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Based on hospital policy review, medical record review and staff interviews, the hospital staff failed to ensure a restraint was discontinued at the earliest possible time for 2 of 2 patients receiving a restrictive intervention (#10 and #3).

The findings include:

Review on 06/10/2015 of current hospital policy "Physical Restraint and Seclusion" revised/reviewed 08/2014, revealed "APPLICABILITY This policy applies to all patients placed in restraint or seclusion throughout (Hospital). ...PROCEDURE ...Discontinuation of restraint or seclusion occurs by the registered nurse once the behaviors or situations that prompted these measures are assessed to no longer be harmful to the safety of the patient, staff members, or other and treatment may be accomplished through less restrictive means. ..."

1. Open medical record review for Patient #10 revealed a hospital admission via the emergency department on 06/07/2015 for respiratory failure following a drug overdose. Continued review revealed the patient received mechanical ventilation and sedation until condition stabilized and the mechanical ventilation was discontinued on 06/08/2015 at 0900. Review of nurse's progress notes for 06/08/2015 at 1200 - 1300 revealed the patient became increasingly "belligerent screaming obscenities" to the point the patient was placed in four point behavioral restraints at 1230. Review of physician's orders revealed "Violent/Self-Destructive Restraint" order form dated "6/8" without evidence of a time the order was initiated. Continued review of the physician's order revealed the four-point restraint order was valid for four hours for adults 18 years of age or older. Review of nurse's progress notes revealed the patient was administered Geodon (antipsychotic medication used for sedation) intramuscularly into left thigh at 1300. Review of the Behavioral Health Restraint and Seclusion Observation form where every 15 minute observation of Safety Checks, Behavior, Care Delivery, Limb Release and Skin Integrity were documented, revealed documentation stating the patient's behavior was "Quiet" and/or "Sleeping" from 1400 until 2015, with the exception of "Screaming" at 1515. Further review of physician's orders revealed a physician's order for Right Soft Lower Limb Restraint at 1600. There was no evidence the patient was exhibiting behaviors that warranted the restrictive intervention at 1600. The restraints were discontinued at 2015.

Interview with the critical care nurse manager and the chief quality and patient safety officer on 06/11/2015 at 1000 revealed the restraints were removed one by one even though the nurse's progress note documentation indicated the patient was "Resting quietly" at 1400 on 06/08/2015. The interview revealed no evidence the patient's behavior warranted continued use of behavioral restraints after the Geodon was administered at 1300.


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2. Closed medical record review on 06/10/2015 for Patient #3, revealed a 35 year old male admitted to the hospital's emergency department (ED) on 04/10/2015 at 1534 with a chief complaint of "DRUNK CUSSING PEOPLE AT MCDONALDS ASKED MPD (local police department) TO BRING HIM HERE TO TALK TO SOMEONE." Review revealed the patient was evaluated by a physician and discharged on 04/11/2015 at 1750 with a diagnosis of Alcohol Intoxication. Record review revealed while in the ED the patient was placed into restraint on 04/10/2015 at 1600 and released on 06/11/2015 at 0000 (8 hours). Review of a "Restraint Order and Management Form" (#1) dated 04/10/2015 at 1605 revealed an initial "Violent/Self Destructive Restraint Order" for 4-point limb restraints, Order valid for 4 hours for adults 18 years of age or older. Review of a "Restraint Order and Management Form" (#2) dated 04/10/2015 at 2000 revealed a renewal "Violent/Self Destructive Restraint Order" for 4-point limb restraints, Order valid for 4 hours for adults 18 years of age or older. Review of "BH Restraint and Seclusion Observation" form(s) dated 04/10/2015 revealed the patient was monitored every 15 minutes from 1600 to 0000 (04/11/2015) while continuously being restrained. Review revealed the patients behaviors were assessed and documented by ED staff from 1815 to 1915 (1 hour) as "7" - Sleeping or "10" - Other: Pulling at restraints and from 2045 to 0000 (3 hours 15 minutes) as "9" - Quiet or "7" - Sleeping. Record review failed to reveal any available documentation of violent/self destructive behaviors between 1815 to 1915 and 2045 to 0000 to justify continued use of restraint when the patient was assessed by staff as being asleep or quiet. Record review revealed restraints were not discontinued at the earliest possible time.

