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Based on record review and interview, the facility failed to maintain the Emergency Preparedness (EP) plan. This was evidenced by the failure to provide policy and procedure indicating the facility's role and awareness in providing treatment and care under an 1135 waiver in the event of an emergency. This affected patients and staff at the Main Hospital, and could result in the facility being inadequately prepared to provide care at an alternate location during an emergency.


Findings:

During record review and interview with administrative staff, the EP policies and procedures were requested and reviewed.

Main Hospital:

On 5/16/18 at 3:40 p.m., there was no policy and procedure outlining the facility's plan in providing care and treatment at an alternate location under an 1135 waiver, in the event of an emergency. Upon interview, Administrative Staff 1 confirmed the finding.

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by ceiling penetrations. This affected two of three smoke compartments at the Main Hospital, and could result in the passage of smoke to other areas in the event of a fire.

Findings:

During a tour of the facility with staff, the walls and ceiling were observed.

Main Hospital:

1. On 5/15/18 at 11:00 a.m., the walls and ceiling in the Operating Room were observed. There was an approximately one-quarter inch diameter penetration with cables traveling through it, located in the ceiling above the Anesthesia Area.

2. On 5/15/18 at 11:04 a.m., the walls and ceiling in the Operating Ante-Room were observed. There was an approximately one inch diameter penetration with a water pipe traveling through it, located in the South-East corner of the ceiling.

Based on observation, document review, and interview, the facility failed to maintain the emergency lighting units. This was evidenced by the failure to conduct annual testing for the battery back-up emergency lighting units. This affected two of three smoke compartments at the Main Hospital, and could result in limited visibility during an emergency.

NFPA 101, Life Safety Code, 2012 Edition.
19.2.9 Emergency Lighting.
19.2.9.1 Emergency lighting shall be provided in accordance
with Section 7.9

7.9.3 Periodic Testing of Emergency Lighting Equipment.
7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.
7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1 (3).
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

7.9.3.1.2 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Self-testing/self-diagnostic battery-operated emergency lighting equipment shall be provided.
(2) Not less than once every 30 days, self-testing/self-diagnostic battery-operated emergency lighting equipment shall automatically perform a test with a duration of a minimum of 30 seconds and a diagnostic routine.
(3) Self-testing/self-diagnostic battery-operated emergency lighting equipment shall indicate failures by a status indicator.
(4) A visual inspection shall be performed at intervals not exceeding 30 days.
(5) Functional testing shall be conducted annually for a minimum of 1 1/2 hours.
(6) Self-testing/self-diagnostic battery-operated emergency lighting equipment shall be fully operational for the duration of the 1 1/2-hour test.
(7) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

7.9.3.1.3 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Computer-based, self-testing/self-diagnostic battery-operated emergency lighting equipment shall be provided.
(2) Not less than once every 30 days, emergency lighting equipment shall automatically perform a test with a duration of a minimum of 30 seconds and a diagnostic routine.
(3) The emergency lighting equipment shall automatically perform annually a test for a minimum of 1 1/2 hours.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.3(2) and (3).
(5) The computer-based system shall be capable of providing a report of the history of tests and failures at all times.

Findings:

Main Hospital:

During a facility tour, document review, and interview with staff, testing records for the emergency lighting units were requested for review.

On 5/14/18 at 2:05 p.m., the facility was observed with emergency battery back-up lighting units located at the Nursing Station and Operating Room (OR) areas, equipped with test buttons. No documentation was provided for 90 minute annual testing of the lighting units. Upon interview, Staff 2 confirmed the finding, stating that the units are tested for 30 seconds monthly.

Based on observation, document review, and interview, the facility failed to maintain the emergency exit signs. This was evidenced by the failure to perform annual testing for the battery back-up exit signs. This affected three of three smoke compartments at the Main Hospital, and could result in a delay in evacuation in the event of a power outage.

