B about the tape that had been removed from the door and stated that the housekeeper stated the tape was placed on the door because the door locks when allowed to latch and housekeeping enters the room frequently. Staff B informed the housekeeper that the door must latch.

Based on record review and staff interviews, the facility failed to assure that the sprinkler system is maintained and tested in accordance with the NFPA 13 and NFPA 25. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting 4 of the 4 smoke zones. The facility has a capacity of 25 in patients with a census of 10 at the time of survey.

Findings Include:

During the survey on 4-15-2010 between 9:15 A.M. and 3:45 P.M. the following is observed:

--1 No documentation of monthly inspections of the sprinkler system
--2 Record review indicates the sprinkler system is past due for the quarterly flow test. The last documented flow test was 12/3/2009.

Staff B was present and acknowledged that the sprinkler system needs to be properly maintained, inspected and flow tested quarterly.

Based on observation, record review and staff interview, the facility failed to provide documentation proving that water heaters requiring a boiler inspection have been inspected and certified. Failure to comply with the State's inspection requirements could result in a hazardous condition due improper installation or the malfunction of a heat-producing appliance. The facility has a capacity of 25 in patients with a census of 10 at the time of survey.

Findings Include:

During the survey on 4-15-2010 between 9:15 A.M. and 3:45 P.M. the following is observed:

Water heaters 1 and 2 in the boiler room installed in 2009 do not have current boiler certificates posted. Observation revealed that both water heaters had been inspected by the State of Kansas Boiler Inspector, because identification numbers KS56195 and KS56196 had been issued but no boiler certificates were posted.

Staff B was present, observed the finding, and acknowledged the cited deficiency at the time of the finding with this KSFM surveyor.

Based on record review and staff interview the facility failed to conduct and properly document testing, inspection and maintenance of the generator in accordance with NFPA 99 and NFPA 110. This deficient practice fails to ensure that the generator will not fail when needed in the event of an emergency, affecting all 4 of 4 smoke zones. The facility has a capacity of 25 in patients with a census of 10 at the time of survey.

Findings Include:

During the survey on 4-15-2010 between 9:15 A.M. and 3:45 P.M. the following is observed:

--1 No monthly load testing of the generator has been conducted or documentation provided
--2 No weeking inspection of the generator has been recorded or conducted

Staff C, the employee assigned for maintenance of the generator, stated that the generator is exercised weekly but the load testing and weekly inspections have not been performed or documented.

Based on observation and staff interview the facility failed to assure that electrical equipment is properly maintained and installed in accordance with NFPA 70, National Electric Code. This deficient practice could cause an electrical failure or fire, affecting 1 out of 4 smoke zones. The facility has a capacity of 25 in patients with a census of 10 at the time of survey.

Findings Include:

During the survey on 4-15-2010 between 9:15 A.M. and 3:45 P.M. the following is observed:

Wiring and cable from the PYXIS med machine passes through the ceiling tile from one side of the room to the other in the med-surg drug room.

Staff B was present, observed the finding, and acknowledged the cited deficiency at the time of the survey and this surveyor was informed by Staff B that the pharmacist placed a call to the installation company to expedite the needed repairs.

Based on observation and staff interviews, the facility failed to assure that the 2 hour wall separating the health care facility from the business occupancy is sealed, failing to provide the proper fire resistance rating. This affects 2 of the 4 smoke zones. The facility has a capacity of 25 in patients with a census of 10 at the time of survey.

Findings Include:

During the survey on 4-15-2010 between 9:15 A.M. and 3:45 P.M. the following is
observed:

The 2 hour wall separating healthcare from business occupancy has wiring passing through the wall in conduit sleeves that are not properly sealed as follows:
a. 3 conduit sleeves located above the ceiling tile level at the entrance to the surgery corridor are missing fire resistant sealant.
b. 1 conduit sleeve located above the ceiling tile level at the entrance to the clinic area from the main lobby.

Staff B was present and stated that recently some data or communication systems work had been performed by an outside contractor and that the conduit sleeves would be sealed immediately with a code compliant material. Surveyor confirmed that sealant had been properly applied at the time of the survey.

Based on observation and staff interview the facility failed to ensure proper separation of the gift shop from other spaces. This deficient practice would allow for the spread of smoke and fire to travel into the adjacent area, affecting 2 of 4 smoke zones. The facility has a capacity of 25 in patients with a census of 10 at the time of survey.

