HospitalInspections.org

Based on observation the facility failed to provide adequate smoke barriers.

The inspector observed, while accompanied by the Maintenance Supervisor during the hours of the inspection from 8:00 am to 12:00 pm on 10/30/2013 that there were numerous penetrations both large and small in the all smoke barriers observed.

Based on observation the facility failed to provide adequate hazardous area separation.

The inspector observed, while accompanied by the Maintenance Supervisor during the hours of the inspection from 8:00 am to 12:00 pm on 10/30/2013 that there were the following issues. They were: 1) there was a broken closer in the following location - Central Storage/Pharmacy, 2) the closer required adjustment the following locations - Medical Records/Nurse Station, Lab Storage, 3) there was a missing closer in all of these locations - the Pantry, Equipment/Linen Storage adjacent to the wiring closet, the Respiratory Storage, Surgery Equipment/Linen Storage, E.D. Soiled Utility, E.D. Storage (old plaster room), and 4) there was a missing ceiling tile in the Lab Storage room.

Based on observation the facility failed to provide an adequate fire plan.

The inspector observed, while accompanied by the Maintenance Supervisor during the hours of the inspection from 8:00 am to 12:00 pm on 10/30/2013 that the fire plan does not define personnel duties to any extent.

Based on observation the facility failed to provide adequate fire drills.

The inspector observed, while accompanied by the Maintenance Supervisor during the hours of the inspection from 8:00 am to 12:00 pm on 10/30/2013 that the facility had been conducting fire drills during the day shift but not in the night shift. Over 2013 there had been only one fire drill during the night shift.

Based on observation the facility failed to provide cross referencing for the FACP.

The inspector observed, while accompanied by the Maintenance Supervisor during the hours of the inspection from 8:00 am to 12:00 pm on 10/30/2013 that the electrical panel and breaker for the FACP was not colored red and labeled properly.

Based on observation the facility failed to provide an adequate fire alarm.

The inspector observed, while accompanied by the Maintenance Supervisor during the hours of the inspection from 8:00 am to 12:00 pm on 10/30/2013 that the fire alarm had failed the last inspection due to the FACP blowing out a fuse every time it sets off the alarm and two duct detectors failed.

Based on observation the facility failed to provide adequate fire extinguishers.

The inspector observed, while accompanied by the Maintenance Supervisor during the hours of the inspection from 8:00 am to 12:00 pm on 10/30/2013 that almost all of the fire extinguishers did not have current inspection tags.

Based on observation the facility failed to provide adequate storage of the medical gas cylinders.

The inspector observed, while accompanied by the Maintenance Supervisor during the hours of the inspection from 8:00 am to 12:00 pm on 10/30/2013 that there were the following issues. They were: 1) the medical gas bottles were not secured to prevent them from falling, 2) there was dead leaves building up around the nitrous bottles, and 3) there was combustible storage in the bulk oxygen tank area.

Emergency Generator

The room or space in which the EPS equipment is located shall not be used for storage purposes. - NFPA 110, 2002: 7.11.1.

Based on observation the facility failed to provide an adequate emergency generator enclosure and initially the emergency generator failed to start.

The inspector observed, while accompanied by the Maintenance Supervisor during the hours of the inspection from 8:00 am to 12:00 pm on 10/30/2013 that there were the following issues. The space that the emergency generator was located contained the following: 1) storage gasoline, and 2) stored lawn equipment. This must all be relocated.

Also, the generator failed to start. A service company was called to do repairs on the generator. The representative of the company stated that the controls were old and not reliable. Please state what has been done or will be done to make the generator reliable.


Disaster or Emergency Plan and Drills:

A complete emergency plan is based on chapter 11 of NFPA 99, 1999. The plan shall be the responsibility of the emergency preparedness committee and shall be evaluated and revised as directed by senior management. The emergency preparedness committee shall model the emergency preparedness plan on the incident command system (ICS) in coordination with local emergency response agencies. The plan shall include the following: 1) identification of emergency response personnel, 2) continuity of essential building systems (electricity, water, ventilation, fire protection systems, fuel sources, medical gas and vacuum system, and communication systems), 3) staff management, 4) patient management, 5) logistics (pharmaceuticals, supplies, food, linen, and industrial and potable water), 6) security, 7) public affairs, 8) staff education, 9) drills, and 10) operational recovery. See chapter 11 of NFPA 99, 1999 for additional details of the above.

The disaster plan shall be a " living " document that is updated after lessons learned from drills and actual disaster plan implementation. It shall contain the critical information that will be used to train staff and maintain the knowledge base independent of the current management.

NFPA 99, 11-5.3.9 and hospital regulations requires one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both. This means that a second drill does not need to be a mass casualty drill, but can be a less involved exercise. Hospitals are required by state regulations to coordinate with the state Emergency Operations Center.

Based on observation the facility failed to provide any disaster drills.

The inspector observed, while accompanied by the Maintenance Supervisor during the hours of the inspection from 8:00 am to 12:00 pm on 10/30/2013 that the facility had not been doing disaster drills.