NFPA 101, Life Safety Code, 2012 Edition
19.2.10.1 Means of egress shall have signs in accordance with Section 7.10, unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4.
7.10.9 Testing and Maintenance.
7.10.9.1 Inspection. Exit signs shall be visually inspected for
operation of the illumination sources at intervals not to exceed
30 days or shall be periodically monitored in accordance
with 7.9.3.1.3.
7.10.9.2 Testing. Exit signs connected to, or provided with, a
battery-operated emergency illumination source, where required
in 7.10.4, shall be tested and maintained in accordance with
7.9.3.
7.9.3 Periodic Testing of Emergency Lighting Equipment.
7.9.3.1 Required emergency lighting systems shall be tested in
accordance with one of the three options offered by 7.9.3.1.1,
7.9.3.1.2, or 7.9.3.1.3.
7.9.3.1.1 Testing of required emergency lighting systems
shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a
minimum of 3 weeks and a maximum of 5 weeks between
tests, for not less than 30 seconds, except as otherwise
permitted by 7.9.3.1.1(2).
(2)*The test interval shall be permitted to be extended beyond
30 days with the approval of the authority having
jurisdiction.
(3) Functional testing shall be conducted annually for a minimum
of 1 1/2 hours if the emergency lighting system is battery
powered.
(4) The emergency lighting equipment shall be fully operational
for the duration of the tests required by 7.9.3.1.1(1)
and (3).
(5) Written records of visual inspections and tests shall be
kept by the owner for inspection by the authority having
jurisdiction.

Findings:

During a facility tour, record review, and interview with staff, the exit signs were observed and records were requested.

Main Hospital:

On 5/14/18 at 2:00 p.m., the facility was observed with approximately 13 battery back-up exit signs equipped with test buttons on the side, located through-out the facility corridors and common areas. No documentation was provided for the 90 minute annual testing of the signs. Upon interview, Staff 2 confirmed the finding, stating that they are tested monthly for 30 seconds.

Based on observation and interview, the facility failed to maintain the hazardous areas. This was evidenced by not maintaining the minimum opening protection requirement. This affected two of three smoke compartments at the Main Hospital, and could result in a delay in containing smoke and/or fire to hazardous areas.


Findings:

During a facility tour and interview with staff , the hazardous areas were observed.

Main Hospital:

1. On 5/15/18 at 12:00 p.m., the Main Laboratory was observed. The Laboratory was not classified as a severe hazard. It was unsprinklered with a minimum one hour protected enclosure. The two metal fire doors to the Main Laboratory were located directly off the Respiratory Waiting Room. Both of the doors were in the full-open position, without having self-closing devices installed. Upon interview, Staff 2 confirmed the finding.

2. On 5/15/18 at 2:00 p.m., the Central Linen Supply/Storage Room was observed. The room was greater than 50 square feet in size (approximately 200 square feet), unsprinklered with a minimum one hour protected enclosure, and used for multiple stored linen supplies for the facility. The corridor door was not equipped with a self-closing device. Upon interview, Staff 1 confirmed the finding.

Based on observation, document review, and interview, the facility failed to maintain the cooking facilities. This was evidenced by range hood cleaning maintenance/certification were not performed on a semi-annual basis. This affected one of three smoke compartments at the Main Hospital, and could potentially result in the uncontrolled spread of a grease fire in the cooking area.

NFPA 101. Life Safety Code, 2012 Edition
19.3.2.5 Cooking Facilities.
19.3.2.5.1 Cooking facilities shall be protected in accordance with 9.2.3
9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 Edition
Chapter 11 Procedures for the Use, Inspection,
Testing, and Maintenance of Equipment
11.4* Inspection for Grease Buildup. The entire exhaust system
shall be inspected for grease build up by a properly trained,
qualified, and certified person(s) acceptable to the authority having
jurisdiction and in accordance with Table 11.4.
Table 11.4 Schedule of Inspection for Grease Buildup
Type or Volume
of Cooking
Inspection
Frequency
Systems serving solid fuel cooking
operations
Monthly
Systems serving high-volume cooking
operations, such as 24-hour cooking,
char-broiling, or wok cooking
Quarterly
Systems serving moderate-volume cooking
operations
Semiannually
Systems serving low-volume cooking
operations, such as churches, day camps,
seasonal businesses, or senior centers
Annually.