Interview on 06/10/2015 at 1257 with Director #2, revealed the ED staff use pre-printed paper forms for documenting restraint and seclusion and monitoring. Interview revealed staff may also document in the electronic medical record. Interview revealed patients are monitored every 15 minutes when in restraint. Interview revealed staff should document the behaviors that warrant the use of restraint. Interview revealed staff are to use the least restrictive intervention. Interview revealed restraints are to be removed as soon as the behaviors resolve and the patient is calm. Interview revealed staff documented the patient as being asleep or calm at 1815 to 1915 and 2045 to 0000. Interview revealed there was no available medical record documentation warranting continued use of restraints. Interview revealed the patient should have been released from restraint. Interview revealed the staff "followed policy except for releasing at the earliest time." Interview revealed "it is a learning opportunity." Interview verified the ED staff failed to follow policy.

Interview on 0610/2015 at 1332 with Director #1 revealed "I agree with you, the patient should have been released."

Based on hospital policy and procedure reviews, medical record reviews, and staff interviews the hospital's staff failed to ensure the physician or other licensed independent practitioner (LIP) or trained RN conducting the face-to-face evaluation within 1 hour after the initiation of restraint evaluated and documented the patient's immediate situation; the patient's reaction to the intervention; the patient's medical and behavioral condition; and the need to continue or terminate the restraint for 2 of 2 patients (#10 and #3) restrained for the management of violent or self-destructive behaviors.


The findings include:

Review on 06/10/2015 of current hospital policy "Physical Restraint and Seclusion" revised/reviewed 08/2014, revealed "APPLICABILITY This policy applies to all patients placed in restraint or seclusion throughout (Hospital). ...PROCEDURE ...Assessment and Monitoring of Violent/Self-Destructive Behavior: Monitoring and assessments shall include a minimum of the elements indicated on the current relevant approved forms and templates. A responsible licensed independent practitioner, physician's assistant, or advance practice RN will perform a face-to-face assessment of the patient's physical and psychological status within 1 hour of the initiation of behavioral restraint or seclusion. Evaluate the patient's immediate situation, reaction to intervention, and medical and behavioral condition to determine the need to continue or discontinue the restraint. ..."

1. Open medical record review for Patient #10 revealed a hospital admission via the emergency department on 06/07/2015 for respiratory failure following a drug overdose. Continued review revealed the patient received mechanical ventilation and sedation until condition stabilized and the mechanical ventilation was discontinued on 06/08/2015 at 0900. Review of nurse's progress notes for 06/08/2015 at 1200 - 1300 revealed the patient became increasingly "belligerent screaming obscenities" to the point the patient was placed in four point behavioral restraints at 1230. Review of physician's orders revealed "Violent/Self-Destructive Restraint" order form dated "6/8" without evidence of a time the order was initiated. Continued review revealed the order form included "One hour face-to-face assessment performed: The patient's immediate situation, reaction to the intervention, and medical behavioral condition has been evaluated and the restraint is necessary for patient safety." The face-to-face portion of the form was signed by a physician, dated "6/8" and the time was noted as "12" which was 30 minutes prior to the initiation of the four-point restraints documented in the nursing progress note. Continued review of the physician's orders revealed a second physician's order form for restraints dated "6/8" with a time of "1600" for a right lower limb soft restraint. Review of the order revealed no evidence of a one hour face-to-face assessment. Review of the nurse's progress notes revealed the right lower restraint was removed at 1830 on 06/08/2015.

Interview with the critical care nurse manager on 06/11/2015 at 1000 revealed the nurses filled out the "Care Plan" portion of the "physician's restraint order form" and ensured the physician signed the form correctly. The interview revealed the one hour face-to-face assessment should have been conducted after the patient was placed in restraints and the assessment should have been documented in the physician's progress notes.

Interview with the quality manager on 06/11/2015 at 1100 revealed the face-to-face assessment and restraint form was an attestation by the physician that the required face-to-face evaluation components of the patient's "immediate situation, reaction to the intervention and medical and behavioral condition has been evaluated." The interview revealed the hospital practice is for the physician to not document the results of the evaluation but attest the evaluation was conducted.