Receptacle Testing in Patient Care Areas - NFFA 99, 1999, 3-3.3.3

(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

NFPA 99, 1999, 3-3.4.2.3(a) states that testing shall be performed after initial installation, replacement or servicing of a device, and that additional testing shall be performed at intervals defined by documented performance data. Since data is not typically available from the manufacturer, the facility may document the failure rates of the receptacles and provide a testing schedule that will safeguard their patients. This shall be done by the Safety Committee, approved by the Governing Board, and written into the safety policies and procedures. H.L.R. 2007, ?133.142. Until this assessment has been done, receptacle testing shall be performed in all general care areas every 12 months and in critical care areas every 6 months. (NFPA 99, 1984).

Based on observation the facility failed to provide complete receptacle testing

The inspector observed, while accompanied by the Maintenance Supervisor during the hours of the inspection from 8:00 am to 12:00 pm on 10/30/2013 that the receptacle testing had not included retention force measurements. The staff have been replacing receptacles that felt loose, but no actual measurement of retention force had been done.


Fuel and Water Preferred Customer Status

" Continuity of Essential Building Systems. When designated by the emergency preparedness management plan to provide continuous service in a disaster or emergency, health care facilities shall establish contingency plans for the continuity of essential building systems, as applicable: (a) Electricity, (b) Water, (c) Ventilation, (d) Fire protection systems, (e) Fuel sources, (f) Medical gas and vacuum systems (if applicable), (g) Communications systems. " - NFPA 99, 1999, 11-5.3.2

Based on observation the facility failed to provide documentation of preferred customer status for fuel and water.

The inspector observed, while accompanied by the Maintenance Supervisor during the hours of the inspection from 8:00 am to 12:00 pm on 10/30/2013 that the facility failed to provide letters from vendors for emergency fuel and water indicating that they have a preferred customer status in the event of an emergency.

Based on observation the facility failed to provide adequate monthly load test.

The inspector observed, while accompanied by the Maintenance Supervisor during the hours of the inspection from 8:00 am to 12:00 pm on 10/30/2013 that the monthly load test were not at 30% of the name plate kW.

Based on observation the facility failed to provide labeled critical outlets and labeled panel directories.

The inspector observed, while accompanied by the Maintenance Supervisor during the hours of the inspection from 8:00 am to 12:00 pm on 10/30/2013 that there were the following issues. They were: 1) the critical outlets in the E.D. were not labeled with the panel and breaker supplying the power to the receptacle, and 2) the electrical panels all over the facility were not properly labeled.

Based on observation the facility failed to provide adequate smoke barriers.

The inspector observed, while accompanied by the Maintenance Supervisor during the hours of the inspection from 8:00 am to 12:00 pm on 10/30/2013 that there were numerous penetrations both large and small in the all smoke barriers observed.

Based on observation the facility failed to provide adequate hazardous area separation.

The inspector observed, while accompanied by the Maintenance Supervisor during the hours of the inspection from 8:00 am to 12:00 pm on 10/30/2013 that there were the following issues. They were: 1) there was a broken closer in the following location - Central Storage/Pharmacy, 2) the closer required adjustment the following locations - Medical Records/Nurse Station, Lab Storage, 3) there was a missing closer in all of these locations - the Pantry, Equipment/Linen Storage adjacent to the wiring closet, the Respiratory Storage, Surgery Equipment/Linen Storage, E.D. Soiled Utility, E.D. Storage (old plaster room), and 4) there was a missing ceiling tile in the Lab Storage room.

Based on observation the facility failed to provide an adequate fire plan.

The inspector observed, while accompanied by the Maintenance Supervisor during the hours of the inspection from 8:00 am to 12:00 pm on 10/30/2013 that the fire plan does not define personnel duties to any extent.

Based on observation the facility failed to provide adequate fire drills.

The inspector observed, while accompanied by the Maintenance Supervisor during the hours of the inspection from 8:00 am to 12:00 pm on 10/30/2013 that the facility had been conducting fire drills during the day shift but not in the night shift. Over 2013 there had been only one fire drill during the night shift.

Based on observation the facility failed to provide cross referencing for the FACP.

The inspector observed, while accompanied by the Maintenance Supervisor during the hours of the inspection from 8:00 am to 12:00 pm on 10/30/2013 that the electrical panel and breaker for the FACP was not colored red and labeled properly.

Based on observation the facility failed to provide an adequate fire alarm.

The inspector observed, while accompanied by the Maintenance Supervisor during the hours of the inspection from 8:00 am to 12:00 pm on 10/30/2013 that the fire alarm had failed the last inspection due to the FACP blowing out a fuse every time it sets off the alarm and two duct detectors failed.

Based on observation the facility failed to provide adequate fire extinguishers.

The inspector observed, while accompanied by the Maintenance Supervisor during the hours of the inspection from 8:00 am to 12:00 pm on 10/30/2013 that almost all of the fire extinguishers did not have current inspection tags.

Based on observation the facility failed to provide adequate storage of the medical gas cylinders.