Findings:

During a facility tour, document review, and interview with staff, the kitchen hood was observed, and service/certification records were requested.

Main Hospital:

1. On 5/14/18 at 11:50 a.m., the Dietary cooking area was observed. The range hood did not have a current cleaning sticker in-place. The last hood cleaning by a certified vendor was unknown. No documentation was available for a semi-annual hood cleaning.

Upon interview, Staff 2 confirmed that the hood cleaning consist of surface cleaning conducted in-house by the Kitchen Staff, not by a certified vendor that included the hood/vent.

Based on observation and interview, the facility failed to maintain the Fire Alarm Control Panel (FACP). This was evidenced by the failure to install an initiation device at the FACP location. This affected three of three smoke compartments at the Main Hospital, and could result in fire alarm system failure in the event of a fire at the panel location.

NFPA 101, Life Safety Code, 2012 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with section 9.6
9.6.1* General.
9.6.1.5* To ensure operational integrity, the fire alarm system
shall have an approved maintenance and testing program
complying with the applicable requirements of NFPA 70, National
Electrical Code, and NFPA 72, National Fire Alarm and Signaling
Code.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition.
10.14.3 Initiating Devices.
10.14.3.1 Initiating devices of the manual or automatic type
shall be selected and installed so as to minimize nuisance
alarms.
10.15* Protection of Fire Alarm System. In areas that are not
continuously occupied, automatic smoke detection shall be
provided at the location of each fire alarm control unit(s),
notification appliance circuit power extenders, and supervising
station transmitting equipment to provide notification of
fire at that location.
Exception: Where ambient conditions prohibit installation of automatic
smoke detection, automatic heat detection shall be permitted.

Findings:

During a tour of the facility with staff, the FACP location was observed.

Main Hospital:

On 5/15/18 at 2:25 p.m., the FACP was located in a non-continuously occupied room, behind a closed door. The room did not contain an initiation (smoke or heat detector) device. Upon interview, Staff 2 confirmed the finding.

Based on observation, document review, and interview, the facility failed to maintain the fire alarm system (FAS). This was evidenced by the failure to perform a semi-annual FAS inspection. This affected three of three smoke compartments at the Main Hospital, and could result in a system malfunction or delay in notification in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with section 9.6
9.6.1* General.
9.6.1.5* To ensure operational integrity, the fire alarm system
shall have an approved maintenance and testing program
complying with the applicable requirements of NFPA 70, National
Electrical Code, and NFPA 72, National Fire Alarm and Signaling
Code.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition.
Chapter 14 Inspection, Testing, and Maintenance
14.1 Application.
14.1.1 The inspection, testing, and maintenance of systems,
their initiating devices, and notification appliances shall comply
with the requirements of this chapter.
14.3 Inspection.
14.3.1* Unless otherwise permitted by 14.3.2 visual inspections
shall be performed in accordance with the schedules in
Table 14.3.1 or more often if required by the authority having
jurisdiction.
14.3.2 Devices or equipment that is inaccessible for safety
considerations (e.g., continuous process operations, energized
electrical equipment, radiation, and excessive height)
shall be permitted to be inspected during scheduled shutdowns
if approved by the authority having jurisdiction.
14.3.4 The visual inspection shall be made to ensure that
there are no changes that affect equipment performance.

