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Based on observation and interview, this facility is not assuring that all smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 19.3.7.3. This deficient practice affected three out of eight smoke zones and all visitors, residents and staff in these smoke zones. This facility had a capacity of 25 and a census of 25 patients at the time of the survey.

Findings include:

Observation and interview on 6/21/18, between 10:00 a.m. and 4:00 p.m., revealed the following deficiencies:

1) There was a large hole, (approximately 5 to 6 inches), located in the ceiling tile of the Endoscopy Room.
2) There was a penetration, (approximately 2 X 3 inches), in the wall directly above electrical panel, 1CL1, in the Electrical Room just outside the emergency room.

Record review of the facility layout showed the deficient practice affected three out of eight smoke zones.

This deficient practice was confirmed by Maintenance Staff A at the time of discovery.

Based on observation and interview, this facility is not providing clear unobstructed exit access and exit doors in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 7.5.2.2. This deficient practice affects maintenance personnel and staff in one out of eight smoke compartments. This facility had a capacity of 25 and a census of 25 residents at the time of the survey.

Findings include:

Observation and interview on 6/21/18, at 2:15 p.m., revealed the second means of egress (exit door) in the Boiler Room was obstructed by storage items placed in front of the doorway.

Maintenance Staff A verified this observation at the time of the survey process.

Based on observation and interview, the facility did not provide an exit sign that is readily visible from the direction of exit access in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 19.2.10.1 and 7.10. This deficient practice affects residents, staff, and visitors in the radiology corridor. The facility had a capacity of 25 and a census of 25 residents at the time of the survey.

Findings include:

Observation and interview on 6/21/18, at 1:15 p.m., revealed there was no illuminated directional exit sign located at the west end of the Radiology Corridor.

According to the facility layout, these designated exits are required.

This deficient practice was confirmed by Maintenance Staff A at the time of discovery.

Based on interview and record review, the facility failed to protect the range hood in accordance with NFPA 96 by having them inspected and tested every six months. This deficient practice affected one of eight smoke zones in the building. This facility had a capacity of 25 and a census of 25 residents at the time of the survey.

Findings include:

Record review and interview on 6/21/18, at 12:10 p.m., revealed the commercial cooking suppression systems was inspected and tested on 11/22/16 and 5/17/17. These inspection and testing reports reveal the maintenance on the cooking suppression system is overdue.

This deficient practice was confirmed by Maintenance Staff A at the time of the exit.

Based on observations and interview, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, 5.2.1.1.2, by ensuring sprinkler head escutcheon rings are flush to the ceiling surface and providing a sprinkler head wrench at the riser location. This deficient practice of failing to provide prompt correction of deficiencies did not ensure proper operation and prompt repair of the system. This affected all staff, residents and visitors located within these smoke zones. This facility had a capacity of 25 and a census of 25 residents at the time of the survey.

Findings include:

Observations and interview on 6/21/18, between 10:00 a.m. and 4:00 p.m., revealed the following deficiencies:

1) There was no sprinkler head wrench located at the sprinkler riser in the MOB.
2) The sprinkler head escutcheon ring located just outside the Emergency Room back doors (in Radiology) was not flush to the ceiling surface.
3) The sprinkler head located just outside the 2R Elevator doors was missing the escutcheon ring.

This deficient practice was confirmed by Maintenance Staff A at the time of discovery.

Based on observation and interview, the facility failed to maintain portable fire extinguishers in accordance with National Fire Protection Association (NFPA) 10, Standard for Portable Fire Extinguishers, 2010 edition, 7.3.1.1.1. This deficient practice affects one fire extinguisher in one out of eight smoke compartments and all kitchen staff. This facility had a capacity of 25 and a census of 25 residents at the time of the survey.

Findings include:

Observation and interview on 6/21/18, at 1:50 p.m., revealed the K-type fire extinguisher located in the Kitchen did not contain an instructional placard located above the fire extinguisher.

The instructional placard shall be placed just above the fire extinguisher and read as follows: In case of appliance fire, use this extinguisher after fixed suppression system has been actuated.

Maintenance Staff A verified this observation at the time of the survey process.

Based on observation, interview and record review, this facility did not assure that four of eight smoke barriers are composed of materials that ensure at least a 30 minute fire resistance rating to prevent the passage of smoke and fire to another smoke zone in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.3.7.3/19.3.7.3. This deficient practice affected three out of eight smoke zones and all visitors, residents and staff in these smoke zones. This facility had a capacity of 25 and a census of 25 patients at the time of the survey.

Findings include:

Observation and interview on 6/21/18, between 10:00 a.m. and 4:00 p.m., revealed the following deficiencies:

1) There was a gap around the one inch conduit pipe located just above electrical panel, 1LL1, located in the Electrical Room just outside the emergency room.
2) There were three penetrations, (approximately 4 X 4 inches), in the Data Room wall near the main entry door.
3) There were several small holes in the wall just above the main entry door in the Data Room.
4) There was a small hole, (located just above the door hardware), in the Data Room entry door.

