HospitalInspections.org

Based on observation and staff interview, the facility failed to maintain appropriate exit discharge and failed to ensure the means of egress is continuously maintained free of all obstructions to full use in case of emergency in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 3.

Findings include:

1. Observation on 4/6/21 at approximately 10:56 a.m. revealed the Dietary/Materials Management Corridor, which is an emergency exit egress corridor, measured approximately eight (8) feet and was reduced to approximately four (4) feet by vending machines, boxes, and housekeeping carts being stored in this corridor.

2. Interview on 4/6/21 at approximately 10:58 a.m. with the Facilities Director verified these findings. The findings were also acknowledged by the Chief Executive Officer at the exit interview on 4/7/21 at approximately 2:35 p.m.

Based on observation and staff interview, the facility failed to ensure appropriate protection of smoke and/or fire barriers within the facility in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 3.

Findings include:

1. An observation on 4/7/21 at approximately 9:43 a.m. revealed approximately three (3) penetrations above the corridor (interstitial space) of the two (2)-hour fire rated barrier doors that separate the Critical Access Hospital and the Clinic.

2. An observation on 4/7/21 at approximately 9:45 a.m. revealed penetrations in the upper left hand corner of the two (2)-hour fire rated barrier door frame at the Clinic entrance.

3. An observation on 4/7/21 at approximately 9:46 a.m. revealed penetrations in the wall above the door frame of the two (2)-hour fire rated barrier doors at the Clinic entrance.

4. An observation on 4/7/21 at approximately 9:45 a.m. revealed a penetration above the ceiling (interstitial space) in the two (2)-hour fire rated barrier near the Clinic entrance and Exam Room W-2.

5. An observation on 4/7/21 at approximately 10:30 a.m. revealed an approximately four (4) inch by eighteen (18) inch penetration above the ceiling (interstitial space) in the two (2)-hour fire rated barrier in the Radiology Sleep Room, where the Radiology corridor wall joins the Sleep Room wall.

6. An observation on 4/7/21 at approximately 10:55 a.m. revealed penetrations above the ceiling (interstitial space) in the two (2)-hour fire rated barrier in the Mammography/Sleep Room.

7. An observation on 4/7/21 at approximately 11:01 a.m. revealed penetrations above the ceiling (interstitial space) in the two (2)-hour fire rated barrier above the Radiology Supervisor's Desk and the Staff Restroom.

8. An observation on 4/7/21 at approximately 11:37 a.m. revealed penetrations above the ceiling (interstitial space) in the two (2)-hour fire rated barrier that separates the Critical Access Hospital and the Long Term Care Unit, near the Long Term Care Unit doors.

9. An observation on 4/7/21 at approximately 11:47 a.m. revealed penetrations above the ceiling (interstitial space) in the two (2)-hour fire rated barrier that separates the Critical Access Hospital and the Long Term Care Unit, near the Nurse's Lounge.

10. An observation on 4/7/21 at approximately 12:05 p.m. revealed an approximately four (4) inch by twenty-four (24) inch penetration above the ceiling (interstitial space) in the two (2)-hour fire rated barrier that separates the Critical Access Hospital and the Long Term Care Unit, near the corner of the Discharge Planner's Office and Patient Room 300.

11. Interview on 4/7/21 at approximately 12:07 p.m. with the Environmental Services Coordinator verified these findings. The findings were also acknowledged by the Chief Executive Officer at the exit interview on 4/7/21 at approximately 2:35 p.m.

Based on observation and staff interview, the facility failed to ensure that hazardous areas are protected and separated from other spaces in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 3.

Findings include:

1. An observation on 4/5/21 at approximately 3:16 p.m. revealed the patient records/storage room in the Lab had a door closure, which was disconnected.

2. An observation on 4/6/21 at approximately 8:52 a.m. revealed a door in the Lab of Coplin Clinic (Elizabeth), which was labeled "Fire Door Keep Closed" and had the door closure disconnected.

3. An observation on 4/6/21 at approximately 8:57 a.m. revealed a door in the Radiology of Coplin Clinic, which was labeled "Fire Door Keep Closed" and was propped open with a sand bag.

4. An observation on 4/6/21 at approximately 11:16 a.m. revealed the Housekeeping/Laundry Break Room, which was also a storage room, had a door with a closure, which was disconnected.

5. An observation on 4/7/21 at approximately 1:54 p.m. revealed Patient Room 410 was being used as a storage room and did not have a door closure.

6. Interview on 4/7/21 at approximately 1:56 p.m. with the Environmental Services Coordinator verified these findings. The findings were also acknowledged by the Chief Executive Officer at the exit interview on 4/7/21 at approximately 2:35 p.m.

Based on document review and staff interview, the facility failed to ensure that records of system testing for the fire alarm system were readily available in accordance with NFPA (National Fire Protection Association) 72. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 3.

Findings include:

1. Document review on 4/6/21 at approximately 12:39 p.m. revealed no documentation of smoke detector sensitivity testing, to include the manufacturer's listed sensitivity range, actual tested range, or a pass/fail result for the facility smoke detectors was provided during survey.

2. Interview on 4/6/21 at approximately 12:41 p.m. with the Facilities Director verified this finding. The finding was also acknowledged by the Chief Executive Officer at the exit interview on 4/7/21 at approximately 2:35 p.m.

Based on document review and staff interview, the facility failed to ensure that automatic sprinkler and standpipe systems were maintained in accordance with NFPA (National Fire Protection Association) 25. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 3.

Findings include:

1. Document review on 4/6/21 at approximately 12:34 p.m. revealed no documentation that the sprinkler system had been inspected during the 3rd Quarter of 2020 was available for review.

2. Interview on 4/6/21 at approximately 12:36 p.m. with the Facilities Director verified this finding. This finding was also acknowledged by the Chief Executive Officer at the exit interview on 4/7/21 at approximately 2:35 p.m.

Based on observation and staff interview, the facility failed to ensure that portable fire extinguishers were installed and maintained in accordance with NFPA (National Fire Protection Association) 10. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 3.

Findings include:

1. An observation on 4/6/21 at approximately 8:43 a.m. revealed a fire extinguisher located in the Lab of the Coplin Clinic (Elizabeth), which had not received monthly inspection since 2/17/21.

2. An observation on 4/6/21 at approximately 10:42 a.m. revealed a Class-K fire extinguisher located in the Kitchen, which had not received monthly inspection since 3/4/21.

3. Interview on 4/6/21 at approximately 10:43 a.m. with the Facilities Director verified these findings. The findings were also acknowledged by the Chief Executive Officer at the exit interview on 4/7/21 at approximately 2:35 p.m.

Based on observation and staff interview, the facility failed to ensure that electrical wiring and equipment shall be in accordance with NFPA (National Fire Protection Association) 70. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 3.

Findings include:

1. Observation on 4/5/21 at approximately 1:35 p.m. revealed an electrical breaker panel missing an appropriate cover in the Infusion Room of the Physical Therapy Department.

2. Observation on 4/5/21 at approximately 1:49 p.m. revealed an electrical breaker panel missing an appropriate cover in Exam Room 1 of the Emergency Department.

3. Interview on 4/5/21 at approximately 1:50 p.m. with the Facilities Director verified these findings. The findings were also acknowledged by the Chief Executive Officer at the exit interview on 4/7/21 at approximately 2:35 p.m.

Based on document review and staff interview, the facility failed to ensure that air-conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA (National Fire Protection Association) 90A. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 3.

Findings include:

1. Document review on 4/6/21 at approximately 12:53 p.m. revealed no documentation of testing for fire dampers located throughout the facility was available for review.

2. Interview on 4/6/21 at approximately 12:55 p.m. with the Facilities Director verified this finding. This finding was also acknowledged by the Chief Executive Officer at the exit interview on 4/7/21 at approximately 2:35 p.m.

Based on document review and staff interview, the facility failed to maintain and test electrical receptacles at patient bed locations in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 3.

Findings include:

1. Document review on 4/6/21 at approximately 1:08 p.m. revealed no documentation for testing of the physical integrity, continuity of the grounding circuit, correct polarity of the hot and neutral connections, or the retention force of the grounding blade for each electrical receptacle at the patient bed locations in the facility for the previous twelve (12) months was available for review.

2. Interview on 4/6/21 at approximately 1:10 p.m. with the Facilities Director verified this finding. This finding was also acknowledged by the Chief Executive Officer at the exit interview on 4/7/21 at approximately 2:35 p.m.

Based on observation and staff interview, the facility failed to ensure that power cords and extension cords were used in accordance with NFPA (National Fire Protection Association) 99. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 3.

Findings include:

1. Observation on 4/5/21 at approximately 2:25 p.m. revealed a floor model negative pressure isolation unit, which was plugged into a power strip in Exam Room 3/4/5 of the Emergency Department.

2. Interview on 4/5/21 at approximately 2:26 p.m. with the Facilities Director verified these findings. The findings were also acknowledged by the Chief Executive Officer at the exit interview on 4/7/21 at approximately 2:35 p.m.

Based on observation, document review, and staff interview, the facility failed to maintain the testing and maintenance requirements for fixed and portable patient-care equipment in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 3.

Findings include:

1. Observation on 4/5/21 at approximately 12:40 p.m. revealed a fluid pump (1046260) in Exam Room 2 of the Emergency Department, which was due preventative maintenance on 09/19.

2. Observation on 4/5/21 at approximately 2:19 p.m. revealed two (2) Spot Vital Signs 4400 monitors in Exam Room 3/4/5 of the Emergency Department, which had no preventative maintenance inspection sticker and were not part of the medical equipment inventory.

3. Observation on 4/5/21 at approximately 2:20 p.m. revealed a defibrillator in Exam Room 3/4/5, which was due inspection on 4/21, but did not indicate the day of the month.

4. Observation on 4/5/21 at approximately 2:58 p.m. revealed an exam table/chair in the Wound Care Room, which had no preventative maintenance inspection sticker and was not part of the medical equipment inventory.

5. Observation on 4/6/21 at approximately 9:02 a.m. revealed the X-Radiation (X-Ray) Machine in Radiology at the Coplin Clinic (Elizabeth) had last received annual preventive maintenance on 3/21/19.

6. Interview on 4/6/21 at approximately 9:04 a.m. with the X-Ray Technician (Coplin Clinic) verified these findings. The findings were also acknowledged by the Chief Executive Officer at the exit interview on 4/7/21 at approximately 2:35 p.m.