Table 14.3.1 Visual Inspection Frequencies-semiannually
3. Batteries
4. Transient suppressors
5. Fire alarm control unit trouble signals
7. In- building fire emergency voice/alarm communications equipment
8. Remote annunciators
9. Initiating devices
10. Guard's tour equipment
11. Combination systems (a) Fire extinguisher electronic monitoring device/systems
(b) Carbon monoxide detectors/systems
12. Interface equipment
13. Alarm notification appliances
14. Exit marking audible notification appliances
15. Supervising station alarm systems-transmitters
16. Special procedures
17. Supervising station alarm systems-receivers
18. Public emergency alarm reporting system transmission equipment
20. Mass notification system, non-supervised systems installed prior to adoption of this edition

14.6.2 Maintenance, Inspection, and Testing Records.
14.6.2.1 Records shall be retained until the next test and for
1 year thereafter.
14.6.2.4* A record of all inspections, testing, and maintenance
shall be provided that includes the following information regarding
tests and all the applicable information requested in
Figure 14.6.2.4:
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance,
tests, or combination thereof, and affiliation, business
address, and telephone number
(6) Name, address, and representative of approving agency(
vies)
(7) Designation of the detector(S) tested
(8) Functional test of detectors
(9)*Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat
detectors
(12) Functional test of mass notification system control units
(13) Functional test of signal transmission to mass notification
systems
(14) Functional test of ability of mass notification system to
silence fire alarm notification appliances
(15) Tests of intelligibility of mass notification system speakers
(16) Other tests as required by the equipment manufacturer ' S
published instructions
(17) Other tests as required by the authority having jurisdiction
(18) Signatures of tester and approved authority representative
(19) Disposition of problems identified during test (e.g., system
owner notified, problem corrected/successfully retested,
device abandoned in place)

Findings:

During a facility tour, document review, and interview with staff, the FAS was observed and records were requested.

Main Hospital:

On 5/15/18 at 12:30 p.m., the facility was observed with an automatic FAS. The current Annual Fire Alarm Inspection/Testing Report was dated 5/4/18. No semi-annual (6 month) inspection prior to the annual testing was available for review. Upon interview, Staff 2 confirmed that the FAS is inspected and tested on an annual basis.

Based on document review and interview, the facility failed to maintain interim fire measures. This was evidenced by failure to provide written protocol to ensure that if the fire alarm system was out of service for more than 4 hours in a 24 hour period, the Authority Having Jurisdiction (AHJ) would be notified. This affected three of three smoke compartments at the Main Hospital, and could potentially result in the AHJ not having the ability to exercise oversight if the fire alarm system should become inoperable.

Findings:

During document review and interview with staff, the interim fire measures and policy were reviewed.

Main Hospital:

On 5/14/18 at 11:30 a.m., the approved Fire Watch policy was reviewed. The policy did not include notification to the Department of Public Health (CDPH) if the fire alarm system was out of service for more than 4 hours in a 24 hour period. Upon interview, Staff 1 confirmed the finding.

Based on observation, document review, and interview, the facility failed to maintain the smoke detection system. This was evidenced by the failure to provide a current smoke detector sensitivity testing for fire alarm system hard-wired detectors, and maintain the battery operated single-station smoke alarms in accordance with manufacturer's specifications for testing. This affected three of three smoke compartments at the Main Hospital, and could result in delayed notification or false alarm of a fire due to a malfunctioning smoke detector/alarm.

NFPA 101, Life Safety Code, 2012 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with section 9.6
9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

NFPA 72, National Fire Alarm Code, 2010 Edition
14.1 Application.
14.1.1 The inspection, testing, and maintenance of systems, their initiating devices, and notification appliances shall comply with the requirements of this chapter.
14.1.2 The inspection, testing, and maintenance of single and multiple-station smoke and heat alarms and household fire alarm systems shall comply with the requirements of this
chapter.
14.2.1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this Code and conform to the equipment manufacturer ' s published instructions.

14.4.5.3.1 Sensitivity shall be checked within 1 year after installation.
14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3
14.4.5.3.3 After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years.
14.4.5.3.3.1 If the frequency is extended, records of nuisance alarms and subsequent trends of these alarms shall be maintained.
14.4.5.3.4 To ensure that each smoke detector or smoke alarm is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/fire alarm control unit arrangement whereby the detector causes a signal at the fire alarm control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction.
14.4.5.3.5 Unless otherwise permitted by 14.4.5.3.6, smoke detectors or smoke alarms found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
14.4.5.3.6 Smoke detectors or smoke alarms listed as field adjustable shall be permitted to either be adjusted within the listed and marked sensitivity range, cleaned, and recalibrated, or be replaced.
14.4.5.3.7 The detector or smoke alarm sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector or smoke alarm.

