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Building A-2

Through observation during the survey, November 1, 2018, it was determined that the facility failed to continuously maintain the means of egress free of all obstructions or impediments to full instant use in case of fire or other emergency.

During the walkthrough of the facility, with theMaintenance Director, the corridor from the IT trailer to the exit contained storage in the corridor which reduced the path of the egress to less than forty four inches (44"). There shall be no storage within this corridor if utilized as an agress path.

This deficiency potentially effected one room within the facility.

Building A-2

Through observation during the survey, Novermber 1, 2018, it was determined that the facility had not maintained the exit access door.

During the walk through of the facility, with the Maintenance Director;
1) The Therapy Room contained a manual latch on right door of the set of double doors
2) There was a manual latch on upper part of the Dutch door to medical records room. This "Upper" door must positively latch into the bottom door without any manual means.
Per NFPA 101 2012 Edition, section 19.3.6.3.13
3) Lock and latch on entry door from corridor to IT room, this door is currently utilized as the only exit from the IT trailer, therefore the door cannot have a lock on the door in which you cannot exit through the door without special knowledge or one operation.

These deficiencies potentially effected 3 rooms within the space.

Building A-5-Grandby

Through observation during the survey, November 1, 2018, it was determined the facility failed to maintain all battery back-up lighting.

During the walk through and testing, with the Maintenance Director, the battery back up emergency light located in the transfer switch room failed to illuminate when the "test button" was pushed.

This deficiency potentially effected the entire building with no emergency light at the transfer switch.

Building A-1

Through record review during the survey, November 1, 2018, it was determined that the facility failed to test the horizontal fire shutters as required.

During the review of the facility records, the Maintenance Director, could not produce documentation showing that the two (2)horizontal sliding shutters, between the kitchen and dining room, had been tested. These doors separated the kitychen area from the dining room area and the kitchen area did not contain smoke detection or sprinkler protection. The kitchen was covered by heat detection only.
Per NFPA 80 2010 Edition, section 5.2.1

This deficiency effected one room and one smoke compartment.

Building A-2

Through observation during the survey, November 1, 2018, it was determined that the facility failed to maintain the hazardous areas.

During the walk-through of the facility with the Maintenance Director;
1) The bulk laundry room door contained a kick-stand type door hold open device on the door. These devices are not allowed on hazardous area room doors.
2) The Medical Records room did not contain a self-closing device on the door. Due to the amount of combustible materials in the room, the room is deemed a hazardous area.

These deficiencies potentitally effected one smoke compartment and two rooms.

Building A-1

Through record review during the survey, November 1, 2018, it was determined that the facility failed to maintain the hood suppression system as required by NFPA 96.

During the review of the facility records, the Maintenance Director, could not produce documentation for the following items:
1) That the kitchen hood had been tested semi-annually and links replaced as required.
Per NFPA 101, section 19.3.2.5.1 and 9.2.3, and NFPA 96 2011 Edition, section 11.2.1 and 11.2.4
2) That the kitchen hood had been cleaned at least annually, or more often depending on amount of cooking of greased laden vapors, as required.
Per NFPA 96, 11.4.

These deficiencies possibly effected one smoke compartment and three employees and four to five visitors or patients.

Building A-5-Granby

Through observation during the survey, November 1, 2018, it was determined that the facility failed to install the Alcohol Based Hand Rub (ABHR) dispensers correctly.

During the walkthrough of the facility, with the Maintenance Director, one (1) alcohol based hand rub dispensers (ABHR) was located above a duplex electrical receptacle at ER bay #3

This deficiency potentially effected one smoke compartment.

Building A-1

Through observation during the course of the survey, November 1, 2018, it was determined that the facility failed to maintain the interior finish as required.
 
During the walk through of the facility, with the Maintenance Director, the x-ray room utilized wood paneling (such as Wainscoationg) as a wall covering on all walls. Documentation was not available to indicate that the walls were treated to meet a Class A rating as required in a non-sprinkler protected building.
NFPA 101, section 10.2

This deficiency effected one room, one smoke compartment, and one patient and one staff member.

Building A-5-Granby

Through a review of the records during the survey, November 1, 2018, it was determined that the facility failed to test the fire alarm system components as required.

During the review of the facility records, with the Maintenance Director, documentation was not available to show that the batteries of the fire alarm panel were visually inspected monthly.
Per NFPA 72, Table 14.3.1 for battery inspection and Table 14.4.5 for battery testing

These deficiencies potentially effected all staff and all patients within the facility.

Building A1

Through a review of the records during the survey, November 1, 2018, it was determined that the facility failed to test the fire alarm system components as required.

During the review of the facility records, with the Maintenance Director, documentation was not available for the following:
1) The semi-annual testing of the fire alarm batteries were conducted.
2) The batteries od the fire alarm panel must be visually inspected monthly.
Per NFPA 72, Table 14.3.1 for battery inspection and Table 14.4.5 for battery testing
3) Documentation to verify that the smoke detectors had been sensitivity tested every other year as required. The last documented sensitivity test occurred in 2016.
NFPA-72, section 14.4.5.3.2.

These deficiencies potentially effected all staff and all patients within the facility.

