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Based on observation and staff interview it was determined, the facility failed to maintain a clear and unobstructed corridor. Blocked exits and unsecured equipment in the corridors could cause harm to the patients and staff in the event of an emergency.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.2.3.4 "Any required aisle, corridor, or ramp shall not be less than 48 in. (1220 mm) in clear width where serving as means of egress from patient sleeping rooms, unless otherwise permitted by one of the following: (5) Where the corridor width is at least 8 ft (2440 mm), projections into the required width shall be permitted for fixed furniture, provided that all of the following conditions are met: (a) The fixed furniture is securely attached to the floor or to the wall. (b) The fixed furniture does not reduce the clear unobstructed corridor width to less than 6 ft (1830mm), except as permitted by 19.2.3.4(2). (c) The fixed furniture is located only on one side of the corridor. (d) The fixed furniture is grouped such that each grouping does not exceed an area of 50 ft* (4.6 m*). (e) The fixed furniture groupings addressed in 19.2.3.4(5)(d) are separated from each other by by a distance of at least 10 ft (3050 mm). (f) The fixed furniture is located so as to not obstruct access to building service and fire protection equipment."

Findings include:

The Plant Services Manager and the surveyor observed on May 01, 2019, this facility had projections located in the corridor and by the emergency exits greater then the code allows. None of the equipment stated below was secured to the floor or the wall. The following was observed:

1. Radiology corridor, a portable X-Ray machine and a wheelchair.
2. Acute Care corridor, three Vital Sign Carts ( WOW's.)
3. Emergency Department corridor, three chairs by the Ambulance entrance doors.
4. Rear Surgical corridor, tables and carts in the emergency exit corridor.

The Chief Executive Officer and key members of hospital staff acknowledged during the exit conference on May 01, 2019, this facility had projections located in the corridor and by the emergency exits greater then the code allows.

Based on record review and interview with staff it was determined, the facility failed to have documented evidence that the kitchen hood system was inspected semi-annually in accordance with NFPA 96. Failing to inspect the kitchen hood entire fire extinguishing system semi-annually could allow a build-up of grease and provide fuel for a fire. A fire in the kitchen may cause harm to the patients and staff.

NFPA 101 Life Safety Code, 2012 Edition, Chapter 19, Section 19.3.2.5, "Cooking Facilities." "Cooking facilities shall be protected in accordance with 9.2.3." Section 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....Chapter 11, Procedures for the use , Inspection, Testing, and Maintenance of Equipment. Section 11.2 Maintenance of the fire extinguishing systems and listed exhaust hoods containing a constant or fire activated water system that is listed to extinguish a fire in the grease removal devices hood exhaust plenums and exhaust ducts shall be made by properly trained, qualified, and certified persons acceptable to the authority having jurisdiction at least 6 months."

Findings Include:

The Plant Services Manager and the surveyor reviewed the documentation for the kitchen hood suppression system on May 01, 2019. There was no documented evidence that the fire extinguishing system was inspected in accordance with NFPA 96 Edition semi-annually in 2018 and 2017. The only documentation reviewed was dated 02/14/18 and 02/17/17.

The Chief Executive Officer and key hospital staff acknowledged during the exit conference on May 01, 2019, there was no documented evidence that the fire extinguishing system was inspected in accordance with NFPA 96 Edition semi-annually in 2018 and 2017.

Based on observation and interview with staff it was determined, the facility failed to provide automatic sprinkler protection throughout the facility. Failing to provide automatic sprinklers to all areas of the facility could cause harm to the patients in time of a fire.

NFPA 101 Life Safety Code 2012, Chapter 19, Section 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 Section 19.3.5.5." Section 19.3.5.5 "In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where the authority having jurisdiction has prohibited sprinklers, without causing the building to be classified as non-sprinklered. Section 9.7."

Findings include:

The Plant Services Manager and the surveyor observed on May 01, 2019, that the facility was not provided automatic sprinkler protection throughout the facility. The activity storage room was missing an automatic sprinkler protection.

