HospitalInspections.org

Based on observation the facility failed to ensure a hazardous area was protected. Findings:

On 2-18-16 at 1:27pm the hazardous area containing two boilers had plywood walls.

It was observed at 1:28pm the doors accessing this hazardous area were not equipped with self closing hardware.

The Director of Operations acknowledged the plywood walls and no self closing hardware.

Based on observation and staff interview it was determined that the facility failed to ensure all egress pathways to be maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Findings:
On 2/18/16 at 2:25 p.m., a Zeiss microscope was observed to be stored in the egress path located at the operating room marked exit.
At 2:27 p.m., the Director of Plant Operations, and the Director of Surgical Services acknowledged the microscope with in the exit pathway leading out of the surgical suite.
NFPA 101, 2000 Edition, Chapter 7
7.1.10.1 requires the means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on observation and interview with staff the facility failed to ensure: proper airflow and air quality was being monitored and documented, and the facility failed to provide and ensure heating, ventilating, and air-conditioning systems complied with the manufacturer's specifications and recommendations. Findings:

On 2/18/16 at 9:32 a.m., the operating rooms airfilter quality logs were not available when requested. Airflow manometer readings were not being recorded, logged or documented. The airflow quality of the life of the final filters were not being documented or maintained.

On 2/19/16 at 11:01 a.m., The air handler unit identied by facility staff as AHU#1 servicing operating room's #1, #2 and #3 was observed to not have manometers installed.

At 11:04 a.m., The director of plant operations and maintanence staff member were asked to show the surveyor where the manometers were located on the facility HVAC system. Manometers could not be identified nor located on any of the existing facility HVAC system.

NFPA 101, 2000 Edition, Chapter 19.5.2.1,
NFPA 90A, Chapter 19.5.2.2.

AIA Health Care Guidelines & ANI/ASHE Standard 170-208 Ventilation of Health Care Facilities requires manometers to be used to determine the life of the filter. A 1.1 of ANI/ASHE Annex A states that filters shall be replaced on air pressure drop in accordance with the manometer readings.


NFPA 101, 2000 Edition, Chapter 9
9.2 HEATING, VENTILATING, AND AIR CONDITIONING
9.2.1 Air Conditioning, Heating, Ventilating Ductwork, and Related Equipment.
Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.
9.2.2 Ventilating or Heat-Producing Equipment.
Ventilating or heat-producing equipment shall be in accordance with NFPA 91, Standard for Exhaust Systems for Air Conveying of Vapors, Gases, Mists, and Noncombustible Particulate Solids; NFPA 211, Standard for Chimneys, Fireplaces, Vents, and Solid Fuel-Burning Appliances; NFPA 31, Standard for the Installation of Oil-Burning Equipment; NFPA 54, National Fuel Gas Code; or NFPA 70, National Electrical Code, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

_______________________________________________________________________________

Based on record review, staff interview and observation it was determined that the facility failed to ensure and comply with manufactures specifications regarding proper installation and use of one surgical sterilizer. Findings:

On 2/18/16 at 02:20 p.m., The sterilizer located in the surgical suite storeage room was observed to not be provided with a hood to exhaust heat, steam and by-products of dust caused from the combination of paper and steam under pressure per code.

At 02:21 p.m., the Director of Plant Operations acknowledged the non-vented sterilizer within the surgical suite.


International Mechanical Code, 502.1, 2009 edition and ANSI/ASHE Standard 170.2008, table 7.1.

NFPA 101, 2000 Edition, Chapter 20.5 Building Services
20.5.2.1-
Heating, ventilating, and air-conditioning comply with the manufacturer's specifications and section 9.2. Exception: As modified in 20.5.2.2*.
20.5.2.2*-
Any heating device, other than a central heating plant, shall be designed and installed so that combustible material will not be ignited by the device or its appurtenances. If fuel-fired, such heating devices shall be chimney connected or vent connected, shall take air for combustion directly from the outside, and shall be designed and installed to provide for complete separation of the combustion system from the atmosphere of the occupied area. Any heating device shall have safety features to immediately stop the flow of fuel and shut down the equipment in case of either excessive temperature or ignition failure.
Exception: Approved, suspended unit heaters shall be permitted in locations other than means of egress and patient treatment areas, provided that such heaters are located high enough to be out of the reach of persons using the area and are equipped with the safety features required by 20.5.2.2.

