HospitalInspections.org

The facility did not ensure that the common wall of the non-conforming building was a fire barrier having at least a two-hour fire resistance rating constructed of materials required for the addition, as required by the referenced, "Life Safety Code" .

1. On 08/22/16 at 9:00 AM the surveyor, while accompanied by the Engineering Director observed that portions of the 2-hr. fire rated wall assembly that is located to the rear of the Observation Examination Room within the Emergency Department has been removed to accommodate additional stretchers & patients and the separation between the 2 (two), adjoining buildings no longer meets the requirements of section # 19.1.1.4.2 of the " Life Safety Code" ;i.e. issue was cited at last survey and not addressed;

2. On 08/22/16 at 9:00 AM the surveyor, while accompanied by the Engineering Director observed that portions of the 2-hr. fire rated wall assembly that is located at Crisis Center area/ Behavioral Holding within the Emergency Department has been removed to accommodate additional behavioral rooms & patients and the separation between the 3 (three), adjoining buildings no longer meets the requirements of section # 19.1.1.4.2 of the " Life Safety Code " ; i.e. issue was cited at last survey and not addressed.

The facility did not ensure that stairways, elevator shafts, light and ventilation shafts, chutes and other vertical openings between floors were enclosed with construction having a fire resistance rating of at least one hour as required by the referenced LSC.

On 08/23/16 at 9:15 AM and at other times during the survey day, the surveyor, while accompanied by the facility Maintenance Director observed in rooms #5.203, #5.240, #5.336, and #4.130 that there were penetrations for the passage of data wires through the concrete floor deck of each room that were not sealed with materials having a fire resistance rating of at least 2 hours.

The Pequot Health Center facility did not ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating in accordance with 8.3.

On 08/22/16 at 11:00 AM and at other times throughout the survey, the surveyor while accompanied by the Maintenance Director and Quality Staff observed that the smoke barriers throughout the facility had voids around penetrations and within conduit used for the passage of wires that were not sealed using a UL approved system for fire stopping through a smoke barrier; i.e., either not sealed and/or non-rated materials used.

The facility did not ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating in accordance with 8.3.

On 08/23/16 at 9:25 AM, the surveyor, while accompanied by the facility Maintenance Director observed that there were voids around penetrations through the smoke barrier above the suspended ceiling assembly at the corridor smoke doors to Section 5.1 and the Cath Lab, which were not sealed with materials having at least a half hour fire resistance rating.

The Pequot Health Center facility did not ensure that hazardous areas protected by an automatic extinguishing system were separated by smoke resisting partitions and self-closing doors as required by 19.3.2.1

On 08/22/16 at 1:14 PM, the surveyor while accompanied by the Maintenance Director and Quality Staff observed that there were voids in the walls in Electrical Room #1026 which were not sealed with materials having a fire resistance of at least 1 hour; i.e., large holes not sealed and non-rated materials used.

The facility did not ensure that emergency lighting of at least 1½-hour duration is provided, as required by " Life Safety Code " section # ' s 7.9 & 19.2.9.1

1. On 08/23/16 at 10:30 AM the surveyor was not provided with documentation from the Engineering Director to indicate that the emergency light system at the Wound Care Center in Waterford was inspected monthly ,as required by section # 7.9 of the referenced "Life Safety Code ";

2. On 08/23/16 at 10:30 AM the surveyor was not provided with documentation from the Engineering Director to indicate that the emergency light system at the Wound Care Center in Waterford was tested annually, as required by section # 7.9 of the referenced "Life Safety Code ";

3. On 08/22/16 at 1:00 PM the surveyor, while accompanied by the Engineering Director, observed that emergency lighting for the interior of the hyperbaric chambers that were located at the Wound Care Center in Waterford was not provided, as required by section # 19-2.3.3 of NFPA 99, "Health Care Facility ' s ".

The facility did not ensure that the design, installation and use of its commercial cooking equipment was in accordance with NFPA 96: Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations as required by the referenced LSC.