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2. Closed medical record review on 06/10/2015 for Patient #3, revealed a 35 year old male admitted to the hospital's emergency department (ED) on 04/10/2015 at 1534 with a chief complaint of "DRUNK CUSSING PEOPLE AT MCDONALDS ASKED MPD (local police department) TO BRING HIM HERE TO TALK TO SOMEONE." Review revealed the patient was evaluated by a physician and discharged on 04/11/2015 at 1750 with a diagnosis of Alcohol Intoxication. Record review revealed while in the ED the patient was placed into restraint on 04/10/2015 at 1605 and released on 06/11/2015 at 0000 (7 hours 55 minutes). Review of a "Restraint Order and Management Form" (#1) dated 04/10/2015 at 1605 revealed an initial "Violent/Self Destructive Restraint Order" for 4-point limb restraints, Order valid for 4 hours for adults 18 years of age or older. Review revealed the statement "One hour face-to-face assessment performed: The patient's immediate situation, reaction to the intervention, and medical and behavior conditions has been evaluated and the restraint is necessary for patient safety." Review revealed the hand written signature of a physician dated 04/10/2015 at 1700. Record review failed to reveal any available documentation by the physician of the findings of the assessment of the patient's immediate situation; the patient's reaction to the intervention; the patient's medical and behavioral condition; and the need to continue or terminate the restraint or seclusion at the time the one hour face-to-face was conducted (1700). Further record review of a "Restraint Order and Management Form" (#2) dated 04/10/2015 at 2000 revealed a renewal "Violent/Self Destructive Restraint Order" for 4-point limb restraints, Order valid for 4 hours for adults 18 years of age or older. Review revealed the statement "One hour face-to-face assessment performed: The patient's immediate situation, reaction to the intervention, and medical and behavior conditions has been evaluated and the restraint is necessary for patient safety." Review revealed the hand written signature of a physician dated 04/10/2015 at 2000. Record review failed to reveal any available documentation by the physician of the findings of the assessment of the patient's immediate situation; the patient's reaction to the intervention; the patient's medical and behavioral condition; and the need to continue or terminate the restraint or seclusion at the time the one hour face-to-face was conducted (2000).

Interview on 06/10/2015 at 1103 with Director #1 revealed physicians sign an attestation statement that the one hour face-to-face was performed. Interview revealed in the past the physicians were not documenting the required elements for the face-to-face in the progress notes so the hospital changed to an attestation statement. Interview revealed the attestation is the same for all patients and is not specific or detailed to the individual patient's restraint episode. Interview verified the physician(s) who conducted the one hour-face-to-face assessment(s) for Patient #3 failed to document the findings of the assessment of the patient's immediate situation; the patient's reaction to the intervention; the patient's medical and behavioral condition; and the need to continue or terminate the restraint or seclusion at the time(s) the one hour face-to-face was conducted at 1700 and 2000 respectively.

Based on Scope of Service review, policy and procedure reviews, observations during tours, and staff interviews the hospital staff failed to ensure unauthorized individuals cannot gain access to or alter patient medical records after hours of operation for 1 of 1 Health Information Management (HIM) Departments toured (HIM #1).

The findings include:

Review on 06/11/2015 of current policy "Health Information Management Scope of Service 2014 Update" (not dated), revealed "...The Health Information Management Department is comprised of the Director, Clinical Documentation Improvement Specialist, Systems Coordinator, HIM Technician and Release of Information Clerk who work to provide Health Information Management Services. The department uses the....Medicare Conditions of Participation....for parameters and standards of services. Geographically, the Health Information Management Department is located on the ground floor of the hospital across from the Administration Offices. HOURS OF OPERATION Monday-Friday 8:30 a.m. - 4:30 p.m. ..."

Review on 06/11/2015 of current policy "Location and Security of Medical Records", HIM 432, last dated 05/2015, revealed "I. POLICY: It is the policy of this facility that medical records be maintained in a secure and confidential manner. The facility HIM director, Practice Manger or other individual with PHI (Protected Health Information) maintenance responsibilities will be responsible for the security, storage and maintenance of medical records (including paper) and/or individual patient reports against loss, defacement, tampering, and unauthorized access. ...II. PROCEDURE: Acute Care Setting Areas housing health information shall be restricted to authorized personnel only and these areas will be locked at all times. ...Medical records will be maintained within the Health Information Management Department and the HIM department will remain locked 24 hours a day for security purposes. ...Access to the HIM department during off hours by facility staff and physicians will be granted by assigning restricted access responsibility to certain key individuals, such as a nursing supervisor or a designated individual in the emergency department. ...UNDER NO CIRCUMSTANCES ARE RECORDS TO BE REMOVED FROM THEIR SECURE LOCATION, EXCEPT AS SPECIFIED BELOW MEDICAL RECORD DEPARTMENT ...when an original record is removed from Health Information Management, the following procedure should be followed. 1. Only Health Information Management employees are permitted to retrieve medical records and/or reports from the record files for a requestor. ...PRACTICE OR OTHER SETTING ...7. Only employees with PHI maintenance responsibilities are permitted to retrieve medical records and/or reports from the record files for a requestor. ..."

