HospitalInspections.org

This STANDARD was not met as evidenced by:

Based on observation and staff interview, the facility failed to ensure that all construction-related penetrations in corridor walls were patched to resist the passage of smoke. A total of four openings affected the smoke resistance of the exit corridors on the "A" side of the building.

Findings include:

On 4/5/12 at approximately 2:00 PM, selected ceiling tiles were randomly removed near the smoke barriers. The following penetrations in the corridor walls were revealed:

a) One foot by one foot opening in the wall between the corridor and the Janitor's Closet,
b) Eight inch by eight inch opening in the wall between the corridor and the Electrical Room,
c) Eight inch by eighteen inch opening in the corridor wall between the "A" side and Main Hallway,
d) Fourteen inch by ten inch opening in the corridor wall near entry to the 300 Hall.

The Maintenance Supervisor was interviewed and he indicated that the openings were created by a contractor who had recently installed a wireless communication system. The Maintenance Supervisor indicated that the contractor would be called back to patch the holes, under warrantee.

This STANDARD was not met as evidenced by:

Based on observation the facility failed to ensure that there were no impediments to the closing of patient room doors which opened onto the common area of each Hall. One of six halls was affected by this deficient practice.

Findings include:

On 4/4/12 at 9:45 AM, it was observed that the hooks supporting the Infection Control Kit and hanging over the top of the door to patient room #219 interfered with the latching of that door. Two other doors with Kits were observed as being difficult to close, although they did eventually latch.

NFPA 101, 9.6.1.3 The provisions of section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.

9.6.1.4 A fire alarm system required for life safety shall be installed, tested and maintained in accordance with the applicable requirements of National Fire Protection Association (NFPA) 70, National Electric Code, and NFPA 72, National Fire Alarm Code...


This STANDARD was not met as evidenced by:

Based on document review, the facility failed to ensure that all of their smoke detectors passed smoke sensitivity testing. This condition elevated the risk of fire/smoke injuries for staff and residents in three of six patient care pods, and common areas (i.e. Admin., Dining, etc.). (Note: Patient rooms in the 400, 500, and 600 Pods are protected by single-station, smoke detection devices.)

Findings include:

This deficient practice was first revealed on 12/20/11 during a survey of the SNF located within the Hospital. The facility's maintenance records showed that 41 of 98 (42%) smoke detectors failed the smoke sensitivity test. The test results were detailed in the facility's, Simplex/Grinnell report dated 12/2/11. The facility's Plan of Correction (POC) for the SNF was dated 1/9/12 and it stated, "The upgrade of the (smoke detector) panel should eliminate any current deficiencies". The date of completion given by the facility was, "February 6, 2012 pending vendor approval and availability".

On 4/4/12 during a survey of the Hospital, it was discovered that there was no action taken to address the smoke sensitivity failures identified in the Simplex/Grinnell report. The facility did have a proposal to install a new fire alarm system including; new, addressable, smoke detectors. The facility produced a copy of an e-mail, dated 4/5/12 from EDS Electronics indicting that proposed that work could begin on 4/9/12 and could be completed by mid August, 2012. (Note: Smoke detector, "actuation" testing between 5/16/11 and 2/15/12 by EDS Electronics indicates that all detectors passed.)

These findings were acknowledged by the CEO, Maintenance Manager, and Department Heads during the exit interview on 4/5/12.

NFPA 13 (2010 ed.), 8.3.3.2 Where quick response sprinklers are installed, all sprinklers within a compartment shall be quick response unless otherwise permitted in 8.3.3.3.

This STANDARD was not met:

Based on observation, the facility failed to ensure that all sprinklers within a compartment were either standard response or quick response. This condition was found in one, non-patient, room within the building.

Findings include:

On 4/5/12 at 9:15 AM it was observed that in the Respiratory Hold Room there were two un-matched sprinkler heads. One was a red, frangible-bulb, quick response sprinkler head and the other was a fusible-link, side sprinkler head.

NFPA 10 (2002 ed) 1.5.6* Fire extinguishers shall not be obstructed or obscured from view. In large rooms, and in certain locations where visual obstructions cannot be completely avoided, means shall be provided to indicate the extinguisher location.

This STANDARD was not met as evidenced by:

Based on observation and staff interview the facility failed to provide unobstructed access to one portable, Type K, fire extinguisher in the Dietary Department.

