HospitalInspections.org

Based on observation the facility failed to provide adequate fire separation between the hospital and the adjacent clinic.

The inspector observed, while accompanied by the Director of Maintenance and the Maintenance Tech during the hours of the inspection from 10:30 am to 2:00 pm on 1/29/2014 that there was a penetration in the fire wall above the clinic door.

Based on observation the facility failed to provide adequate smoke barriers.

The inspector observed, while accompanied by the Director of Maintenance and the Maintenance Tech during the hours of the inspection from 10:30 am to 2:00 pm on 1/29/2014 that there were penetrations in the following smoke barrier locations: 1) by the Kitchen, and 2) by the Nurse Station.

Based on observation the facility failed to provide adequate hazardous area separation.

The inspector observed, while accompanied by the Director of Maintenance and the Maintenance Tech during the hours of the inspection from 10:30 am to 2:00 pm on 1/29/2014 that there were the following issues.

These areas had penetrations in their fire walls: 1) Clean Supply, 2) Soiled Utility, 3) Soiled Linen by the Kitchen, and 4) the Boiler Room.

The following areas required a closer on the door: 1) Clean Supply, 2) Soiled Utility, and 3) Clean Linen by Pharmacy.

The following area did not have a latching door: Central Supply.

Based on observation the facility failed to provide adequate fire drill training.

The inspector observed, while accompanied by the Director of Maintenance and the Maintenance Tech during the hours of the inspection from 10:30 am to 2:00 pm on 1/29/2014 that the staff did not always get training on the RACE acronym after fire drills.

Based on observation the facility failed to provide adequate clearance below the sprinkler heads.

The inspector observed, while accompanied by the Director of Maintenance and the Maintenance Tech during the hours of the inspection from 10:30 am to 2:00 pm on 1/29/2014 that there was not 18 inches clear below the bottom of the sprinkler head in the Central Storage.

Storage 18 " below Heads: " A minimum clearance of 18 inches shall be maintained between the top of storage and sprinkler deflectors " - NFPA 13, 2002: 8.5.6.1.

Based on observation the facility failed to provide adequate medical gas storage.

The inspector observed, while accompanied by the Director of Maintenance and the Maintenance Tech during the hours of the inspection from 10:30 am to 2:00 pm on 1/29/2014 that the bulk oxygen storage location did not have a " No Parking " sign.

In addition, the individual bottles must be restrained such that they cannot fall over.

Storage of flammable liquids

Established laboratory practices shall limit working supplies of flammable or combustible liquids. The total volume of Class I, II, and IIIA liquids outside of approved storage cabinets and safety cans shall not exceed 1 gal (3.78 L) per 100 ft2 (9.23 m2). The total volume of Class I, II, and IIIA liquids, including those contained in approved storage cabinets and safety cans, shall not exceed 2 gal (7.57 L) per 100 ft2 (9.23 m2). No flammable or combustible liquid shall be stored or transferred from one vessel to another in any exit corridor or passageway leading to an exit. At least one approved flammable or combustible liquid storage room shall be available within any health care facility regularly maintaining a reserve storage capacity in excess of 300 gal (1135.5 L). Quantities of flammable and combustible liquids for disposal shall be included in the total inventory. (NFPA 99, 1999, 10-7.2.2)

Based on observation the facility failed to provide adequate storage of flammable liquids.

The inspector observed, while accompanied by the Director of Maintenance and the Maintenance Tech during the hours of the inspection from 10:30 am to 2:00 pm on 1/29/2014 that there were 18, 16 oz. bottles of alcohol stored in a 6 by 8 foot room.


Receptacle Testing in Patient Care Areas - NFFA 99, 1999, 3-3.3.3

(a) The physical integrity of each receptacle shall be confirmed 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).

NFPA 99, 1999, 3-3.4.2.3(a) states that testing shall be performed after initial installation, replacement or servicing of a device, and that additional testing shall be performed at intervals defined by documented performance data. Since data is not typically available from the manufacturer, the facility may document the failure rates of the receptacles and provide a testing schedule that will safeguard their patients. This shall be done by the Safety Committee, approved by the Governing Board, and written into the safety policies and procedures. H.L.R. 2007, ?133.142. Until this assessment has been done, receptacle testing shall be performed in all general care areas every 12 months and in critical care areas every 6 months. (NFPA 99, 1984).

Based on observation the facility failed to provide complete receptacle testing per NFPA 99: 3-3.3.3. in patient care areas.