Findings:

During a facility tour, document review, and interview with staff, the smoke detection system was observed and records were requested.

Main Hospital:

1. On 5/15/18 at 11:03 a.m., the facility was observed with single station battery operated smoke alarms, located in common areas and rooms through-out the facility. The manufacturer's testing requirements indicated "weekly" testing required. No documentation was available that indicated testing was performed on a weekly basis. Upon interview, Staff 2 confirmed the finding, stating that testing was performed on a monthly basis.

2. On 5/15/18 at 2:28 p.m., the facility was observed with hard wired smoke detectors located in corridors and rooms. The current smoke detector sensitivity report was requested for review. No current or previous reports were available for review. Documentation titled "Annual Fire Alarm Inspection/Test" dated 5/5/18, indicated that smoke detectors had functional testing performed, but not sensitivity. Upon interview, Staff 2 confirmed the finding.

Based on observation, document review, and interview, the facility failed to maintain the automatic sprinkler system. This was evidenced by missing eight monthly sprinkler valve and gauge visual inspections, and one of two semi-annual waterflow alarm device tests. This affected three of three smoke compartments at the Main Hospital, and could result in the malfunction of the automatic sprinkler system in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.5 Extinguishment Requirements.
19.3.5.3 Where required by 19.1.6, buildings containing hospitals
or limited care facilities shall be protected throughout by an
approved, supervised automatic sprinkler system in accordance
with Section 9.7, unless otherwise permitted by 19.3.5.5.

9.7 Automatic Sprinklers and Other Extinguishing Equipment.
9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following:
9.7.5 Maintenance and Testing. All automatic sprinkler and
standpipe systems required by this Code shall be inspected,
tested, and maintained in accordance with NFPA 25, Standard
for the Inspection, Testing, and Maintenance of Water-Based Fire Protection
Systems.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition.
4.3 Records
4.3.1* Records shall be made inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request.

5.2.4 Gauges
5.2.4.1* Gauges on a wet pipe sprinkler shall be inspected monthly to ensure that they are in good condition and the normal water supply pressure is being maintained.

5.3.3.2* Vane-type and pressure switch-type waterflow alarm
devices shall be tested semiannually.

13.3.2.1.1 Valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly.
13.3.2.2* The valve inspection shall verify that the valves are in the following condition:
(1) In the normal open or closed position
(2)*Sealed, locked, or supervised
(3) Accessible
(4) Provided with correct wrenches
(5) Free from external leaks
(6) Provided with applicable identification

13.4.1.1* Alarm valves and system riser check valves shall be externally inspected monthly and shall verify the following:
(1) The gauges indicate normal supply water pressure is being maintained.
(2) The valve is free of physical damage.
(3) All valves are in the appropriate open or closed position.
(4) The retarding chamber or alarm drains are not leaking.
13.6.1.1.1 Valves secured with locks or electrically supervised in accordance with applicable NFPA standards shall be inspected monthly.
13.3.3.5* Supervisory Switches.
13.3.3.5.1 Valve supervisory switches shall be tested semiannually.
13.3.3.5.2 A distinctive signal shall indicate movement from
the valve ' s normal position during either the first two revolutions
of a hand wheel or when the stem of the valve has moved
one-fifth of the distance from its normal position.

17.12 Sprinkler Waterflow Alarm-Initiating Devices.
17.12.2* Activation of the initiating device shall occur within 90 seconds of waterflow at the alarm-initiating device when flow occurs that is equal to or greater than that from a single sprinkler of the smallest orifice size installed in the system.

Findings:

During observation, document review, and interview with staff, the automatic fire sprinkler system was observed, and records were requested.