Observations during tour on 06/10/2015 from 1530 to 1600 of the hospital's main HIM department (HIM #1) revealed the department was located on the ground floor of the hospital on a main hallway, adjacent to the physician's lounge and across from the hospital's administration offices. Observation revealed at the end of the hallway was an exit discharge to the outside of the building. Observation revealed the HIM department had three (3) entry doors: a public door (#1) and employee door (#2) allowing entry from the main hallway; and a physician's door (#3) allowing entry from the physician's lounge. Observation revealed the public and employee doors were secured with a keyed lock and the physician's door was secured with an electronic key pad. Upon entry into the HIM department from the public door, observation revealed a "bank" of nine (9) rolling track multi-shelf storage units. Observation revealed numerous paper medical records stored on the shelves of each unit. Observation revealed the medical records could be removed from the shelves without difficulty by the surveyor. Observation revealed the storage units could be visualized from all three entry doors. Observation revealed across from the bank of storage units was a separate interior office space for the Medical Staff Services Coordinator's Office (MSSO - a wholly separate and distinct department from HIM) with one entry/exit door. Further observation revealed distally from the storage units, adjacent to the physician's entry door was an area with workspace and computers.

Interview during tour on 06/10/2015 at 1545 with Director #3, revealed the HIM department's public hours of operation were Monday - Friday 0830 to 1630. Interview revealed HIM staff were present onsite: Monday, Thursday, and Friday from 0830-1630; Tuesday and Wednesday from 0830 to 1930; and Sunday from 0830 to 1700. Interview revealed no HIM staff were present onsite on Saturday. Interview revealed the hospital uses an electronic medical records (EMR) system. Interview revealed paper documents are scanned into the EMR. Interview revealed the bank of storage units located in the HIM department contained old emergency department, outpatient, and expired patients medical records. Interview revealed the records were being stored in the HIM department because "the cost estimate to scan the documents was too expensive." Interview revealed the HIM department had three entry/exit doors. Interview revealed a public entrance, employee entrance, and a physician's entrance from the physician's lounge. Interview revealed HIM staff, MSSO Staff, and physicians have access to the main HIM department. Interview revealed HIM staff and MSSO staff have keys to the public and employee doors and physicians use a code to enter from the physician's lounge. Interview revealed the MSSO hours of operation are 0700 to 1830. Interview revealed the MSSO has 2 (non-HIM) employees. Interview revealed the MSSO staff enter the HIM department to get to their office. Interview revealed physicians do come and meet with MSSO staff in their office. Interview revealed the HIM department staff are not always present when the MSSO staff are present. Interview revealed the two departments have varying hours of operation. Interview revealed the area adjacent to the physician's entry door was used in the past for physicians to come and complete charts. Interview revealed the physicians were given a key pad code to enter the HIM department from the physician's lounge. Interview revealed physicians can enter the department at any time during or after hours. Interview revealed access to medical records is based on the individual's core job functions. Interview revealed only those who are authorized and have necessity should access medical records of patients that they have provided care to. Interview revealed physicians are not granted access to all medical records. Interview revealed since the hospital went to an EMR, physicians can access and complete charts from any computer. Interview revealed "now, there is no real reason for access" to the HIM department by physicians when unsupervised by HIM staff. Interview revealed physicians can still currently enter the HIM department. Interview revealed the keypad code was last changed 6 months ago. Interview revealed the physicians were given the code. Interview revealed the Director could not determine the number of individuals who may have the keypad code to the physician's door. Interview revealed unauthorized individuals could access the medical records being stored in the bank of storage units in the HIM department. Interview verified the observation findings.