The Chief Executive Officer and key hospital staff acknowledged in the exit conference on May 01, 2019, that the facility was not provided automatic sprinkler protection throughout the facility.

Based on observation and staff interview it was determined, the the facility failed to assure that all parts of the facility were provided sprinkler system coverage. Failing to provide sprinkler coverage in storage areas by blocking the sprinkler heads could result in harm to the patients in time of a fire.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.1, "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." ." Chapter 9, Section 9.7.1.1, " Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems." NFPA 13, Chapter 8, Section 8.5.6 Clearance to Storage. Section 8.5.6.1 Unless the requirements of 8.5.6.2, 8.5.6.3, 8.5.6.4. or 8.5.6.5 are met a clearance between the deflector and the storage shall be 18 inches. (457mm) or greater."

Findings include:

The Plant Services Manager and the surveyor observed on May 01, 2019, there were obstructions within 18" of the sprinkler heads preventing full suppression coverage in the following areas:

1. Pharmacy Network closet.
2. Main Pharmacy area shelves.
3. Infusion Center storage closet.
4. Gift shop ceiling fan.

The Chief Executive Officer and key hospital staff acknowledged during the exit conference on May 01, 2019, there were obstructions within 18" of the sprinkler heads preventing full suppression coverage.

Based on observation and interview it was determined, the facility failed to fill penetrations in the smoke barriers in the facility. Failing to seal the penetrations, holes, and openings in the smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility which could cause harm to the patients in the time of a fire.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire resistance rating of at least ½ hour." Chapter 8, Section 8.5.6.2 "Penetrations for cables cable trays, conduits, pipes, tubes, vents wires and similar items to accommodate electrical, plumbing and communications systems that pass through a wall, floor or /ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof /ceiling of a smoke barrier assembly shall be protected by a system or material capable of restricting the transfer of smoke."

Findings include:

The Plant Services Manager and the surveyor observed on May 01, 2019, observed unsealed penetrations in the smoke barriers in the following locations:

1. Two penetrations in the Surgery Center main corridor.
2. Two penetrations in the ER/Radiology corridor.

The Chief Executive Officer and key hospital staff acknowledged during the exit conference on May 01, 2019, that there was unsealed penetrations in the smoke barriers.

Based on observation and staff interview it was determined, the facility failed to allow access to electrical equipment panels. Blocking of access to electrical panels or equipment may delay personnel from controlling an emergency situation. Patients could be harmed if a fire should start because of a delay.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.5.1.1 "Utilities shall comply with the provisions of Section 9.1.", Section 9.1.2 "Electrical wiring and equipment shall be in accordance with NFPA 70, 2011 Edition, "National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction." NEC, 2011 ARTICLE 110, SECTION 110-26 Spaces About Electrical Equipment. "Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons." Table 110-26(a) Working Space Minimum of three (3) feet in all directions."

"(NO STORAGE ALLOWED IN THE WORKING SPACE)"

Findings include:

The Plant Services Manager and the surveyor observed on May 01, 2019, electrical panels were blocked and limiting immediate emergency access in the following areas:

1. In the Labratory- blocked by a storage cart.
2. In Radiology, near room 2- blocked by a chair.

The Chief Executive Officer and key hospital staff acknowledged during the exit conference on May 01, 2019, that electrical panels were blocked and limiting immediate emergency access.

Based on record review and staff interview it was determined, the facility failed to perform the required fire drills. Failing to conducted the fire drills in accordance with the life safety code to familiarize staff with conditions under an actual fire can result in harm to patients and staff during an actual fire or emergency situation.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.7.1.6 "Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers and administrative staff) with the signals and emergency action required under varied conditions." NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.7.2.2 "written health care occupancy fire safety plan shall provide for the following:

1. Use of alarms
2. Transmission to the fire department
3. Emergency phone call to the fire department
4. Response to alarms
5. Isolation of fire
6. Evacuation of immediate area
7. Evacuation of smoke compartment
8. Preparation of floors and building for evacuation
9. Extinguishment of fire."

