HospitalInspections.org

5. Building - Regional Orthopedics

Based on record review and interview, the provider failed to continuously maintain automatic sprinklers in reliable operating condition (five year obstruction test not done). Findings include:

1. Record review at 2:30 p.m. on 1/30/18 revealed no documentation the five year sprinkler obstructive test had been performed at the Orthopedic Clinic. Review of the contractor's 6/23/17 service report revealed the contractor provided the information regarding the five year requirement should be done. There was no documentation any action had been taken regarding the notice of the lack of a five year fire sprinkler system-internal inspection.

Interview with the maintenance technician at the time of the record review confirmed that condition.

Failure to continuously maintain the automatic sprinkler system as required increases the risk of death or injury due to fire.

The deficiency affected one of numerous required tests on the automatic sprinkler system.

Based on observation and interview, the provider failed to maintain unobstructed corridors in two randomly observed areas (second floor obstetrics and main floor operating room). Findings include:

1. Observation and interview at 8:15 a.m. on 1/31/18 revealed the second floor obstetrics eight foot wide egress corridor was obstructed due to equipment installations. A pop machine and a snack machine were placed in the exit corridor to the east exit stairs (adjacent to the elevator) on the second floor. The snack machine and the pop machine extended three feet into the corridor reducing the egress corridor width to five feet.

2. Observation and interview at 1:15 p.m. on 1/31/18 revealed the central sterile (CS) hall was an eight foot wide corridor. The corridor was obstructed due to equipment installations and supply storage. An imaging unit, autoclave records, autoclave items, and a trauma cart were placed in the CS hall. The CS hall was the main corridor used to transport patients to and from the operating rooms on beds. The obstructive items extended two feet into the corridor reducing the egress corridor width to six feet.

3. Interview with the maintenance technician at the time of the observations confirmed those findings.

The deficiencies had the potential to affect 100% of the occupants in the smoke compartment.

Based on observation and interview, the provider failed to maintain two separate hazardous areas (clean work room and supplies room) as required. Findings include:

1. Observation at 9:05 a.m. on 1/30/18 revealed the clean work room in the patient wing was over 100 square feet and had large amounts of combustibles stored in it. The door was not equipped with a closer.

2. Observation at 9:15 a.m. on 1/30/18 revealed the supply room in the patient wing was over 100 square feet and had large amounts of combustibles stored in it. The door was equipped with a closer that did not work.

3. Interview with the maintenance technician at the times of the observations confirmed those findings.

The deficiency affected two of numerous requirements for hazardous storage rooms and had the potential to affect 100% of the occupants of the smoke compartment.

Based on observation and interview, the provider failed to properly install alcohol based hand rub (ABHR) dispensers in one randomly observed room (basement physical therapy). Findings include:

1. Observation at 10:00 a.m. on 1/30/18 revealed the basement physical therapy had a nine ounce can of Steris brand ABHR mounted directly above the light switch for the room.

Interview with the maintenance technician at the time of the observation confirmed that finding.

The deficiency affected one of numerous requirements for ABHR use.

Based on observation and interview, the provider failed to maintain corridor smoke separation or monitoring of that area for one randomly observed area (pharmacy) as required. Findings include:

1. Observation at 8:45 a.m. on 1/30/18 revealed the pharmacy room had a 24 inch by 30 inch sliding glass window into the pharmacy from the corridor. The sliding glass window could not be considered smoke tight to the corridor. The pharmacy did not have a smoke detector tied into the fire alarm system in that room.

Interview with the maintenance supervisor at the time of the observation confirmed that finding.

The deficiency had the potential to affect 100% of the occupants of that smoke compartment.

Based on observation and interview, the provider failed to maintain documentation of required maintenance for two of two elevators. Findings include:

1. Document review at 2:45 p.m. on 1/30/18 revealed no documentation the two elevators had been inspected and tested as specified in ASME A17.1, Safety Code for Elevators and Escalators. There was also no documentation the Firefighter's Service was operated monthly with a written record.

Interview with the maintenance technician at the time of the document review revealed there were elevator inspection forms from an outside contractor for 2016 dated 6/8/16. He stated he did not know where possible records for 2017 would have been.

The deficiency affected two of numerous requirements for the maintenance of elevators.

Based on record review, observation, and interview, the provider failed to:
*Maintain documentation of fire drills for the entire 2017 for both 6:00 a.m. - 6:00 p.m. and 6:00 p.m. - 6:00 a.m. shifts.
*Hold fire drills at varying times during those two shifts.
*Document transmission of the fire alarm signal during the drills.
*Ensure staff were familiar with fire drill procedures (Rescure, Alarm, Contain, Extinguish, and Relocate - RACER acronym for training).
Findings include:

1. Record review at 3:15 p.m. on 1/30/18 revealed the hospital had two shifts (6:00 a.m. - 6:00 p.m. and 6:00 p.m. to 6:00 a.m.). Documentation of fire drills for calendar year 2017 were as follows:

First 6:00 a.m. to 6:00 p.m. Shift Second 6:00 p.m. to 6:00 a.m. Shift
7/25/17 21:30
8/31/17 14:45
10/31/17 21:15
11/28/17 14:00
12/29/17 14:25

The documentation lacked fire drills for January, February, March, April, May, June, and September 2017. The documented timing of the drills did not indicate varied times for holding fire drills as required for the training of staff (2:00 to 2:45 p.m. and 9:15 p.m. to 9:30 p.m. drill times documented).

2. Record review at 3:25 p.m. on 1/30/18 revealed the fire drill sign off sheets for staff did not include documentation the fire alarm signal was received at the monitoring agency.

3. Record review at 3:30 p.m. on 1/30/18 revealed the provider used the acronym RACER for addressing simulated fires during fire drills. During the drill two staff responded to the fire simulation in the patient room and removed the patient (volunteer maintenance technician) from the room and both pulled separate fire alarm boxes. The door to the patient room fire location had not been closed.

4. Interview with the maintenance technician at the time of the record reviews and the observations confirmed those findings. He stated there had been call backs to the facility from the monitoring agency in the past confirming the fire alarm signal had been transmitted. Also it was stated some boxed documentation for fire drills might have been relocated to a facility in Rapid City.

The deficiency had the potential to affect 100% of the building occupants.

Based on observation, record review, and interview the provider failed to maintain a remote alarm in a continuously occupied location (Caterpillar generator annunciator). Findings include:

1. Observation at 9:00 a.m. on 1/30/18 revealed the Caterpillar generator annunciator was mounted in the patient wing nurses station. When tested by the maintenance technician the annunciator failed to show trouble with the generator being offline. The generator was first tested by taking the non-running generator offline while in the generator room. A second test involved running the generator without carrying a load. Neither scenario showed any indication on the annunciator at the nurses station. Testing of the electrical supply to the annunciator revealed the device was provided with electrical power. Record review of the generator log book revealed the Caterpillar generator would carry a load when tested monthly.

Interview with the maintenance technician at the time of the observation confirmed those findings. He stated he was unsure why the annunciator would not show the Caterpillar generator's offline status.

This deficiency has the potential to affect 100% of the occupants of the building.