Findings Include:

During the survey on 4-15-2010 between 9:15 A.M. and 3:45 P.M. the following is observed:

The door between the main lobby area and gift shop was held open by a wooden wedge.

Staff B removed the wooden wedge at the time of the survey. Gift shop volunteers informed Staff B that the gift shop door was being wedged open because "customers could not tell if the gift shop was open with the door closed".

Based on observation and staff interview the facility failed to ensure proper separation of hazardous areas from other spaces. This deficient practice would allow for the spread of smoke and fire to travel into the adjacent area, affecting 1 of 4 smoke zones. The facility has a capacity of 25 in patients with a census of 10 at the time of survey.

Findings Include:

During the survey on 4-15-2010 between 9:15 A.M. and 3:45 P.M. the following is observed:

--1 The dirty housekeeping room door in the surgery area door did not latch. The latching mechanism and striking plate had both been taped over to prevent the door from latching.
--2 The surgical storage room door was held open by a wooden wedge.

Staff B removed the tape at the time of the survey allowing the door to latch and the wooden wedge. Later during the survey a housekeeper asked Staff B about the tape that had been removed from the door and stated that the housekeeper stated the tape was placed on the door because the door locks when allowed to latch and housekeeping enters the room frequently. Staff B informed the housekeeper that the door must latch.

Based on record review and staff interviews, the facility failed to assure that the sprinkler system is maintained and tested in accordance with the NFPA 13 and NFPA 25. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting 4 of the 4 smoke zones. The facility has a capacity of 25 in patients with a census of 10 at the time of survey.

Findings Include:

During the survey on 4-15-2010 between 9:15 A.M. and 3:45 P.M. the following is observed:

--1 No documentation of monthly inspections of the sprinkler system
--2 Record review indicates the sprinkler system is past due for the quarterly flow test. The last documented flow test was 12/3/2009.

Staff B was present and acknowledged that the sprinkler system needs to be properly maintained, inspected and flow tested quarterly.

Based on observation, record review and staff interview, the facility failed to provide documentation proving that water heaters requiring a boiler inspection have been inspected and certified. Failure to comply with the State's inspection requirements could result in a hazardous condition due improper installation or the malfunction of a heat-producing appliance. The facility has a capacity of 25 in patients with a census of 10 at the time of survey.

Findings Include:

During the survey on 4-15-2010 between 9:15 A.M. and 3:45 P.M. the following is observed:

Water heaters 1 and 2 in the boiler room installed in 2009 do not have current boiler certificates posted. Observation revealed that both water heaters had been inspected by the State of Kansas Boiler Inspector, because identification numbers KS56195 and KS56196 had been issued but no boiler certificates were posted.

Staff B was present, observed the finding, and acknowledged the cited deficiency at the time of the finding with this KSFM surveyor.

Based on record review and staff interview the facility failed to conduct and properly document testing, inspection and maintenance of the generator in accordance with NFPA 99 and NFPA 110. This deficient practice fails to ensure that the generator will not fail when needed in the event of an emergency, affecting all 4 of 4 smoke zones. The facility has a capacity of 25 in patients with a census of 10 at the time of survey.

Findings Include:

During the survey on 4-15-2010 between 9:15 A.M. and 3:45 P.M. the following is observed:

--1 No monthly load testing of the generator has been conducted or documentation provided
--2 No weeking inspection of the generator has been recorded or conducted

Staff C, the employee assigned for maintenance of the generator, stated that the generator is exercised weekly but the load testing and weekly inspections have not been performed or documented.

Based on observation and staff interview the facility failed to assure that electrical equipment is properly maintained and installed in accordance with NFPA 70, National Electric Code. This deficient practice could cause an electrical failure or fire, affecting 1 out of 4 smoke zones. The facility has a capacity of 25 in patients with a census of 10 at the time of survey.

Findings Include:

During the survey on 4-15-2010 between 9:15 A.M. and 3:45 P.M. the following is observed:

Wiring and cable from the PYXIS med machine passes through the ceiling tile from one side of the room to the other in the med-surg drug room.

Staff B was present, observed the finding, and acknowledged the cited deficiency at the time of the survey and this surveyor was informed by Staff B that the pharmacist placed a call to the installation company to expedite the needed repairs.