HospitalInspections.org

Based upon observations and staff interviews on 8/2/17 during the physical tour of the facility between approximately 1215 and 1430 hours the facility has failed to ensure that doors that are equipped with hold-open devices will close fully and automatically when the hold-open devices release. This could result in toxic products of combustion getting into the room and into the exit corridor or adjacent smoke compartment which would endanger the residents, staff and/or visitors within the smoke compartment.

The findings include, but are not limited to:



The room doors that open into the corridor from rooms #308,303 and 302 had inoperative / disabled self-closing devices

The Northwest double-doors that open into the corridor from the LTC common area had an inoperative self-closing coordinating device.


The above was discussed and acknowledged by the Facility Maintenance Director who said the doors to 303,302 ad 308 had the closing devices disabled because they were being used for Sleep Study procedures, and that he had not previously observed inoperative coordinating device.

Based upon observations and staff interviews on 8/2/17 during the physical tour of the facility between approximately 1215 and 1430 hours, the facility has failed to maintain doors in hazardous areas as capable of resisting the passage of smoke. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the residents, staff and/or visitors within the smoke compartment.

The findings include, but are not limited to:


-The door to the corridor from the Storage room (unnumbered) over 50 square feet across from Room 301 was observed to have an unsealed through penetration near the top of the door due to missing door hardware.

-The door to OR/Storage room over 50 square feet was blocked open by a door stop and was prevented from automatically closing and latching.




The above was discussed with the Maintenance Director who said they had not previously observed the penetration and blocked open door.

Based upon observations and staff interviews on 8/9/17 during the physical tour of the facility between approximately 1215 and 1430 hours and during record review between approximately 1045 and 1215 hours the facility has failed to maintain laboratory exhaust hoods in accordance with NFPA 99 and NFPA 45. This could result in the failure of exhaust hoods to properly ventilate hazardous chemical fumes, resulting in potential harm to staff, patients and visitors.



The findings include, but are not limited to:


The Lab and Pharmacy exhaust hoods have not had their annual inspection conducted since 2-17-16 as required by 2011 NFPA 45-8.13.1.

The above was discussed and acknowledged by the Maintenance Director who said contractor who had previously been conducting the inspections went out of business and that they went past the due date as they were attempting to find another contractor.

Based upon observation and staff interviews on 8/2/17 during the document review period of the inspection between approximately 1045 and 1215 hours the facility has failed to maintain the fire alarm system as required by NFPA 72. This could result in the failure of the fire alarm system to operate properly in the event of a fire which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:


-According to the 7-6-2017 Annual Fire Alarm Confidence Test report, Audio Visual strobes in the corridor near room 202 and by ER#3 did not activate when tested. The facility was unable to provide any documentation indicating they had been repaired or replaced.


The above was discussed and acknowledged by the Maintenance Director who said their Fire Alarm contractor has not been out to replace the strobes yet.

Based upon observations and staff interviews on 8/2/17 during the physical tour of the facility between 1215 and 1430 hours the facility has failed to maintain doors protecting corridor openings as capable of resisting smoke. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the residents, staff and/or visitors within the smoke compartment.

The findings include, but are not limited to:


The Staff Dining room door that opens into the corridor was not equipped with positive-latching hardware.


The above was discussed and acknowledged by the Facility Maintenance Director who said the lack of positive latching hardware had never been previously mentioned to him.

Based upon observations and staff interviews on 8/2/17 during the physical tour of the facility between approximately 1215 and 1430 hours, the facility has failed to ensure all electrical wiring is in accordance with NFPA 70. This could result in an electrical hazard due to misuse, endangering the residents, staff and/or visitors within the facility.



The findings include, but are not limited to:

-There was a missing cover plate on an electrical outlet cover plate in the TV-cabling junction room.

-There was a missing electrical junction box cover in the Business office.



The above was discussed and acknowledged by the Facility maintenance Director who said they had not previously observed the missing covers.

Based upon record review and staff interviews on 8/2/17 during the review of facility documentation between approximately 1045 and 1215 hours the facility has failed to maintain and test fire and smoke dampers in accordance with NFPA 80 and NFPA 105. This could result in failure of the dampers to operate and close in the event of a fire, allowing the spread of the products of combustion from one compartment to another, endangering the patients, staff and/or visitors.

The findings include, but are not limited to:


The facility could not provide any documentation indicating their fire and smoke dampers have been inspected and tested within the last six years.
Per NFPA 80-19.4.1 Each damper shall be tested and inspected 1 year after installation and 19.4.1.1 The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years.


The above was discussed and acknowledged by the Maintenance Director who said they were unaware of the damper testing requirements.

Based upon record review and staff interviews on 8/2/17 during document review between approximately 1045 and 1215 hours the facility has failed to conduct all fire drills as required by NFPA 101. This could potentially result in the staff and facility being unaware of an inoperative fire alarm system as well as resulting in a failure of staff to train in a life-like fire situation which could then result in staff not responding in a coordinated manner in the event of an actual fire or other emergency, endangering residents, staff and/or visitors.

The findings include, but are not limited to:


The facility could not provide any documentation indicating fire drills including staff actions for fire response have been conducted on any shift from August 2016 to November 2016.


The above was discussed and acknowledged by the Maintenance Director who said he believes the drills were conducted, but is unsure where the records are.

Based upon observations and staff interviews on 8/8/17 during the physical tour of the facility between approximately 1215 and 1430 hours the facility has failed to maintain the Medical Gas alarm system in accordance with NFPA 99. This could result in the failure of notification of overpressure or low pressure of the medical gas system, which could potentially endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

The Master Medical Gas Alarm panel located at the Central Nurse's station was inoperative and no visual alarms lights would activate when tested.

The above was discussed and acknowledged by the Maintenance Director who said he was unaware of the inoperative panel at the Nurse's station but that it had been repaired following 2016's inspection.

Based upon record review and staff interviews on 8/2/17 during the physical inspection of the facility between approximately 1215-1430 hours the facility has failed to maintain the emergency generator in accordance with NFPA 110. This could result in a failure of the emergency power system which would leave the facility without egress and task lighting in the event of a power failure which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:


-There is no battery backup emergency lighting device in the Automatic Generator transfer switch/mechanical room as required by NFPA 110-7.3.1.

The above was discussed and acknowledged by the Maintenance Director who said that they were unaware of the emergency lighting requirement for the transfer switch room.

Based upon observations and staff interviews on 8/2/17 during the physical tour of the facility between approximately 1215 and 1430 hours, the facility has failed to ensure all electrical wiring is in accordance with NFPA 70 and that extension cords are not used as a substitute for fixed wiring of a structure. This could result in an electrical hazard due to misuse or prolonged use of an extension cord, endangering the residents, staff and/or visitors within the facility.



The findings include, but are not limited to:

-There was an Air Conditioner plugged into an extension cord that was being used in place of permanent wiring in the Chief Nursing Officer's office

There was an extension cord being used in place of permanent wiring with a TV in the main Waiting room.



The above was discussed and acknowledged by the Maintenance Director who said they had not previously observed the extension cords.