Findings include:

The Plant Services Manager and the surveyor reviewed the fire drill documentation on May 01, 2019. There was no drill conducted for the first shift in the fourth quarter of 2018.

The Chief Executive Officer and key hospital staff acknowledged during the exit conference on May 01, 2019, there was no drill conducted for the first shift in the fourth quarter of 2018.

Based on record review and interview with staff, it was determined the facility failed to have written documentation of the Annual Inspection and Testing of Door openings in accordance with NFPA 80, 2010 Edition, "Standard for Fire doors and Other Opening Protective's." Failing to inspect and test fire rated door assemblies in accordance with NFPA 80 annually could cause harm to the patients.

NFPA 101 2012 Life Safety Code Section 8.3.3. Fire door and Windows Section 8.3.3.1 "Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed labeled fire door assemblies and fire window assemblies and their accompanying hardware,including all frames, closing devices, anchorage and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening protective, except as otherwise specified in this code."

NFPA 80 Section 5.2* Inspections Section 5.2.1*"Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for the AHJ. Section 5.2.3 Functional Testing. Section 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing."

NFPA 80 Section 13.4 Automatic closing Section 5.2.5 Horizontal sliding,Vertically Sliding, and Rolling Doors.
Section 5.2.14.3 "All horizontal or vertical sliding or rolling fire doors shall be inspected and tested annually to check for proper operation at frequent intervals to ensure operation."

Findings include:

The Plant Services Manager and the surveyor reviewed the annual fire rated door assembly records on May 01, 2019. The facility did not have written records for 2018 of the Annual Inspection and Testing of Door Openings in accordance with NFPA 80 Standard for Fire Doors and Other Opening Protective's.

The Chief Executive Officer and key hospital staff acknowledged during the exit conference on May 01, 2019, that there was no documentation to review of the annual fire rated door assemblies for 2018.

Based on observation and interview, it was determined the facility failed to ensure that staff did not plug appliances into power strips. The use of appliances plugged into a power strip could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.

NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2 , "All Patient Care Areas," Sections 6.3.2.2..6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings include:

The Plant Services Manager and the surveyor observed on May 01, 2019, a refrigerator plugged into a power strip and not directly plugged in to the receptacle wall outlet in Registration.

The Chief Executive Officer and key hospital staff acknowledged during the exit conference on May 01, 2019, a refrigerator plugged into a power strip and not directly plugged in to the receptacle wall outlet in Registration.

Based on observation and interview, it was determined the facility failed to have the light switch 5 ft above the finished floor in the oxygen storage room. Failing to mount or protect the wall outlet receptacles from physical damage could cause harm to the patients and staff if an oxygen bottle accidentally hits the wall receptacle outlets.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 11 Section 11.6.2.3 (11) Free standing cylinders shall be properly chained or supported in a proper cylinder stand or cart."

NFPA 99 2012 Edition Standard for Health Care Facilities." Chapter 5 Section 5.1.3.3.2 Design and Construction. Section 5.1.3.3.2 "(5) They shall be in compliance with NFPA 70 National Electrical Code, for ordinary locations. Locations for central supply systems and the storage of positive -pressure gases shall meet the following requirements." Section 5-1.3.3.2 "(5) Electrical devices should be physically protected, such as by use of protective barrier around the electrical devices, or by location of the electrical device such that it will avoid causing damage to the cylinders or containers. The device could be located at or above finished floor 1.5 m (5 ft) or other location that will not allow the possibility of the cylinders or containers to come into contact with the electrical device required by this section." Section 5.1.3.3.2 "(10) They shall protect electrical devices from physical damage."

Findings include:

The Plant Services Manager and the surveyor observed on May 01, 2019, the light switch in the oxygen supply room was not a minimum of 5 ft above the finished floor.

The Chief Executive Officer and key hospital staff acknowledged in the exit confrence on May 01, 2019, that the light switch in the oxygen supply room was not 5 ft above the finished floor.