Through observation during the survey, November 1, 2018, it was determined that the facility failed tomaintain smoke detector spacing as required.

During the walk through of the facility, with the Maintenance Director, it was determined that one smoke detector located outside of the X-ray room was located one inch (1") from the air supply diffusser. The spacing from air diffussers, intake or exhaust, must be a minimum of three feet (3')
Per NFPA 72, 2010 Edition, section 17.7.4.1

This deficiency potentially effected one smoke compartment.

Building A-2

Through observation during the survey, November 1, 2018, it was determined the facility failed to maintain the automatic sprinkler system in reliable operating condition.

During the walk through of the facility with theMaintenance Director:
1) Documentation was not available to indicate that a 5 year internal obstruction test was completed on the system.
Per NFPA 25 2011 Edition, section 14.2.2
2) The compressor, for the dry sprinkler system, activated during the survey with the inspectors present. The Maintenance Director was asked how often this happens and he stated "twice a day". The compressor starting and running indicates a leak in the dry system.
3) Dry system heads are dated 1968, indicating that they are over fifty (50) years old. A 50 year test due on heads or replacement of all heads must be done.
Per NFPA 25 2011 Edition, section 5.3.1.1.1
4) One painted sprinkler head located in the laundry room. This same sprinkler head was missing an escutcheon plate as well.
Per NFPA 25 2011 Edition, section 5.2.1.1.2

These deficiencies potentially effected all staff and all patients.

Building A-5-Granby

Through observation during the survey, November 1, 2018, it was determined the facility failed to maintain the automatic sprinkler system in reliable operating condition.

During the walk through of the facility with the Maintenance Director:
1) Documentation was not available to indicate a semi-annual test on the sprinkler system.
Per NFPA 25 2011 Edition, section 5.3.3.2
2) No documentation indicating that a full trip on the dry sprinkler system has occured in the past three years.
Per NFPA 25 2011 Edition, section 13.4.4.2.2
3) Documentation not available indicating that a 5 year obstruction test has been completed.
Per NFPA 25 2011 Edition, section 14.2

These deficiencies could potentially effect the entire hospital and all staff and patients.

Building A-1

Through record review during the survey, November 1, 2018, it was determined the facility failed to test smoke dampers and failed to exercise fire dampers at least every six years.

During the review of the records, with the Maintenance Director, documentation on the fire damper and/or fire/smoke damper was not available during the survey.
Per NFPA 105 2010 Edition, Section 6.5.2 for smoke dampers and NFPA 80 2010 Edition, section 19.4.1.1

This deficiency potentially effected all staff and patients within the facility.

Building A-5-Granby

Through record review during the survey, November 1, 2018, it was determined the facility failed to test smoke dampers and failed to exercise fire dampers at least every six years.

During the review of the records, with the Maintenance Director, documentation on the fire damper and/or fire/smoke damper was not available during the survey.
Per NFPA 105 2010 Edition, Section 6.5.2 for smoke dampers and NFPA 80 2010 Edition, section 19.4.1.1

This deficiency potentially effected all staff and patients within the facility.

Building A-1

Through record review during the survey, November 1, 2018, it was determined that the facility failed to maintain and install generator components as required.
 
During the review of the facility records, with the Maintenance Director:
1) Documentation was not available to indicate that a load bank test was completed within the past year on the diesel generator. The monthly average of load was 95 amps-which was not the 30% required monthly of approximately 132 amps.
Per NFPA 110 2010 Edition, section 8.4.2.3
2) Documentation of the monthly battery check was not available during the inspection.
Per NFPA 110 2010 Edition, section
3) A remote audible alarm and visual light was not located at a readily observable area within the facility.
Per NFPA 110 2010 Edition, Table 5.6.5.2 and 5.6.6
4) A remote shut off switch, located outside of the generator room, was not installed as required.
Per NFPA 110 2010 Edition, section 8.3.7

These deficiencies potentially effected all staff and patients within the facility.

Building A-5-Granby

Through record review during the survey, November 1, 2018, it was determined that the facility failed to maintain and install generator components as required.

During the review of the facility records, with the Maintenance Director, documentation was not available to indicate the transfer time of 10 seconds to emergency power during monthly testing of the ATS switches and generator.

This deficiency potentially effected the entire facility and all patients and staff.

Building A-1

Through observation during the survey, November 1, 2018, it was determined the facility failed to test all battery back-up lighting as required.
 
During the document review, with the Maintenance Director, documentation was not available to indicate that the battery back up emergency lights were tested yearly for ninety (90) minutes.
Per NFPA 101 2012 Edition, section 7.9.3.1.1(3)

This deficiency effected four rooms within the facility (four operating rooms and the generator ATS switch room).

Building A-1

Through observation during the survey, November 1, 2018, it was determined that the facility failed to install and maintain electrical equipment in accordance with NFPA 70, National Electrical Code.
 
During the walkthrough of the facility, with the Maintenance Director,a multi use plug adapter was being utilized in the Emergency Department room.
Note: This deficiency was corrected during the survey by the Maintenance Director removing the device.

This deficiency effected one room in one smoke compartment.