On 08/23/16 at 11:55 AM, the surveyor, while accompanied by the facility Maintenance Director observed that the wheeled, natural-gas fired appliances located in the cooking line were not equipped with a system that would prevent damage to the flexible fuel lines; i.e. tether/cables installed but not being used on the gas equipment with wheels under the hood.

The facility did not ensure that draperies, curtains, including cubicle curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies are flame resistant in accordance with section # 10.3.1 of the referenced, Life Safety Code, NFPA 13, "Standard for the Installation of Sprinkler Systems " and NFPA 701.

On 08/23/16 at 9:30 AM the surveyor, while accompanied by the Engineering Director, observed that the portable, privacy curtain located within the Dialysis Nursing Unit was not labeled as flame resistant, as required by the "Life Safety Code" and NFPA 701, "Standard Methods of Fire Tests for Flame Propagation of Textiles and Films " ; i.e. no label, tag or documentation to indicate curtain is flame resistant.

The facility did not ensure that nonflammable medical gas systems and equipment used for the administration of inhalation therapy and for resuscitative purposes was in compliance with NFPA 99: Heath Care Facility ' s.

1. On 08/23/16 at 11:30 AM the surveyor was not provided with documentation from the Engineering Director to indicate that an Installers Report was developed for the medical gas repairs at the Wound Care Center in Waterford; i.e. manifold & vaporizer project of 08/23/15-no installers report available (not completed at time of work);

2. On 08/23/16 at 9:40 AM the surveyor, while accompanied by the Engineering Director, observed that spare, oxygen cylinders were being stored out in the open within the Isolation Room located within the Dialysis Nursing Unit; i.e. facility has policy of storing cylinders in green cabinets-policy not followed.

1. The Pequot Health Center facility did not ensure that the required remote manual stop station for the facility ' s emergency generator was functional at all times and operating as required in NFPA 110 " Standard for Emergency and Standby Power Systems " Section 3-5.5.6 and as part of the facilities preventive maintenance program.

On 08/22/16 at 12:35 PM, the surveyor while accompanied by the Maintenance Director and Quality Staff observed that the facility ' s emergency and standby power systems lacked a remote manual stop station as required by 3-5.5.6; i.e., the facility lacked a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.

2. The Pequot Health Center facility did not ensure that the facility ' s emergency generator was functional at all times and operating as required in NFPA 99 " Health Care Facilities " Section 3-4.1.1.8.
On 08/23/16 at 1:00 PM, the surveyor was not provided with documentation by the Maintenance Director and Quality Staff person to indicate that when the monthly load tests of the facility ' s generator was conducted that the generator failed start and pick-up the required load within 10 seconds; i.e., transfer times for load test for most test were eleven (11) to twenty-one (21) seconds.

3. The Pequot Health Center facility did not ensure that all employees are periodically instructed as to their duties during a fire emergency as required by NFPA 101 " Life Safety Code " 19.7.1 and annually as required in NFPA 99 " Health Care Facilities " 11-5.3.8.

On 8/23/16 at 2:30 PM, the surveyors were not provided with documentation by the Maintenance Director, Quality Staff person and Training staff to indicate that that all employees received annual, fire safety education that was site specific, non-generic or otherwise reflected/supported the facility ' written plan of protection for all persons in the event of a fire. Such in-service training shall be conducted for all, new employees and annually for all others NFPA 99 " Health Care Facilities " 11-5.3.8; i.e., on line training is a generic Health Stream program that was not site specific. In addition documentation was not available to indicate that training was completed annually (365 day) as required.

4. The Pequot Health Center facility did not ensure that electrical receptacle outlets in-patient areas were being inspected at least annually as required in NFPA 99 " Health Care Facilities " .

On 08/23/16 at 11:30 AM, the surveyor was not provided with documentation by the Maintenance Director and Quality Staff person to indicate that electrical receptacle outlets in patient areas are inspected annually as required in NFPA 99, Section 3-3.3.3 and 3-3.4.2.3 and as part of the facilities preventive maintenance program; i.e., documentation of annual testing for the physical integrity of each receptacle, the continuity of grounding circuit in each receptacle, correct polarity of the hot and neutral connections in each receptacle, and the retention force of the grounding blade of each receptacle was not available.