Main Hospital:

1. On 5/14/18 at 2:45 p.m., documentation titled, "Annual Sprinkler Inspection," dated 4/11/18 and Annual Fire Alarm Inspection dated 5/5/18, indicated that the sprinkler water-flow alarm devices were tested annually. The facility was not able to provide additional water-flow alarm test reports for semi-annual testing. Upon interview, Staff 2 confirmed the finding, stating that the water-flow alarm devices was tested on an annual basis, not semi-annually.

2. On 5/14/18 at 3:15 p.m., the facility was observed with partial automatic fire sprinkler system coverage located in the Basement, Operating Room, Radiology, and Administration. Records indicated that eight of twelve monthly visual inspections for the sprinkler system riser check valves and pressure gauges were not completed in the months of January, February 2018, and May, June, July, August, October and November 2017. Upon interview, Staff 2 confirmed the finding, stating that the visual inspections were performed only at the quarterly inspections, not on a monthly basis.

Based on document review and interview, the facility failed to maintain interim fire measures. This was evidenced by the failure to provide written protocol to ensure that if the automatic fire sprinkler system was out of service for more than 10 hours in a 24 hour period, the Authority Having Jurisdiction (AHJ) would be notified. This affected three of three smoke compartments at the Main Hospital, and could potentially result in the AHJ not having the ability to exercise oversight if the sprinkler system should become inoperable.

Findings:

During document review and interview with staff, the interim fire measures and policy were reviewed.

Main Hospital:

On 5/14/18 at 11:30 a.m., the approved Fire Watch policy was reviewed. The policy did not include the automatic fire sprinkler system and notification to the Department of Public Health (CDPH) if the system was out of service for more than 10 hours in a 24 hour period. Upon interview, Staff 1 confirmed the finding.

Based on observation and interview, the facility failed to maintain the portable fire extinguishers. This was evidenced by a fire extinguisher that was mounted higher than the maximum allowed height of sixty inches. This affected one of three smoke compartments, and could result in the inability of staff to readily access the extinguisher in the event of a fire.

NFPA 101 Life Safety Code, 2012 edition
19.3.5.12 Portable fire extinguishers shall be provided in all
health care occupancies in accordance with 9.7.4.1.
9.7.4.1* Where required by the provisions of another section
of this Code, portable fire extinguishers shall be selected, installed,
inspected, and maintained in accordance with
NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 2010, edition.

6.1.3.8 Installation Height.
6.1.3.8.1 Fire extinguishers having a gross weight not exceeding
40 lb (18.14 kg) shall be installed so that the top of the fire
extinguisher is not more than 5 ft (1.53 m) above the floor.
6.1.3.8.2 Fire extinguishers having a gross weight greater
than 40 lb (18.14 kg) (except wheeled types) shall be installed
so that the top of the fire extinguisher is not more than 3 1/2 ft
(1.07 m) above the floor.
6.1.3.8.3 In no case shall the clearance between the bottom
of the hand portable fire extinguisher and the floor be less
than 4 in. (102 mm).

Findings:

During a tour of the facility and interview with staff, the portable fire extinguishers were observed.

Main Hospital:

On 5/15/18 at 11:02 a.m., the portable ABC fire extinguisher located in the Operating Room, was mounted to the wall with the top of the operative handle at 64 inches above the floor. The extinguisher weighed less than 40 pounds. Upon interview, Staff 1 confirmed the finding.

Based on observation, the facility failed to maintain the integrity of the building corridor construction. This was evidenced by an unsealed ceiling penetration. This affected one of three smoke compartments at the Main Hospital, and could result in the passage of smoke to other areas in the event of a fire, leading to a full facility evacuation.

Findings:

During a tour of the facility with staff, the corridor walls and ceiling were observed.

Main Hospital:

On 5/15/18 at 2:10 p.m., there was an approximately two inch diameter corridor ceiling penetration, located above the sink at the Nursing Station.

Based on observation and interview, the facility failed to maintain the corridor doors. This was evidenced by a corridor room door that was obstructed from fully closing and latching. This affected one of three smoke compartments at the Main Hospital, and could result in the inability to contain smoke and/or fire to a room.

