HospitalInspections.org

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Based on the observation during the survey on 03/03/2017, the facility failed to provide a self-closing device on a door to a hazardous area. Findings include:

The following doors to hazardous rooms were observed without a self-closing or automatic-closing device:
1. The Laundry Office was over 50 sq. ft. with combustibles (files boxes)
2. The Linen Room inside of the Housekeeping Office was over 50 sq. ft. with combustibles (files boxes)
3. The Old Physican Lounge was over 50 sq. ft. with combustibles

The deficiency impacted 1 of 4 smoke compartments.
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Review of 2012 NFPA 101, 19.3.2.1
Review of 2012 NFPA 101, 19.3.2.1.3
Review of 2012 NFPA 101, 8.7.1.3
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Based on observation of the cooking facilities on 03/03/2017, the facility failed to maintain the dietary hood grease filters so that all exhaust air passes through the grease filters. Findings include:

An approximately 1/2" gap was observed in two places, between three of the grease filters.

The deficiencies impacted 1 of 4 smoke compartments.
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Review of 2012 NFPA 101, 19.3.2.5.1
Review of 2012 NFPA 101, 9.2.3
Review of 2011 NFPA 96, 6.2.3.3
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Based on the observation and documentation of the automatic sprinkler system on 03/03/2017, the facility failed to maintain the automatic sprinkler system gauges. Findings include:

The facility failed to provide documentation that the gauges on the automatic sprinkler riser in the kitchen had been replaced or calibrated within the past five years.

The deficiency impacted 1 of 4 smoke compartments.
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Review of 2012 NFPA 101, 19.3.5.1
Review of 2012 NFPA 101, 9.7.5
Review of 2012 NFPA 101, 9.7.7
Review of 2012 NFPA 101, 9.7.8
Review of 2011 NFPA 25, 5.3.2.1
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Based on observation on 3/2/2017, the facility failed to maintain the fire extinguishers. Findings include:

The last annual inspection was conducted 1/2016 per the tag attached to the fire extinguisher located in the Boiler Room.

The deficiency impacted 1 of 4 smoke compartments.
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Review of 2012 NFPA 101, 19.3.5.12
Review of 2012 NFPA 101, 9.7.4.1
Review of 2010 NFPA 10, 7.3.1.1.1
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Based on observation during the survey on 3/2/2017, the facility failed to maintain the fire extinguishers. Findings include:

The last annual inspection was conducted 1/2016 per the tag attached to the fire extinguisher located by the entrance to the ER waiting room.

The deficiency impacted 1 of 5 smoke compartments.
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Review of 2012 NFPA 101, 19.3.5.12
Review of 2012 NFPA 101, 9.7.4.1
Review of 2010 NFPA 10, 7.3.1.1.1

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Based on review of documentation on 3/3/2017, the facility failed to perform fire drills per code. Findings include:

1. First quarter 2016, no documentation for third shift fire drill.

2. Second quarter 2016, no documentation for second shift or third shift fire drills.

3. Third quarter 2016, no documentation for third shift fire drill.

The deficiency impacted 4 of 4 smoke compartments.
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Review of 2012 NFPA 101, 19.7.1.6
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Based on review of documentation on 3/3/2017, the facility failed to perform fire drills per code. Findings include:

1. First quarter 2016, no documentation for third shift fire drill.

2. Second quarter 2016, no documentation for second shift or third shift fire drills.

3. Third quarter 2016, no documentation for third shift fire drill.

The deficiency impacted 5 of 5 smoke compartments.
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Review of 2012 NFPA 101, 19.7.1.6
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Per documentation provided by maintenance on 3/03/2017, the facility failed to perform monthly load test for the generator. Findings include:

Documentation was not provided for the monthly load test for January of 2016 thru February 13, 2017.

Based on document review and staff interview, the facility failed to exercise the diesel generator once monthly for a minimum of 30 minutes under loading that maintains the minimum exhaust gas temperature or under operating temperature conditions at not less than 30% of the nameplate kW rating. The facility did not document the load transfers of the generator per the requirements of:

2012 NFPA 99, 6.5.4.1.1.2, 6.4.4.1.1.3, and 6.5.4.2
2010 NFPA 110, 1.3, 8.3.2.1, 8.4.1, 8.4.2, and 8.4.2.3

The deficiency impacted the monthly 30 minute exercise and yearly 90 minute exercise of the diesel generator.

The deficiency impacted 1 of 4 smoke compartments.

Findings include:

On 3/3/2017 the facility did not have documentation that the diesel generator was exercised once monthly for a minimum of 30 minutes and did not have documentation of the annual 1 ½ hour load bank test for the previous 12 months. A load bank test is required if the facility does not document that not less than 30% of the diesel generator nameplate kW rating load is pulled during the monthly 30 minute exercise/load transfer or the minimum manufacturer recommended exhaust temperature is meet during the monthly 30 minute exercise/load transfer.

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Per documentation provided by maintenance on 3/03/2017, the facility failed to perform monthly load test for the generator. Findings include:

Documentation was not provided for the monthly load test for January of 2016 thru February 13, 2017.

Based on document review and staff interview, the facility failed to exercise the diesel generator once monthly for a minimum of 30 minutes under loading that maintains the minimum exhaust gas temperature or under operating temperature conditions at not less than 30% of the nameplate kW rating. The facility did not document the load transfers of the generator per the requirements of:

2012 NFPA 99, 6.5.4.1.1.2, 6.4.4.1.1.3, and 6.5.4.2
2010 NFPA 110, 1.3, 8.3.2.1, 8.4.1, 8.4.2, and 8.4.2.3

The deficiency impacted the monthly 30 minute exercise and yearly 90 minute exercise of the diesel generator.

The deficiency impacted 1 of 5 smoke compartments.

Findings include:

On 3/3/2017 the facility did not have documentation that the diesel generator was exercised once monthly for a minimum of 30 minutes and did not have documentation of the annual 1 ½ hour load bank test for the previous 12 months. A load bank test is required if the facility does not document that not less than 30% of the diesel generator nameplate kW rating load is pulled during the monthly 30 minute exercise/load transfer or the minimum manufacturer recommended exhaust temperature is meet during the monthly 30 minute exercise/load transfer.

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Based on interviews and documentation provided on 03/03/2017, the facility failed to provide documentation on the training and continuous education of the risk for personnel applying, maintaining, and handling oxygen cylinders. Findings include:

The facility failed to provide documentation for personnel on the training and continuous education, including safety guidelines and usage requirements on oxygen cylinders.

The deficiency impacted 4 of 4 smoke compartments.
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Review of 2012 NFPA 99, 11.5.2.1

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Based on interviews and documentation provided on 03/03/2017, the facility failed to provide documentation on the training and continuous education of the risk for personnel applying, maintaining, and handling oxygen cylinders. Findings include:

The facility failed to provide documentation for personnel on the training and continuous education, including safety guidelines and usage requirements on oxygen cylinders.

The deficiency impacted 5 of 5 smoke compartments.
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Review of 2012 NFPA 99, 11.5.2.1