Record review of the facility layout showed the deficient practice affected three out of eight smoke zones.

This deficient practice was confirmed by Maintenance Staff A at the time of discovery.

Based on observation and interview, the facility is not providing doors to the corridor that resist the passage of smoke in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 19.3.6.3. This deficient practice would not prevent the spread of smoke, affecting one of eight smoke compartments, including residents, staff, and visitors in the affected compartment. This facility had a capacity of 25 with a census of 25 residents at the time of the survey.

Findings include:

Observation and interview on 6/21/18, at 12:50 p.m., revealed the electric double doors in Surgery Recovery did not close properly when tested.

Maintenance Staff A verified this observation during the survey process.

Based on observation and interview, the facility failed to have an emergency shut off switch installed for the boiler system, other than a central heating plant, designed and installed so combustible materials cannot be ignited by device, and has a safety feature to stop fuel and shut down equipment if there is excessive temperature or ignition failure in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 19.5.2.2. This deficient practice affects all occupants of the building. This facility had a capacity of 25 and a census of 25 residents at the time of the survey.

Findings include:

Observation and interview on 6/21/18, at 1:58 p.m., revealed the boiler system did not have an emergency shut off switch installed in case of an emergency shut down.

Maintenance Staff A verified this observation during the survey process.

Based on record review and interview, this facility did not maintain and test essential electrical system (EES) circuitry as required by National Fire Protection Association (NFPA) 99, Health Care Facilities Code, 2012 edition, 6.4.4.1.2 and 6.4.4.2. The facility failed to maintain the emergency generator by maintaining complete monthly documentation as required by National Fire Protection Association (NFPA) 110, Standard for Emergency and Standby Power Systems, 2010 edition, 8.3.1 or 8.3.4. The deficient practices of not providing complete and verifiable documentation on the inspection, testing, and maintenance of the generator and inspection and exercising the components of the essential electrical system (EES) main and feeder circuit breakers did not ensure proper operation and prompt repair affecting all occupants. This facility had a capacity of 25 and a census of 25 residents at the time of the survey.

Findings include:

Record review and interview conducted on 6/21/18, between 10:00 a.m. and 4:00 p.m., of the facilities generator inspection testing and maintenance records revealed:

1) The available documentation did not indicate the time to transfer or the start and stop times during the monthly load tests on the generator.
2) The available documentation did not indicate the volts and amps were being recorded on all three legs during the monthly load tests on the generator.
3) The facility was unable to provide documentation of inspection and exercising the components of the essential electrical system (EES) main and feeder circuit breakers. The main and feeder circuit breakers must be tested annually.
4) The facility was unable to provide documentation of an annual fuel quality test approved by the American Section of the International Association for Testing Materials (ASTM) on the diesel generator.
5) The facility was unable to provide documentation of weekly inspections on the generator set.
6) The available documentation indicated the facility failed to conduct monthly inspections on the generator during the months of July, August and October during 2017.

Main & Feeder Circuit Breakers

Type 2 EES (Refers to the Type 1 EES requirement of 6.4.4.1.2 for circuit breaker testing.)
6.5.4.1.2 Maintenance and Testing of Circuitry. Circuitry shall
be maintained and tested in accordance with 6.4.4.1.2.

Type 1 EES
6.4.4.1.2 Maintenance and Testing of Circuitry.
6.4.4.1.2.1* Circuit Breakers. Main and feeder circuit breakers
shall be inspected annually, and a program for periodically
exercising the components shall be established according to
manufacturer's recommendations.

A.6.4.4.1.2.1 Main and feeder circuit breakers should be periodically
tested under simulated overload trip conditions to
ensure reliability.

6.4.4.2 Record Keeping. A written record of inspection, performance,
exercising period, and repairs shall be regularly
maintained and available for inspection by the authority having
jurisdiction.

These deficient practices were confirmed by Maintenance Staff A at the time of the survey.

Based on observations and interview, the facility did not provide a storage location for oxygen cylinders separate from combustibles in accordance with National Fire Protection Association (NFPA) 99, Health Care Facilities Code, 2012 edition, 11.3. This deficient practice affects two out of eight smoke compartments and any residents, staff, and visitors in the first and second floor of the MOB. The facility had a capacity of 25 with a census of 25 residents at the time of the survey.

Findings include:

Observations and interview on 6/21/18, between 10:00 a.m. and 4:00 p.m., revealed the following deficiencies:

1) There was one E-size cylinder of oxygen (in the 1st floor Clean Room) stored within five feet of stored plastic tubs holding nasal cannulas and plastic tubing.
2) There was one E-size cylinder of oxygen (in the 2nd floor Clean Room) stored within five feet of stored plastic tubs holding nasal cannulas and plastic tubing.

Maintenance Staff A verified these observations at the time of the survey.