Findings:

During a tour of the facility and interview with staff, the doors were observed.

Main Hospital:

1. On 5/15/18 at 2:12 p.m., the corridor door to Resident Room 9 was observed. The door was obstructed from fully closing and latching, by the foot of Bed-A that was stationed in the swing path of the door. The bed was measured at seven foot-nine inches in length. Upon interview, Staff 2 confirmed the finding.

Based on observation, record review, and interview, the facility failed to maintain the electrical system. This was evidenced by no documentation for receptacle testing at patient bed locations. This affected one of three smoke compartments at the Main Hospital, and could result in the risk of an electrical fire.

NFPA 99 Health Care Facilities Code, 2012 edition
6.3.4.1.3 Receptacles not listed as hospital-grade, at patient
bed locations and in locations where deep sedation or general
anesthesia is administered, shall be tested at intervals not exceeding
12 months.
6.3.4.2 Record Keeping.
6.3.4.2.1* General.
6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modification.
6.3.4.2.1.2 At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter.

Findings:

During record review and interview with staff, the receptacle maintenance records were requested.

Main Hospital:

On 5/18/17 at 2:35 p.m., the patient room and bed locations were observed. The facility was not able to provide an annual receptacle testing log at the time of survey. The last receptacle testing was unknown. Upon interview, Staff 2 confirmed the finding.

Based on observation, the facility failed to maintain the oxygen storage. This was evidenced by oxygen storage enclosures that did not have the minimal required signage. This affected one of three smoke compartments at the Main Hospital, and could result in the unsafe storage of oxygen.

NFPA 99, Health Care Facilities Code, 2012 Edition.
11.3.4 Signs.
11.3.4.1 A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure.
11.3.4.2 The sign shall include the following wording as a minimum:
CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING

Findings:

During a tour of the facility with staff on, the oxygen storage was observed.

Main Hospital:

1. On 5/15/18 at 11:20 a.m., the Manifold Oxygen Storage Enclosure was observed. The enclosure contained six liquid oxygen bulk reservoirs, and multiple H-size tanks that were attached to a manifold. The outside enclosure gate was not equipped with a sign to indicate "Oxidizing Gases Stored With-in."

2. On 5/15/18 at 11:24 a.m., the Portable Reserve Oxygen Storage Enclosure was observed. The enclosure contained multiple H and E-size tanks. The outside enclosure gate was not equipped with a sign to indicate "Oxidizing Gases Stored With-in."

Based on observation, document review, and interview, the facility failed to maintain oxygen risk/safety. This was evidenced by the absence of a continuing in-service/safety training program for all personnel associated with the use of oxygen delivery equipment and maintenance. This affected three of three smoke compartments at the Main Hospital, and could result in the unsafe handling and maintenance of oxygen delivery equipment.

NFPA 99, Health Care Facilities Code, 2012 Edition.
11.5.2 Gases in Cylinders and Liquefied Gases in Containers.
11.5.2.1 Qualification and Training of Personnel.
11.5.2.1.1* Personnel concerned with the application and
maintenance of medical gases and others who handle medical
gases and the cylinders that contain the medical gases shall be
trained on the risks associated with their handling and use.
11.5.2.1.2 Health care facilities shall provide programs of continuing education for their personnel.
11.5.2.1.3 Continuing education programs shall include periodic
review of safety guidelines and usage requirements for
medical gases and their cylinders.
11.5.2.1.4 Equipment shall be serviced only by personnel
trained in the maintenance and operation of the equipment.

Findings:

During observation, document review, and interview with staff, the oxygen delivery equipment was observed, and training records were requested.

Main Hospital:

On 5/14/18 at 3:10 p.m., the facility was observed with portable tank and manifold/piped oxygen delivery systems, supplied by liquid oxygen reservoirs. No documentation was available for a current safety/risk training for all personnel associated with the handling and maintenance of the oxygen delivery systems. Upon interview, Staff 2, confirmed the finding.