1. The facility did not ensure that the required remote manual stop station for the facility ' s four (4) emergency generator was functional at all times and operating as required in NFPA 110 " Standard for Emergency and Standby Power Systems " Section 3-5.5.6 and as part of the facilities preventive maintenance program.

On 08/22/16 at 12:35 PM, the surveyor while accompanied by the Maintenance Director and Quality Staff observed that the facility ' s emergency and standby power systems lacked a remote manual stop station as required by 3-5.5.6; i.e., the facility lacked a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building; engineering removed the stops.


2. The facility did not ensure that all employees are periodically instructed as to their duties during a fire emergency as required by NFPA 101 " Life Safety Code " 19.7.1 and annually as required in NFPA 99 " Health Care Facilities " 11-5.3.8.

On 8/23/16 at 2:30 PM, the surveyors were not provided with documentation by the Maintenance Director, Quality Staff person and Training staff to indicate that that all employees received annual, fire safety education that was site specific, non-generic or otherwise reflected/supported the facility ' written plan of protection for all persons in the event of a fire. Such in-service training shall be conducted for all, new employees and annually for all others NFPA 99 " Health Care Facilities " 11-5.3.8; i.e., on line training is a generic Health Stream program that was not site specific. In addition documentation was not available to indicate that training was completed annually (365 day) as required.

3. The facility did not ensure that electrical receptacle outlets in-patient areas were being inspected at least annually as required in NFPA 99 " Health Care Facilities " .

On 08/23/16 at 11:30 AM, the surveyor was not provided with documentation by the Maintenance Director and Quality Staff person to indicate that electrical receptacle outlets in patient areas are inspected annually as required in NFPA 99, Section 3-3.3.3 and 3-3.4.2.3 and as part of the facilities preventive maintenance program; i.e., documentation of annual testing for the physical integrity of each receptacle, the continuity of grounding circuit in each receptacle, correct polarity of the hot and neutral connections in each receptacle, and the retention force of the grounding blade of each receptacle was not available.





27293

1. The facility did not ensure that electrical receptacle outlets in-patient areas were being inspected at least annually as required in NFPA 99, " Health Care Facility ' s " ;

a. On 08/23/16 at 11:15 AM the surveyor was not provided with documentation from the Engineering Director to indicate that all electrical receptacle outlets in patient areas in the Dialysis Nursing Unit are inspected annually as required in NFPA 99, " Health Care Facility ' s " , section 3-3.3.3 and 3-3.4.2.3, and as part of the facility ' s preventive maintenance program; i.e. there is no documentation of any kind (locations, PASS, FAIL, Comment ' s) for any of the receptacles in unit # 5.150-the Dialysis Unit;

b. On 08/23/16 at 11:20 AM the surveyor was not provided with documentation from the Engineering Director to indicate that all electrical receptacle outlets in patient areas at the Wound Care Center in Waterford are inspected annually as required in NFPA 99, " Health Care Facility ' s " , section 3-3.3.3 and 3-3.4.2.3, and as part of the facility ' s preventive maintenance program; i.e. elect recept testing is not in facility maint program.


2. The facility did not ensure that patient electrical devices were being maintained, as required in NFPA 99, "Health Care Facility ' s" Section 7-6.2.1.2, and as part of the facility ' s preventive maintenance program.

On 08/22/16 at 9:50 AM the surveyor, while accompanied by the Engineering Director observed that the electrodes/pads for the defibulators that were located operating table-side in C-Section Operating Rooms 1 & 2 were expired and not maintained as ready for use, as required by NFPA 99, "Health Care Facility ' s ", section 7-5.1.3, 7-5.2.2.1 and 7-6.2.1.2 and as part of the facility ' s preventive maintenance program; i.e. 6 (six) packages expired (03/15 thru 05/16) in OR #1 and 1 (one) package expired in OR #2 (02/16).