Findings include:

On 4/5/12 at 2:30 PM it was observed that access to both the type K fire extinguisher and the pull actuator for the Ansul unit in the kitchen were obstructed by the storage of food carts in front of these fire-control devices. The Maintenance Supervisor and a Dietary employee indicated that they recently acquired new food carts, and had not yet found a place for the old carts.

WET LOCATIONS:
NFPA 70, Section 517-20(a) Wet Locations. 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.

ITEMS NEAR ELECTRICAL EQUIPMENT
NFPA 70, Section 110-26 (a) (1) Depth of Working Space. The depth of working space in the direction of access to live parts shall not be less than indicated in Table 110-26(a). Distances shall be measured from the live parts is such are exposed or from the enclosure front or opening is such are enclosed.
Nominal Voltage to Ground of 0 -150 = 3 feet
Nominal Voltage to Ground of 150 - 600 = 4 feet

"DEAD FRONT" PANELBOARDS
NFPA 70, ARTICLE 408 Switchboards and Panelboards, 408.38 Enclosure. Panelboards shall be mounted in cabinets, cutout boxes, or enclosures designed for the purpose and shall be dead front. 408.7 Unused Openings. Unused openings for circuit breakers and switches shall be closed using identified closures, or other approved means that provide protection substantially equivalent to the wall of the enclosure.

These STANDARDS were not met as evidenced by:

Based on observation, the facility failed to ensure that; ground fault circuit interruption (GFCI) protection was provided at all wet locations, sufficient working space was provided in front of electrical panels, and all openings to "live parts" in the panelboard were sealed.

Findings include:

On 4/5/12 during a tour of the facility the following electrical deficiencies were observed:

a) The drinking fountain near the entrance to the 600 Hall was plugged into an outlet not protected by a GFCI.

b) Food carts were being stored in front of three electrical panels in the kitchen. A metal storage rack was placed in front of a 250 amp, electrical panel box in the Janitor Closet near the 200 Hall.

c) On 4/4/12 at 10:00 AM an open breaker slot was observed in a panelboard located in the Electrical Room. (Note: The opening provided potential access to "live parts".)

This STANDARD was not met as evidenced by:

Based on observation and staff interview, the facility failed to ensure that all construction-related penetrations in corridor walls were patched to resist the passage of smoke. A total of four openings affected the smoke resistance of the exit corridors on the "A" side of the building.

Findings include:

On 4/5/12 at approximately 2:00 PM, selected ceiling tiles were randomly removed near the smoke barriers. The following penetrations in the corridor walls were revealed:

a) One foot by one foot opening in the wall between the corridor and the Janitor's Closet,
b) Eight inch by eight inch opening in the wall between the corridor and the Electrical Room,
c) Eight inch by eighteen inch opening in the corridor wall between the "A" side and Main Hallway,
d) Fourteen inch by ten inch opening in the corridor wall near entry to the 300 Hall.

The Maintenance Supervisor was interviewed and he indicated that the openings were created by a contractor who had recently installed a wireless communication system. The Maintenance Supervisor indicated that the contractor would be called back to patch the holes, under warrantee.

This STANDARD was not met as evidenced by:

Based on observation the facility failed to ensure that there were no impediments to the closing of patient room doors which opened onto the common area of each Hall. One of six halls was affected by this deficient practice.

Findings include:

On 4/4/12 at 9:45 AM, it was observed that the hooks supporting the Infection Control Kit and hanging over the top of the door to patient room #219 interfered with the latching of that door. Two other doors with Kits were observed as being difficult to close, although they did eventually latch.

NFPA 101, 9.6.1.3 The provisions of section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.

9.6.1.4 A fire alarm system required for life safety shall be installed, tested and maintained in accordance with the applicable requirements of National Fire Protection Association (NFPA) 70, National Electric Code, and NFPA 72, National Fire Alarm Code...


This STANDARD was not met as evidenced by:

Based on document review, the facility failed to ensure that all of their smoke detectors passed smoke sensitivity testing. This condition elevated the risk of fire/smoke injuries for staff and residents in three of six patient care pods, and common areas (i.e. Admin., Dining, etc.). (Note: Patient rooms in the 400, 500, and 600 Pods are protected by single-station, smoke detection devices.)