The inspector observed, while accompanied by the Maintenance Supervisor during the hours of the inspection from 8:00 am to 12:00 pm on 10/30/2013 that there were the following issues. They were: 1) the medical gas bottles were not secured to prevent them from falling, 2) there was dead leaves building up around the nitrous bottles, and 3) there was combustible storage in the bulk oxygen tank area.

Emergency Generator

The room or space in which the EPS equipment is located shall not be used for storage purposes. - NFPA 110, 2002: 7.11.1.

Based on observation the facility failed to provide an adequate emergency generator enclosure and initially the emergency generator failed to start.

The inspector observed, while accompanied by the Maintenance Supervisor during the hours of the inspection from 8:00 am to 12:00 pm on 10/30/2013 that there were the following issues. The space that the emergency generator was located contained the following: 1) storage gasoline, and 2) stored lawn equipment. This must all be relocated.

Also, the generator failed to start. A service company was called to do repairs on the generator. The representative of the company stated that the controls were old and not reliable. Please state what has been done or will be done to make the generator reliable.


Disaster or Emergency Plan and Drills:

A complete emergency plan is based on chapter 11 of NFPA 99, 1999. The plan shall be the responsibility of the emergency preparedness committee and shall be evaluated and revised as directed by senior management. The emergency preparedness committee shall model the emergency preparedness plan on the incident command system (ICS) in coordination with local emergency response agencies. The plan shall include the following: 1) identification of emergency response personnel, 2) continuity of essential building systems (electricity, water, ventilation, fire protection systems, fuel sources, medical gas and vacuum system, and communication systems), 3) staff management, 4) patient management, 5) logistics (pharmaceuticals, supplies, food, linen, and industrial and potable water), 6) security, 7) public affairs, 8) staff education, 9) drills, and 10) operational recovery. See chapter 11 of NFPA 99, 1999 for additional details of the above.

The disaster plan shall be a " living " document that is updated after lessons learned from drills and actual disaster plan implementation. It shall contain the critical information that will be used to train staff and maintain the knowledge base independent of the current management.

NFPA 99, 11-5.3.9 and hospital regulations requires one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both. This means that a second drill does not need to be a mass casualty drill, but can be a less involved exercise. Hospitals are required by state regulations to coordinate with the state Emergency Operations Center.

Based on observation the facility failed to provide any disaster drills.

The inspector observed, while accompanied by the Maintenance Supervisor during the hours of the inspection from 8:00 am to 12:00 pm on 10/30/2013 that the facility had not been doing disaster drills.


Receptacle Testing in Patient Care Areas - NFFA 99, 1999, 3-3.3.3

(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

NFPA 99, 1999, 3-3.4.2.3(a) states that testing shall be performed after initial installation, replacement or servicing of a device, and that additional testing shall be performed at intervals defined by documented performance data. Since data is not typically available from the manufacturer, the facility may document the failure rates of the receptacles and provide a testing schedule that will safeguard their patients. This shall be done by the Safety Committee, approved by the Governing Board, and written into the safety policies and procedures. H.L.R. 2007, ?133.142. Until this assessment has been done, receptacle testing shall be performed in all general care areas every 12 months and in critical care areas every 6 months. (NFPA 99, 1984).

Based on observation the facility failed to provide complete receptacle testing

The inspector observed, while accompanied by the Maintenance Supervisor during the hours of the inspection from 8:00 am to 12:00 pm on 10/30/2013 that the receptacle testing had not included retention force measurements. The staff have been replacing receptacles that felt loose, but no actual measurement of retention force had been done.


Fuel and Water Preferred Customer Status

" Continuity of Essential Building Systems. When designated by the emergency preparedness management plan to provide continuous service in a disaster or emergency, health care facilities shall establish contingency plans for the continuity of essential building systems, as applicable: (a) Electricity, (b) Water, (c) Ventilation, (d) Fire protection systems, (e) Fuel sources, (f) Medical gas and vacuum systems (if applicable), (g) Communications systems. " - NFPA 99, 1999, 11-5.3.2

Based on observation the facility failed to provide documentation of preferred customer status for fuel and water.

The inspector observed, while accompanied by the Maintenance Supervisor during the hours of the inspection from 8:00 am to 12:00 pm on 10/30/2013 that the facility failed to provide letters from vendors for emergency fuel and water indicating that they have a preferred customer status in the event of an emergency.

Based on observation the facility failed to provide adequate monthly load test.

The inspector observed, while accompanied by the Maintenance Supervisor during the hours of the inspection from 8:00 am to 12:00 pm on 10/30/2013 that the monthly load test were not at 30% of the name plate kW.

Based on observation the facility failed to provide labeled critical outlets and labeled panel directories.

The inspector observed, while accompanied by the Maintenance Supervisor during the hours of the inspection from 8:00 am to 12:00 pm on 10/30/2013 that there were the following issues. They were: 1) the critical outlets in the E.D. were not labeled with the panel and breaker supplying the power to the receptacle, and 2) the electrical panels all over the facility were not properly labeled.