The facility did not ensure that the common wall of the non-conforming building was a fire barrier having at least a two-hour fire resistance rating constructed of materials required for the addition, as required by the referenced, "Life Safety Code" .

1. On 08/22/16 at 9:00 AM the surveyor, while accompanied by the Engineering Director observed that portions of the 2-hr. fire rated wall assembly that is located to the rear of the Observation Examination Room within the Emergency Department has been removed to accommodate additional stretchers & patients and the separation between the 2 (two), adjoining buildings no longer meets the requirements of section # 19.1.1.4.2 of the " Life Safety Code" ;i.e. issue was cited at last survey and not addressed;

2. On 08/22/16 at 9:00 AM the surveyor, while accompanied by the Engineering Director observed that portions of the 2-hr. fire rated wall assembly that is located at Crisis Center area/ Behavioral Holding within the Emergency Department has been removed to accommodate additional behavioral rooms & patients and the separation between the 3 (three), adjoining buildings no longer meets the requirements of section # 19.1.1.4.2 of the " Life Safety Code " ; i.e. issue was cited at last survey and not addressed.

The facility did not ensure that stairways, elevator shafts, light and ventilation shafts, chutes and other vertical openings between floors were enclosed with construction having a fire resistance rating of at least one hour as required by the referenced LSC.

On 08/23/16 at 9:15 AM and at other times during the survey day, the surveyor, while accompanied by the facility Maintenance Director observed in rooms #5.203, #5.240, #5.336, and #4.130 that there were penetrations for the passage of data wires through the concrete floor deck of each room that were not sealed with materials having a fire resistance rating of at least 2 hours.

The Pequot Health Center facility did not ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating in accordance with 8.3.

On 08/22/16 at 11:00 AM and at other times throughout the survey, the surveyor while accompanied by the Maintenance Director and Quality Staff observed that the smoke barriers throughout the facility had voids around penetrations and within conduit used for the passage of wires that were not sealed using a UL approved system for fire stopping through a smoke barrier; i.e., either not sealed and/or non-rated materials used.

The facility did not ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating in accordance with 8.3.

On 08/23/16 at 9:25 AM, the surveyor, while accompanied by the facility Maintenance Director observed that there were voids around penetrations through the smoke barrier above the suspended ceiling assembly at the corridor smoke doors to Section 5.1 and the Cath Lab, which were not sealed with materials having at least a half hour fire resistance rating.

The Pequot Health Center facility did not ensure that hazardous areas protected by an automatic extinguishing system were separated by smoke resisting partitions and self-closing doors as required by 19.3.2.1

On 08/22/16 at 1:14 PM, the surveyor while accompanied by the Maintenance Director and Quality Staff observed that there were voids in the walls in Electrical Room #1026 which were not sealed with materials having a fire resistance of at least 1 hour; i.e., large holes not sealed and non-rated materials used.

The facility did not ensure that emergency lighting of at least 1½-hour duration is provided, as required by " Life Safety Code " section # ' s 7.9 & 19.2.9.1

1. On 08/23/16 at 10:30 AM the surveyor was not provided with documentation from the Engineering Director to indicate that the emergency light system at the Wound Care Center in Waterford was inspected monthly ,as required by section # 7.9 of the referenced "Life Safety Code ";

2. On 08/23/16 at 10:30 AM the surveyor was not provided with documentation from the Engineering Director to indicate that the emergency light system at the Wound Care Center in Waterford was tested annually, as required by section # 7.9 of the referenced "Life Safety Code ";

3. On 08/22/16 at 1:00 PM the surveyor, while accompanied by the Engineering Director, observed that emergency lighting for the interior of the hyperbaric chambers that were located at the Wound Care Center in Waterford was not provided, as required by section # 19-2.3.3 of NFPA 99, "Health Care Facility ' s ".

The facility did not ensure that the design, installation and use of its commercial cooking equipment was in accordance with NFPA 96: Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations as required by the referenced LSC.