Based on observation it was determined the facility failed to ensure the Type I EES was divided into critical branch, and life safety branch. Findings:

On 2/19/15 at 10:52 a.m., it was observed the facility had multiple electrical panels throughout the facility. None of the electrical panels inspected were clearly labeled life safety branch and/or critical branch. On inspection of each of the electrical panel contents throughout the facility it was observed the components of the LSC branch panel were mixed with the critical branch panel components.

The Director of Plant Operations acknowledged the mixing of electrical panel componets for the life safety branch and critical branch. Each of the electrical panel LSC & Critical componets could were not indentified as being seperated as per code requirements.

NFPA 99, 1999 Edition, Chapter 3 Electrical Systems
3-4.2.2 Specific Requirements.
3-4.2.2.1* General.
Type I essential electrical systems are comprised of two separate systems capable of supplying a limited amount of lighting and power service, which is considered essential for life safety and effective facility operation during the time the normal electrical service is interrupted for any reason. These two systems are the emergency system and the equipment system.
The emergency system shall be limited to circuits essential to life safety and critical patient care. These are designated the life safety branch and the critical branch. The equipment system shall supply major electrical equipment necessary for patient care and basic Type I operation.
Both systems shall be arranged for connection, within time limits specified in this chapter, to an alternate source of power following a loss of the normal source. The number of transfer switches to be used shall be based upon reliability, design, and load considerations. Each branch of the emergency system and each equipment system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA (120 kW).

NFPA 99, 1999 Edition,
Chapter 3-4.2.2.2 Emergency System.
(a) General. Those functions of patient care depending on lighting or appliances that are permitted to be connected to the emergency system are divided into two mandatory branches, described in 3-4.2.2.2(b) and (c).
All ac-powered support and accessory equipment necessary to the operation of the EPS shall be supplied from the load side of the automatic transfer switch(es), or the output terminals of the EPS, ahead of the main EPS overcurrent protection, as necessary, to ensure continuity of the EPSS operation and performance. (NFPA 110: 5-12.5)
(b) Life Safety Branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment:
1. Illumination of means of egress as required in NFPA 101,® Life Safety Code®
2. Exit signs and exit direction signs required in NFPA 101, Life Safety Code
3. Alarm and alerting systems including the following:
a. Fire alarms
b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, " Gas and Vacuum Systems "
4. * Hospital communication systems, where used for issuing instruction during emergency conditions
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location
6. Elevator cab lighting, control, communication, and signal systems
7. Automatically operated doors used for building egress.No function other than those listed above in items 1 through 7 shall be connected to the life safety branch.
Exception: The auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm Code, shall be permitted to be connected to the life safety branch.
(c) * Critical Branch. The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and selected power circuits serving the following areas and functions related to patient care. It shall be permitted to subdivide the critical branch into two or more branches.
1. Critical care areas that utilize anesthetizing gases, task illumination, selected receptacles, and fixed equipment
2. The isolated power systems in special environments
3. Patient care areas - task illumination and selected receptacles in the following:
a. Infant nurseries
b. Medication preparation areas
c. Pharmacy dispensing areas
d. Selected acute nursing areas
e. Psychiatric bed areas (omit receptacles)
f. Ward treatment rooms
g. Nurses ' stations (unless adequately lighted by corridor luminaires)
4. Additional specialized patient care task illumination and receptacles, where needed
5. Nurse call systems
6. Blood, bone, and tissue banks
7. * Telephone equipment rooms and closets
8. Task illumination, selected receptacles, and selected power circuits for the following:
a. General care beds (at least one duplex receptacle per patient bedroom)
b. Angiographic labs
c. Cardiac catheterization labs
d. Coronary care units
e. Hemodialysis rooms or areas
f. Emergency room treatment areas (selected)
g. Human physiology labs
h. Intensive care units
i. Postoperative recovery rooms (selected)
9. Additional task illumination, receptacles, and selected power circuits needed for effective facility operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch.