The inspector observed, while accompanied by the Director of Maintenance and the Maintenance Tech during the hours of the inspection from 10:30 am to 2:00 pm on 1/29/2014 that the retention force tests were not being made.


Line Isolation Monitor Tests.

" The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following:
(a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated.
(b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.
(c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. " - N.F.P.A. 99, 1999, 3-3.3.4.2

Based on observation the facility failed to provide adequate testing.

The inspector observed, while accompanied by the Director of Maintenance and the Maintenance Tech during the hours of the inspection from 10:30 am to 2:00 pm on 1/29/2014 that the line isolation monitors were not being tested.


Fuel and Water Preferred Customer Status

" Continuity of Essential Building Systems. When designated by the emergency preparedness management plan to provide continuous service in a disaster or emergency, health care facilities shall establish contingency plans for the continuity of essential building systems, as applicable: (a) Electricity, (b) Water, (c) Ventilation, (d) Fire protection systems, (e) Fuel sources, (f) Medical gas and vacuum systems (if applicable), (g) Communications systems. " - NFPA 99, 1999, 11-5.3.2

Based on observation the facility failed to provide letters from vendors for emergency fuel and water.

Based on observation the facility failed to provide an adequate electrical system.

The inspector observed, while accompanied by the Director of Maintenance and the Maintenance Tech during the hours of the inspection from 10:30 am to 2:00 pm on 1/29/2014 that there were the following issues.

First, there were no critical power outlets in the med/surge patient rooms.

Second, the outlets in the med/surge rooms were not hospital grade.

Third, there were open j-boxes in the following locations: the maintenance room and the boiler room.

Each patient bed location shall be provided with a minimum of four receptacles. They shall be permitted to be of the single or duplex types or a combination of both. All receptacles, whether four or more, shall be listed " hospital grade " and so identified. Each receptacle shall be grounded by means of an insulted copper conductor sized in accordance the Table 250-122. NFPA 70, 1999, 517-18 (b).

" Each patient bed location shall be supplied by at least two branch circuits, one from the critical branch of the emergency system as required by NFPA 99, ?3-4 and one from the normal system. All branch circuits from the normal system shall originate in the same panelboard. " - HLR, 133.163 (t)(5)(A)(ii)

Based on observation the facility failed to provide adequate fire separation between the hospital and the adjacent clinic.

The inspector observed, while accompanied by the Director of Maintenance and the Maintenance Tech during the hours of the inspection from 10:30 am to 2:00 pm on 1/29/2014 that there was a penetration in the fire wall above the clinic door.

Based on observation the facility failed to provide adequate smoke barriers.

The inspector observed, while accompanied by the Director of Maintenance and the Maintenance Tech during the hours of the inspection from 10:30 am to 2:00 pm on 1/29/2014 that there were penetrations in the following smoke barrier locations: 1) by the Kitchen, and 2) by the Nurse Station.

Based on observation the facility failed to provide adequate hazardous area separation.

The inspector observed, while accompanied by the Director of Maintenance and the Maintenance Tech during the hours of the inspection from 10:30 am to 2:00 pm on 1/29/2014 that there were the following issues.

These areas had penetrations in their fire walls: 1) Clean Supply, 2) Soiled Utility, 3) Soiled Linen by the Kitchen, and 4) the Boiler Room.

The following areas required a closer on the door: 1) Clean Supply, 2) Soiled Utility, and 3) Clean Linen by Pharmacy.

The following area did not have a latching door: Central Supply.

Based on observation the facility failed to provide adequate fire drill training.

The inspector observed, while accompanied by the Director of Maintenance and the Maintenance Tech during the hours of the inspection from 10:30 am to 2:00 pm on 1/29/2014 that the staff did not always get training on the RACE acronym after fire drills.

Based on observation the facility failed to provide adequate clearance below the sprinkler heads.

The inspector observed, while accompanied by the Director of Maintenance and the Maintenance Tech during the hours of the inspection from 10:30 am to 2:00 pm on 1/29/2014 that there was not 18 inches clear below the bottom of the sprinkler head in the Central Storage.

Storage 18 " below Heads: " A minimum clearance of 18 inches shall be maintained between the top of storage and sprinkler deflectors " - NFPA 13, 2002: 8.5.6.1.

Based on observation the facility failed to provide adequate medical gas storage.

The inspector observed, while accompanied by the Director of Maintenance and the Maintenance Tech during the hours of the inspection from 10:30 am to 2:00 pm on 1/29/2014 that the bulk oxygen storage location did not have a " No Parking " sign.