On 08/23/16 at 11:55 AM, the surveyor, while accompanied by the facility Maintenance Director observed that the wheeled, natural-gas fired appliances located in the cooking line were not equipped with a system that would prevent damage to the flexible fuel lines; i.e. tether/cables installed but not being used on the gas equipment with wheels under the hood.

The facility did not ensure that draperies, curtains, including cubicle curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies are flame resistant in accordance with section # 10.3.1 of the referenced, Life Safety Code, NFPA 13, "Standard for the Installation of Sprinkler Systems " and NFPA 701.

On 08/23/16 at 9:30 AM the surveyor, while accompanied by the Engineering Director, observed that the portable, privacy curtain located within the Dialysis Nursing Unit was not labeled as flame resistant, as required by the "Life Safety Code" and NFPA 701, "Standard Methods of Fire Tests for Flame Propagation of Textiles and Films " ; i.e. no label, tag or documentation to indicate curtain is flame resistant.

The facility did not ensure that nonflammable medical gas systems and equipment used for the administration of inhalation therapy and for resuscitative purposes was in compliance with NFPA 99: Heath Care Facility ' s.

1. On 08/23/16 at 11:30 AM the surveyor was not provided with documentation from the Engineering Director to indicate that an Installers Report was developed for the medical gas repairs at the Wound Care Center in Waterford; i.e. manifold & vaporizer project of 08/23/15-no installers report available (not completed at time of work);

2. On 08/23/16 at 9:40 AM the surveyor, while accompanied by the Engineering Director, observed that spare, oxygen cylinders were being stored out in the open within the Isolation Room located within the Dialysis Nursing Unit; i.e. facility has policy of storing cylinders in green cabinets-policy not followed.

1. The Pequot Health Center facility did not ensure that the required remote manual stop station for the facility ' s emergency generator was functional at all times and operating as required in NFPA 110 " Standard for Emergency and Standby Power Systems " Section 3-5.5.6 and as part of the facilities preventive maintenance program.

On 08/22/16 at 12:35 PM, the surveyor while accompanied by the Maintenance Director and Quality Staff observed that the facility ' s emergency and standby power systems lacked a remote manual stop station as required by 3-5.5.6; i.e., the facility lacked a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.

2. The Pequot Health Center facility did not ensure that the facility ' s emergency generator was functional at all times and operating as required in NFPA 99 " Health Care Facilities " Section 3-4.1.1.8.
On 08/23/16 at 1:00 PM, the surveyor was not provided with documentation by the Maintenance Director and Quality Staff person to indicate that when the monthly load tests of the facility ' s generator was conducted that the generator failed start and pick-up the required load within 10 seconds; i.e., transfer times for load test for most test were eleven (11) to twenty-one (21) seconds.

3. The Pequot Health Center facility did not ensure that all employees are periodically instructed as to their duties during a fire emergency as required by NFPA 101 " Life Safety Code " 19.7.1 and annually as required in NFPA 99 " Health Care Facilities " 11-5.3.8.

On 8/23/16 at 2:30 PM, the surveyors were not provided with documentation by the Maintenance Director, Quality Staff person and Training staff to indicate that that all employees received annual, fire safety education that was site specific, non-generic or otherwise reflected/supported the facility ' written plan of protection for all persons in the event of a fire. Such in-service training shall be conducted for all, new employees and annually for all others NFPA 99 " Health Care Facilities " 11-5.3.8; i.e., on line training is a generic Health Stream program that was not site specific. In addition documentation was not available to indicate that training was completed annually (365 day) as required.

4. The Pequot Health Center facility did not ensure that electrical receptacle outlets in-patient areas were being inspected at least annually as required in NFPA 99 " Health Care Facilities " .

On 08/23/16 at 11:30 AM, the surveyor was not provided with documentation by the Maintenance Director and Quality Staff person to indicate that electrical receptacle outlets in patient areas are inspected annually as required in NFPA 99, Section 3-3.3.3 and 3-3.4.2.3 and as part of the facilities preventive maintenance program; i.e., documentation of annual testing for the physical integrity of each receptacle, the continuity of grounding circuit in each receptacle, correct polarity of the hot and neutral connections in each receptacle, and the retention force of the grounding blade of each receptacle was not available.

