HospitalInspections.org

Based on observation and interview with staff, the facility failed to provide doors that are provided with a means suitable for keeping the door closed. Findings:

Doors to the Operating Suite, doors on the east wing, and doors to the gift shop were not provided with latching hardware. Operating Suite doors did not have hardware that will allow egress from the suite and deny access from the corridor side.

Based on observation and interview with staff, the facility failed to maintain complete electronic or written records of tests. Findings:

The annual test report did not document testing of all equipment connected to the fire alarm system. The Combination fire and smoke dampers, the smoke removal system in the operating rooms, magnetic locks, and location of alarm detectors were not documented on the report.

Based on observation and interview with staff, the facility failed to provide an automatic sprinkler system that is installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. Findings:

(1) The loading dock, a room in the basement,and medical records are not sprinklered, or the suppression heads are not provided to give full coverage.
(2) Throughout the hospital IT wiring is draped or hung from fire suppression lines.

Based on observation and interview with staff, and review of the log for surgery department for the month of January of 2012, relative humidity was not maintained equal to or greater than 35% in anesthetizing locations. Finding:

The logs recorded humidity levels below 35%. No actions were taken on days when levels were low.

(1) Based on interview with Operating Room staff, Director of Maintenance and CEO, the facility failed to provide training of personal in the risk associated with electrical equipment located in the Operating Room in accordance with NFPA 99 1999 Edition Section 7-6.5, NFPA 99 Section 3-3.3.4.2 Findings:

(a) Staff interviewed at the time of survey were not familiar with the use of Line Isolation Monitors. 7-6.5

(2) Based on interview with Operating Room staff, Director of Maintenance and CEO, the facility failed to provide training of personnel in fire loss prevention assessment, continuing education of safety and supervision for Operating Rooms in accordance with NFPA 99 Section 12-4.1.2.10. Findings:

(a) No records of training for fire loss prevention, assessment or training for safety education and supervision of the operating room were available. Section 12-4.1.2.10:

(3) Based on interview with Operating Room staff, Director of Maintenance and CEO, the facility failed to have a preventive maintenance program in accordance with NFPA 99 1999 edition chapter 3 -3.3.4.2 (Line Isolation Monitor Test). Findings:

(a) The equipment was not tested at intervals of not more than a month and calibration once a year with record of tests dates,rooms tested,and a record of any modification or failures.
(b) The facility failed to provide testing of receptacles in patient care areas for impedance measurements.

Based on review of the weekly check list for documenting the generator test, the facility failed to document the generator was inspected weekly and exercised under load for 30 minutes per month in accordance with NFPA 99. Findings:

The Generator logs recorded weekly runs but did not document running under load and who conducted the tests.

Based on observation and interview with staff, the facility failed to provide doors that are provided with a means suitable for keeping the door closed. Findings:

Doors to the Operating Suite, doors on the east wing, and doors to the gift shop were not provided with latching hardware. Operating Suite doors did not have hardware that will allow egress from the suite and deny access from the corridor side.

Based on observation and interview with staff, the facility failed to maintain complete electronic or written records of tests. Findings:

The annual test report did not document testing of all equipment connected to the fire alarm system. The Combination fire and smoke dampers, the smoke removal system in the operating rooms, magnetic locks, and location of alarm detectors were not documented on the report.

Based on observation and interview with staff, the facility failed to provide an automatic sprinkler system that is installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. Findings:

(1) The loading dock, a room in the basement,and medical records are not sprinklered, or the suppression heads are not provided to give full coverage.
(2) Throughout the hospital IT wiring is draped or hung from fire suppression lines.

Based on observation and interview with staff, and review of the log for surgery department for the month of January of 2012, relative humidity was not maintained equal to or greater than 35% in anesthetizing locations. Finding:

The logs recorded humidity levels below 35%. No actions were taken on days when levels were low.

(1) Based on interview with Operating Room staff, Director of Maintenance and CEO, the facility failed to provide training of personal in the risk associated with electrical equipment located in the Operating Room in accordance with NFPA 99 1999 Edition Section 7-6.5, NFPA 99 Section 3-3.3.4.2 Findings:

(a) Staff interviewed at the time of survey were not familiar with the use of Line Isolation Monitors. 7-6.5

(2) Based on interview with Operating Room staff, Director of Maintenance and CEO, the facility failed to provide training of personnel in fire loss prevention assessment, continuing education of safety and supervision for Operating Rooms in accordance with NFPA 99 Section 12-4.1.2.10. Findings:

(a) No records of training for fire loss prevention, assessment or training for safety education and supervision of the operating room were available. Section 12-4.1.2.10:

(3) Based on interview with Operating Room staff, Director of Maintenance and CEO, the facility failed to have a preventive maintenance program in accordance with NFPA 99 1999 edition chapter 3 -3.3.4.2 (Line Isolation Monitor Test). Findings:

(a) The equipment was not tested at intervals of not more than a month and calibration once a year with record of tests dates,rooms tested,and a record of any modification or failures.
(b) The facility failed to provide testing of receptacles in patient care areas for impedance measurements.

Based on review of the weekly check list for documenting the generator test, the facility failed to document the generator was inspected weekly and exercised under load for 30 minutes per month in accordance with NFPA 99. Findings:

The Generator logs recorded weekly runs but did not document running under load and who conducted the tests.