Findings include:

This deficient practice was first revealed on 12/20/11 during a survey of the SNF located within the Hospital. The facility's maintenance records showed that 41 of 98 (42%) smoke detectors failed the smoke sensitivity test. The test results were detailed in the facility's, Simplex/Grinnell report dated 12/2/11. The facility's Plan of Correction (POC) for the SNF was dated 1/9/12 and it stated, "The upgrade of the (smoke detector) panel should eliminate any current deficiencies". The date of completion given by the facility was, "February 6, 2012 pending vendor approval and availability".

On 4/4/12 during a survey of the Hospital, it was discovered that there was no action taken to address the smoke sensitivity failures identified in the Simplex/Grinnell report. The facility did have a proposal to install a new fire alarm system including; new, addressable, smoke detectors. The facility produced a copy of an e-mail, dated 4/5/12 from EDS Electronics indicting that proposed that work could begin on 4/9/12 and could be completed by mid August, 2012. (Note: Smoke detector, "actuation" testing between 5/16/11 and 2/15/12 by EDS Electronics indicates that all detectors passed.)

These findings were acknowledged by the CEO, Maintenance Manager, and Department Heads during the exit interview on 4/5/12.

NFPA 13 (2010 ed.), 8.3.3.2 Where quick response sprinklers are installed, all sprinklers within a compartment shall be quick response unless otherwise permitted in 8.3.3.3.

This STANDARD was not met:

Based on observation, the facility failed to ensure that all sprinklers within a compartment were either standard response or quick response. This condition was found in one, non-patient, room within the building.

Findings include:

On 4/5/12 at 9:15 AM it was observed that in the Respiratory Hold Room there were two un-matched sprinkler heads. One was a red, frangible-bulb, quick response sprinkler head and the other was a fusible-link, side sprinkler head.

NFPA 10 (2002 ed) 1.5.6* Fire extinguishers shall not be obstructed or obscured from view. In large rooms, and in certain locations where visual obstructions cannot be completely avoided, means shall be provided to indicate the extinguisher location.

This STANDARD was not met as evidenced by:

Based on observation and staff interview the facility failed to provide unobstructed access to one portable, Type K, fire extinguisher in the Dietary Department.

Findings include:

On 4/5/12 at 2:30 PM it was observed that access to both the type K fire extinguisher and the pull actuator for the Ansul unit in the kitchen were obstructed by the storage of food carts in front of these fire-control devices. The Maintenance Supervisor and a Dietary employee indicated that they recently acquired new food carts, and had not yet found a place for the old carts.

WET LOCATIONS:
NFPA 70, Section 517-20(a) Wet Locations. 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.

ITEMS NEAR ELECTRICAL EQUIPMENT
NFPA 70, Section 110-26 (a) (1) Depth of Working Space. The depth of working space in the direction of access to live parts shall not be less than indicated in Table 110-26(a). Distances shall be measured from the live parts is such are exposed or from the enclosure front or opening is such are enclosed.
Nominal Voltage to Ground of 0 -150 = 3 feet
Nominal Voltage to Ground of 150 - 600 = 4 feet

"DEAD FRONT" PANELBOARDS
NFPA 70, ARTICLE 408 Switchboards and Panelboards, 408.38 Enclosure. Panelboards shall be mounted in cabinets, cutout boxes, or enclosures designed for the purpose and shall be dead front. 408.7 Unused Openings. Unused openings for circuit breakers and switches shall be closed using identified closures, or other approved means that provide protection substantially equivalent to the wall of the enclosure.

These STANDARDS were not met as evidenced by:

Based on observation, the facility failed to ensure that; ground fault circuit interruption (GFCI) protection was provided at all wet locations, sufficient working space was provided in front of electrical panels, and all openings to "live parts" in the panelboard were sealed.

Findings include:

On 4/5/12 during a tour of the facility the following electrical deficiencies were observed:

a) The drinking fountain near the entrance to the 600 Hall was plugged into an outlet not protected by a GFCI.

b) Food carts were being stored in front of three electrical panels in the kitchen. A metal storage rack was placed in front of a 250 amp, electrical panel box in the Janitor Closet near the 200 Hall.

c) On 4/4/12 at 10:00 AM an open breaker slot was observed in a panelboard located in the Electrical Room. (Note: The opening provided potential access to "live parts".)