1. The facility did not ensure that the required remote manual stop station for the facility ' s four (4) emergency generator was functional at all times and operating as required in NFPA 110 " Standard for Emergency and Standby Power Systems " Section 3-5.5.6 and as part of the facilities preventive maintenance program.

On 08/22/16 at 12:35 PM, the surveyor while accompanied by the Maintenance Director and Quality Staff observed that the facility ' s emergency and standby power systems lacked a remote manual stop station as required by 3-5.5.6; i.e., the facility lacked a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building; engineering removed the stops.


2. The facility did not ensure that all employees are periodically instructed as to their duties during a fire emergency as required by NFPA 101 " Life Safety Code " 19.7.1 and annually as required in NFPA 99 " Health Care Facilities " 11-5.3.8.

On 8/23/16 at 2:30 PM, the surveyors were not provided with documentation by the Maintenance Director, Quality Staff person and Training staff to indicate that that all employees received annual, fire safety education that was site specific, non-generic or otherwise reflected/supported the facility ' written plan of protection for all persons in the event of a fire. Such in-service training shall be conducted for all, new employees and annually for all others NFPA 99 " Health Care Facilities " 11-5.3.8; i.e., on line training is a generic Health Stream program that was not site specific. In addition documentation was not available to indicate that training was completed annually (365 day) as required.

3. The facility did not ensure that electrical receptacle outlets in-patient areas were being inspected at least annually as required in NFPA 99 " Health Care Facilities " .

On 08/23/16 at 11:30 AM, the surveyor was not provided with documentation by the Maintenance Director and Quality Staff person to indicate that electrical receptacle outlets in patient areas are inspected annually as required in NFPA 99, Section 3-3.3.3 and 3-3.4.2.3 and as part of the facilities preventive maintenance program; i.e., documentation of annual testing for the physical integrity of each receptacle, the continuity of grounding circuit in each receptacle, correct polarity of the hot and neutral connections in each receptacle, and the retention force of the grounding blade of each receptacle was not available.





27293

1. The facility did not ensure that electrical receptacle outlets in-patient areas were being inspected at least annually as required in NFPA 99, " Health Care Facility ' s " ;

a. On 08/23/16 at 11:15 AM the surveyor was not provided with documentation from the Engineering Director to indicate that all electrical receptacle outlets in patient areas in the Dialysis Nursing Unit are inspected annually as required in NFPA 99, " Health Care Facility ' s " , section 3-3.3.3 and 3-3.4.2.3, and as part of the facility ' s preventive maintenance program; i.e. there is no documentation of any kind (locations, PASS, FAIL, Comment ' s) for any of the receptacles in unit # 5.150-the Dialysis Unit;

b. On 08/23/16 at 11:20 AM the surveyor was not provided with documentation from the Engineering Director to indicate that all electrical receptacle outlets in patient areas at the Wound Care Center in Waterford are inspected annually as required in NFPA 99, " Health Care Facility ' s " , section 3-3.3.3 and 3-3.4.2.3, and as part of the facility ' s preventive maintenance program; i.e. elect recept testing is not in facility maint program.


2. The facility did not ensure that patient electrical devices were being maintained, as required in NFPA 99, "Health Care Facility ' s" Section 7-6.2.1.2, and as part of the facility ' s preventive maintenance program.

On 08/22/16 at 9:50 AM the surveyor, while accompanied by the Engineering Director observed that the electrodes/pads for the defibulators that were located operating table-side in C-Section Operating Rooms 1 & 2 were expired and not maintained as ready for use, as required by NFPA 99, "Health Care Facility ' s ", section 7-5.1.3, 7-5.2.2.1 and 7-6.2.1.2 and as part of the facility ' s preventive maintenance program; i.e. 6 (six) packages expired (03/15 thru 05/16) in OR #1 and 1 (one) package expired in OR #2 (02/16).