Based on observation the facility failed to ensure a hazardous area was protected. Findings:

On 2-18-16 at 1:27pm the hazardous area containing two boilers had plywood walls.

It was observed at 1:28pm the doors accessing this hazardous area were not equipped with self closing hardware.

The Director of Operations acknowledged the plywood walls and no self closing hardware.

Based on observation and staff interview it was determined that the facility failed to ensure all egress pathways to be maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Findings:
On 2/18/16 at 2:25 p.m., a Zeiss microscope was observed to be stored in the egress path located at the operating room marked exit.
At 2:27 p.m., the Director of Plant Operations, and the Director of Surgical Services acknowledged the microscope with in the exit pathway leading out of the surgical suite.
NFPA 101, 2000 Edition, Chapter 7
7.1.10.1 requires the means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on observation and interview with staff the facility failed to ensure: proper airflow and air quality was being monitored and documented, and the facility failed to provide and ensure heating, ventilating, and air-conditioning systems complied with the manufacturer's specifications and recommendations. Findings:

On 2/18/16 at 9:32 a.m., the operating rooms airfilter quality logs were not available when requested. Airflow manometer readings were not being recorded, logged or documented. The airflow quality of the life of the final filters were not being documented or maintained.

On 2/19/16 at 11:01 a.m., The air handler unit identied by facility staff as AHU#1 servicing operating room's #1, #2 and #3 was observed to not have manometers installed.

At 11:04 a.m., The director of plant operations and maintanence staff member were asked to show the surveyor where the manometers were located on the facility HVAC system. Manometers could not be identified nor located on any of the existing facility HVAC system.

NFPA 101, 2000 Edition, Chapter 19.5.2.1,
NFPA 90A, Chapter 19.5.2.2.

AIA Health Care Guidelines & ANI/ASHE Standard 170-208 Ventilation of Health Care Facilities requires manometers to be used to determine the life of the filter. A 1.1 of ANI/ASHE Annex A states that filters shall be replaced on air pressure drop in accordance with the manometer readings.


NFPA 101, 2000 Edition, Chapter 9
9.2 HEATING, VENTILATING, AND AIR CONDITIONING
9.2.1 Air Conditioning, Heating, Ventilating Ductwork, and Related Equipment.
Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.
9.2.2 Ventilating or Heat-Producing Equipment.
Ventilating or heat-producing equipment shall be in accordance with NFPA 91, Standard for Exhaust Systems for Air Conveying of Vapors, Gases, Mists, and Noncombustible Particulate Solids; NFPA 211, Standard for Chimneys, Fireplaces, Vents, and Solid Fuel-Burning Appliances; NFPA 31, Standard for the Installation of Oil-Burning Equipment; NFPA 54, National Fuel Gas Code; or NFPA 70, National Electrical Code, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

_______________________________________________________________________________

Based on record review, staff interview and observation it was determined that the facility failed to ensure and comply with manufactures specifications regarding proper installation and use of one surgical sterilizer. Findings:

On 2/18/16 at 02:20 p.m., The sterilizer located in the surgical suite storeage room was observed to not be provided with a hood to exhaust heat, steam and by-products of dust caused from the combination of paper and steam under pressure per code.

At 02:21 p.m., the Director of Plant Operations acknowledged the non-vented sterilizer within the surgical suite.


International Mechanical Code, 502.1, 2009 edition and ANSI/ASHE Standard 170.2008, table 7.1.

NFPA 101, 2000 Edition, Chapter 20.5 Building Services
20.5.2.1-
Heating, ventilating, and air-conditioning comply with the manufacturer's specifications and section 9.2. Exception: As modified in 20.5.2.2*.
20.5.2.2*-
Any heating device, other than a central heating plant, shall be designed and installed so that combustible material will not be ignited by the device or its appurtenances. If fuel-fired, such heating devices shall be chimney connected or vent connected, shall take air for combustion directly from the outside, and shall be designed and installed to provide for complete separation of the combustion system from the atmosphere of the occupied area. Any heating device shall have safety features to immediately stop the flow of fuel and shut down the equipment in case of either excessive temperature or ignition failure.
Exception: Approved, suspended unit heaters shall be permitted in locations other than means of egress and patient treatment areas, provided that such heaters are located high enough to be out of the reach of persons using the area and are equipped with the safety features required by 20.5.2.2.