Interview on 06/10/2015 at 1553 with MSSO staff #1 revealed she is a credentialing specialist. Interview revealed she works in the MSSO. Interview revealed there are two (2) personnel who work in the MSSO. Interview revealed she is not part of the HIM department and does not work with medical records. Interview revealed the only way to get to the MSSO is to enter through the HIM department. Interview revealed she has a key to enter the HIM department. Interview revealed her work hours are Monday - Friday from 0930 to 1800 and MSSO staff #2's work hours are Monday - Friday 0730 to 1530. Interview revealed she meets with the physician medical advisory committee, medical staff members, and occasionally with other hospital personnel in the MSSO. Interview verified the MSSO staff have unsupervised access to the HIM department when HIM staff are not present.

Based on observations as referenced in the Life Safety Report of Survey completed 03/04/2015, the hospital staff failed to develop and maintain the physical plant and overall hospital environment in a manner to assure the safety and well-being of patients for 2 of 2 hospital buildings toured. (Building 01 and Building 02).

The findings include:

1. Building 01

A) Based on observations, on June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. There is no positive latching hardware on exit access door to Neonatologist office - proposed suite area enclosing office is not defined with access doors to suite equipped with positive latching hardware.

2. Doors to C-section suite are not equipped with positive latching hardware - located on third floor.

3. Door to staff breakroom is not equipped with positive latching hardware - located on third floor near C-section suite.

This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0012.

B) Based on observations, on June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The an unapproved air transfer grill was installed in the smoke wall above the Flash Autoclave located in the OR central core.

2. The smoke wall between suite C and D above the corridor doors. Wall was not sealed smoke tight in order to maintain the fire resistance rating of the area.

3. The elevator lobby on third floor that opens to corridor outside Director of Woman's Services office was not constructed to provide a 1 hour barrier and arranged as a smoke barrier in accordance with NFPA 101 Section 8.3, and NFPA 101: 7.2.13.3

These deficiencies affected approximately seven smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0025.

C) Based on observations, on June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The mechanical/electrical storage room located next to the employee entrance was not 1-hour constructed.

2. There is no self-closing device for fire door to second floor storage room - room is located beside utility pipe chase.

3. Fire door to pharmacy supply is not self-closing and latching - inactive leaf uses manual flush bolt assembly - room is located on the first floor near front entrance.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0025.

D) Based on observations, on June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. Lack of complete special locking arrangement installation for exit door at stairwell #3 - there is no on/off release switch not greater than three feet from door.

2. Lack of complete special locking arrangement installation for exit door at stairwell #3 - the master on/off switch at supervised nurse's station would not release locking arrangement at referenced area in the off position.

3. Lack of complete special locking arrangement installation for lobby smoke door beside Director of Women's Services office - there is no on/off switch not greater than three feet from exit access doors.

4. Lack of complete special locking arrangement installation for cross corridor doors beside room RA130 - there is no master on/off switch at a supervised station in the Radiology area.

This deficiency affected two of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Note: All electromagnetic locking arrangements released doors with activation of the facility smoke detection system and loss of power during test.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0032.

E) Based on observations, on June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. Doors to C-section suite are a pair of doors less than 41.5 inches - doors as arranged require greater than a single motion of the hand to open, close and latch - located on third floor.

2. In the material management storage room there is a storage area that has a steel and wire mesh door frame the was equipped with a pad lock that would prevent an individual from exiting when locked in case of an emergency.

3. The master override switch located at the employee entrance and for the De-con Room in the OR suite did not operate when tested.

4. Doors to the walk-in coolers and freezers are equipped with non-passage hardware. Lock sets allow occupants to be locked inside units in the kitchen area.

This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0032.

F) Based on observations, on June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. There are no emergency light(s) in third floor nursery room containing exit access doors equipped with electromagnetic locking arrangement - method of door release is not obvious in darkness.

This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0046.

G) Based on observations, on June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The smoke duct detectors located in the AHU #8 unit return in the third floor mechanical room were not maintained clean and in good operating condition. Device had excessive dust accumulation on the air sampling tube ports. NFPA 90 A 4-4.4.1

2. The smoke duct detector, located on AHU #19, in second floor mechanical room has excessive dust accumulation on air sampling tube ports. NFPA 90A 4-4.4.1

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0054.

H) Based on observations, on June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

Facility utilizes special locking on doors in the facility and it was determined that the building was not protected throughout by an approved, supervised automatic fire detection system in accordance with NFPA 101: Section 9.6, or an approved, supervised automatic sprinkler system in accordance with NFPA 101 Section 9.7.
NFPA 101: 7.2.1.6.1

1. The hydraulic elevators do not have sprinkler head installed at the bottom of each elevator hoistway not more than 2 ft. (0.61 m) above the floor of the pit as specified by NFPA 13.5-13.6

2. The recessed can wash located on the rear loading dock is not provided sprinkler coverage.

3. The closet in the linen storage room on 1st floor is not provided with sprinkler coverage.

4. The top of the stairwells, throughout the facility, were not provided with sprinkler coverage.

5. The 1st, 2nd and 3rd mechanical room have upright sprinkler heads installed above the ducts and in multiple area they are blocked by pipes and HVAC ducts where they do not provide complete coverage below.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0056.

I) Based on observations, on June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. Main sprinkler valves did not generate a tamper switch supervisory signal with the valves in closed position - located in valve pit at driveway entrance in front of hospital.

2. Main sprinkler valves are covered with rust - pit located at front entrance driveway.

This deficiency affected all smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0061

J) Based on observations, on June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The sprinkler heads located in 1st, 2nd, 3rd, mechanical rooms and elevator equipment room have sprinkler heads rated for Intermediate Temperature Classification, Glass Bulb Color of Green (200°F) in place of Ordinary Temperature Classification, Glass Bulb Color of Orange temperature rating of (135°F) or Red (155°F). All four areas are air conditioned spaces.

2. In the 3rd floor mechanical room there are sprinkler heads rated for intermediate and ordinary temperature classification.

3. On the loading dock the recessed sprinkler covers were not maintained in good condition. Several were sealed to the ceiling, one was tapped over and one was blocked with sheet rock and missing cover.

4. Scattered throughout the facility, in rooms and corridors, sprinkler heads were found to have lint and dust accumulation on the heat sensitive element.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0062

K) Based on observations, on June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. An access door was not provided for in the 2-hour rated wall in the 3rd floor mechanical room in order to allow for testing and inspection of the smoke/fire damper located in the HVAC duct for the vertical penetration.

2. In the Boiler room, Surgery suite, the HVAC duct were not properly secured. One was draped over a light fixture and another was hanging down just inside the room.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0067

L) Based on observations, on June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. There are oxygen cylinders stored less than five feet from combustible storage items in ER clean linen supply and equipment room - located on first floor.

This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0076

M) Based on observations, on June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The generator annunciator panel is not located in a supervised location of the main hospital.

2. The generator annunciator panel failed to read generator set supplying load during loss of normal power to the automatic transfer switch for the Life Safety Branch systems.

3. The Life Safety Branch panelboard, 1 L/E, contains equipment not permitted by NFPA 99 and Article 517 of the National Electrical Code. Air compressors and day tank circulation pump are not permitted to be wired to the Life Safety Branch system.

4. Extension cord with receptacle is wired to the critical branch panelboard 1 Q/E, in main central plant, as circuits #8, and #10. All circuits shall be wired in metal raceway.

5. Emergency power connected to load visual indicator did not function for fire pump transfer switch with loss of normal power to switch - located in sprinkler fire pump area.

6. Unitary light in generator room did not function with loss of normal power to fixture - located above day tank for generator.

7. Critical branch lighting switches at nurses station in third floor Post Partum can not be distinguished from normal power switches.

This deficiency potentially affected all smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0106

N) Based on observations, on June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. Leak sensors for UL 142 double wall, above ground, generator fuel tank are disconnected from supply circuits.

2. Circuit breaker and emergency panel supplying power to SHP equipment is not identified on single hazard panels located in rooms containing referenced systems.

3. The switch cover located in procedure room #1, 1st floor was cracked and not maintained in good condition.

This deficiency affected potentially all smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0147


2. Building 02

A) Based on observations, on June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The double door assembly to room #271 and #270 are equipped with manual flush bolts without self-closing devices - doors can not be closed and latched with a single hand motion.

This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0018.

B) Based on observations, on June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. Fire door to south stairwell will not self-close and latch - located on third floor.

This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0033.

C) Based on observations, on June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The smoke duct detectors located in the AHU #2.1 unit return in the 2nd floor mechanical room were not maintained clean and in good operating condition. Device had excessive dust accumulation on the air sampling tube ports. NFPA 90 A 4-4.4.1

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0054.

D) Based on observations, on June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The tamper switch audible signal can be permanently silenced with the sprinkler valves in the closed position - located in medical office building at fire alarm panel.

This deficiency affected two of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0054.

E) Based on observations, on June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. There is non-medical equipment stored in the corridor area near room 273.

This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0072.










































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