In addition, the individual bottles must be restrained such that they cannot fall over.

Storage of flammable liquids

Established laboratory practices shall limit working supplies of flammable or combustible liquids. The total volume of Class I, II, and IIIA liquids outside of approved storage cabinets and safety cans shall not exceed 1 gal (3.78 L) per 100 ft2 (9.23 m2). The total volume of Class I, II, and IIIA liquids, including those contained in approved storage cabinets and safety cans, shall not exceed 2 gal (7.57 L) per 100 ft2 (9.23 m2). No flammable or combustible liquid shall be stored or transferred from one vessel to another in any exit corridor or passageway leading to an exit. At least one approved flammable or combustible liquid storage room shall be available within any health care facility regularly maintaining a reserve storage capacity in excess of 300 gal (1135.5 L). Quantities of flammable and combustible liquids for disposal shall be included in the total inventory. (NFPA 99, 1999, 10-7.2.2)

Based on observation the facility failed to provide adequate storage of flammable liquids.

The inspector observed, while accompanied by the Director of Maintenance and the Maintenance Tech during the hours of the inspection from 10:30 am to 2:00 pm on 1/29/2014 that there were 18, 16 oz. bottles of alcohol stored in a 6 by 8 foot room.


Receptacle Testing in Patient Care Areas - NFFA 99, 1999, 3-3.3.3

(a) The physical integrity of each receptacle shall be confirmed 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).

NFPA 99, 1999, 3-3.4.2.3(a) states that testing shall be performed after initial installation, replacement or servicing of a device, and that additional testing shall be performed at intervals defined by documented performance data. Since data is not typically available from the manufacturer, the facility may document the failure rates of the receptacles and provide a testing schedule that will safeguard their patients. This shall be done by the Safety Committee, approved by the Governing Board, and written into the safety policies and procedures. H.L.R. 2007, ?133.142. Until this assessment has been done, receptacle testing shall be performed in all general care areas every 12 months and in critical care areas every 6 months. (NFPA 99, 1984).

Based on observation the facility failed to provide complete receptacle testing per NFPA 99: 3-3.3.3. in patient care areas.

The inspector observed, while accompanied by the Director of Maintenance and the Maintenance Tech during the hours of the inspection from 10:30 am to 2:00 pm on 1/29/2014 that the retention force tests were not being made.


Line Isolation Monitor Tests.

" The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following:
(a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated.
(b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.
(c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. " - N.F.P.A. 99, 1999, 3-3.3.4.2

Based on observation the facility failed to provide adequate testing.

The inspector observed, while accompanied by the Director of Maintenance and the Maintenance Tech during the hours of the inspection from 10:30 am to 2:00 pm on 1/29/2014 that the line isolation monitors were not being tested.


Fuel and Water Preferred Customer Status

" Continuity of Essential Building Systems. When designated by the emergency preparedness management plan to provide continuous service in a disaster or emergency, health care facilities shall establish contingency plans for the continuity of essential building systems, as applicable: (a) Electricity, (b) Water, (c) Ventilation, (d) Fire protection systems, (e) Fuel sources, (f) Medical gas and vacuum systems (if applicable), (g) Communications systems. " - NFPA 99, 1999, 11-5.3.2

Based on observation the facility failed to provide letters from vendors for emergency fuel and water.

Based on observation the facility failed to provide an adequate electrical system.

The inspector observed, while accompanied by the Director of Maintenance and the Maintenance Tech during the hours of the inspection from 10:30 am to 2:00 pm on 1/29/2014 that there were the following issues.

First, there were no critical power outlets in the med/surge patient rooms.

Second, the outlets in the med/surge rooms were not hospital grade.

Third, there were open j-boxes in the following locations: the maintenance room and the boiler room.

Each patient bed location shall be provided with a minimum of four receptacles. They shall be permitted to be of the single or duplex types or a combination of both. All receptacles, whether four or more, shall be listed " hospital grade " and so identified. Each receptacle shall be grounded by means of an insulted copper conductor sized in accordance the Table 250-122. NFPA 70, 1999, 517-18 (b).

" Each patient bed location shall be supplied by at least two branch circuits, one from the critical branch of the emergency system as required by NFPA 99, ?3-4 and one from the normal system. All branch circuits from the normal system shall originate in the same panelboard. " - HLR, 133.163 (t)(5)(A)(ii)