Based on observation it was determined the facility failed to ensure the Type I EES was divided into critical branch, and life safety branch. Findings:

On 2/19/15 at 10:52 a.m., it was observed the facility had multiple electrical panels throughout the facility. None of the electrical panels inspected were clearly labeled life safety branch and/or critical branch. On inspection of each of the electrical panel contents throughout the facility it was observed the components of the LSC branch panel were mixed with the critical branch panel components.

The Director of Plant Operations acknowledged the mixing of electrical panel componets for the life safety branch and critical branch. Each of the electrical panel LSC & Critical componets could were not indentified as being seperated as per code requirements.

NFPA 99, 1999 Edition, Chapter 3 Electrical Systems
3-4.2.2 Specific Requirements.
3-4.2.2.1* General.
Type I essential electrical systems are comprised of two separate systems capable of supplying a limited amount of lighting and power service, which is considered essential for life safety and effective facility operation during the time the normal electrical service is interrupted for any reason. These two systems are the emergency system and the equipment system.
The emergency system shall be limited to circuits essential to life safety and critical patient care. These are designated the life safety branch and the critical branch. The equipment system shall supply major electrical equipment necessary for patient care and basic Type I operation.
Both systems shall be arranged for connection, within time limits specified in this chapter, to an alternate source of power following a loss of the normal source. The number of transfer switches to be used shall be based upon reliability, design, and load considerations. Each branch of the emergency system and each equipment system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA (120 kW).

NFPA 99, 1999 Edition,
Chapter 3-4.2.2.2 Emergency System.
(a) General. Those functions of patient care depending on lighting or appliances that are permitted to be connected to the emergency system are divided into two mandatory branches, described in 3-4.2.2.2(b) and (c).
All ac-powered support and accessory equipment necessary to the operation of the EPS shall be supplied from the load side of the automatic transfer switch(es), or the output terminals of the EPS, ahead of the main EPS overcurrent protection, as necessary, to ensure continuity of the EPSS operation and performance. (NFPA 110: 5-12.5)
(b) Life Safety Branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment:
1. Illumination of means of egress as required in NFPA 101,® Life Safety Code®
2. Exit signs and exit direction signs required in NFPA 101, Life Safety Code
3. Alarm and alerting systems including the following:
a. Fire alarms
b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, " Gas and Vacuum Systems "
4. * Hospital communication systems, where used for issuing instruction during emergency conditions
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location
6. Elevator cab lighting, control, communication, and signal systems
7. Automatically operated doors used for building egress.No function other than those listed above in items 1 through 7 shall be connected to the life safety branch.
Exception: The auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm Code, shall be permitted to be connected to the life safety branch.
(c) * Critical Branch. The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and selected power circuits serving the following areas and functions related to patient care. It shall be permitted to subdivide the critical branch into two or more branches.
1. Critical care areas that utilize anesthetizing gases, task illumination, selected receptacles, and fixed equipment
2. The isolated power systems in special environments
3. Patient care areas - task illumination and selected receptacles in the following:
a. Infant nurseries
b. Medication preparation areas
c. Pharmacy dispensing areas
d. Selected acute nursing areas
e. Psychiatric bed areas (omit receptacles)
f. Ward treatment rooms
g. Nurses ' stations (unless adequately lighted by corridor luminaires)
4. Additional specialized patient care task illumination and receptacles, where needed
5. Nurse call systems
6. Blood, bone, and tissue banks
7. * Telephone equipment rooms and closets
8. Task illumination, selected receptacles, and selected power circuits for the following:
a. General care beds (at least one duplex receptacle per patient bedroom)
b. Angiographic labs
c. Cardiac catheterization labs
d. Coronary care units
e. Hemodialysis rooms or areas
f. Emergency room treatment areas (selected)
g. Human physiology labs
h. Intensive care units
i. Postoperative recovery rooms (selected)
9. Additional task illumination, receptacles, and selected power circuits needed for effective facility operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch.