HospitalInspections.org

During the survey on 07/21/2015, at 1100, while accompanied by the Facilities Supervisor, through record review and staff interview, it was discovered that the facility has failed to maintain smoke detectors in accordance with the requirements of the National Fire Alarm Code (NFPA 72). This could allow for a device to initiate nuisance alarms or failure of a device to initiate the fire alarm causing a delay in the reporting of a fire, putting patients, visitors and staff at risk. These findings were acknowledged by the Facilities Supervisor.

The findings include but are not limited to:

The current AFA report of sensitivity testing indicates 28 smoke detectors failed.

During Record Review on 07/20/2015, interview with the Facilities Supervisor revealed that Simplex had performed testing on 07/10/2015 but had not sent the facility the report. The technician had told one of the maintenance staff about 4 horn strobes that were not functioning (since replaced) but said nothing about the smoke detectors that failed the sensitivity test. The facility received the report this morning and submitted it for review at which time it the failures were revealed. The Facilities Supervisor stated that, had he been told of the findings, the repairs would have been conducted in a timely fashion (such as the horn/strobes that they were informed about). Corrections will be made ASAP.

During the survey tour on 07/21/2015, at 0935, while accompanied by the Facilities Supervisor, through observation and staff interview with the ICU Charge Nurse, it was discovered that the facility has failed to provide signage at each room where oxygen is in use or stored. NO SMOKING signs are also not prominently displayed at all of the major entrances to the facility. This has the potential for an ignition source to be introduced to areas where oxygen is in use. This finding was acknowledged by the Facilities Supervisor.

Subsequent discussion with the ICU Charge Nurse and Facilities Supervisor revealed that staff are unclear of this requirement as this is a no-smoking campus. Further interviews revealed that No Smoking signs were removed as ordered by management for aesthetical preferences. During the exit interview at 1215, the Facilities Director stated his intention to re-instate signs at the major entrances to the hospital.

During the survey tour on 07/20/2015, at 1500, while accompanied by the Facilities Supervisor and Building Operator 2, through observation and staff interview, it was discovered that the facility failed to maintain their emergency generator in accordance with the requirements of National Fire Protection Association (NFPA) Standard 110. This could compromise the ability of the emergency power supply to be shut down safely in the event of a generator malfunction, placing staff at risk. These findings were acknowledged by the Facilities Supervisor.

1. Generator is lacking a Remote Stop Switch (per NFPA 110 3-5.5.6)

Discussion with the Facilities Supervisor revealed that he was of the understanding that this requirement was forthcoming at a later date and that the facility has already been taking bids for a remote stop switch installation to move the switches outside of the Gen-set room. At the exit interview, with the Facilities Supervisor and Facilities Director, it was stated that the facility will move ahead with the installation process ASAP.

During the survey tour on 07/20/2015, at 1515, while accompanied by the Facilities Supervisor and Building Operator 2, through observation and staff interview, it was discovered that the facility failed to comply with NFPA 70, also known as the National Electric Code (NEC). This could allow for electrical arcing starting a fire, placing patients, staff and visitors at risk. The findings were acknowledged by the Facilities Supervisor.
The findings include, but are not limited to:
1. Basement level UPS Server Room - open junction box discovered in the overhead.
Facilities Supervisor was unaware that the junction box was not covered and ordered for correction immediately.

During the survey on 07/21/2015, at 1100, while accompanied by the Facilities Supervisor, through record review and staff interview, it was discovered that the facility has failed to maintain smoke detectors in accordance with the requirements of the National Fire Alarm Code (NFPA 72). This could allow for a device to initiate nuisance alarms or failure of a device to initiate the fire alarm causing a delay in the reporting of a fire, putting patients, visitors and staff at risk. These findings were acknowledged by the Facilities Supervisor.

The findings include but are not limited to:

The current AFA report of sensitivity testing indicates 28 smoke detectors failed.

During Record Review on 07/20/2015, interview with the Facilities Supervisor revealed that Simplex had performed testing on 07/10/2015 but had not sent the facility the report. The technician had told one of the maintenance staff about 4 horn strobes that were not functioning (since replaced) but said nothing about the smoke detectors that failed the sensitivity test. The facility received the report this morning and submitted it for review at which time it the failures were revealed. The Facilities Supervisor stated that, had he been told of the findings, the repairs would have been conducted in a timely fashion (such as the horn/strobes that they were informed about). Corrections will be made ASAP.

During the survey tour on 07/21/2015, at 0935, while accompanied by the Facilities Supervisor, through observation and staff interview with the ICU Charge Nurse, it was discovered that the facility has failed to provide signage at each room where oxygen is in use or stored. NO SMOKING signs are also not prominently displayed at all of the major entrances to the facility. This has the potential for an ignition source to be introduced to areas where oxygen is in use. This finding was acknowledged by the Facilities Supervisor.

Subsequent discussion with the ICU Charge Nurse and Facilities Supervisor revealed that staff are unclear of this requirement as this is a no-smoking campus. Further interviews revealed that No Smoking signs were removed as ordered by management for aesthetical preferences. During the exit interview at 1215, the Facilities Director stated his intention to re-instate signs at the major entrances to the hospital.

During the survey tour on 07/20/2015, at 1500, while accompanied by the Facilities Supervisor and Building Operator 2, through observation and staff interview, it was discovered that the facility failed to maintain their emergency generator in accordance with the requirements of National Fire Protection Association (NFPA) Standard 110. This could compromise the ability of the emergency power supply to be shut down safely in the event of a generator malfunction, placing staff at risk. These findings were acknowledged by the Facilities Supervisor.

1. Generator is lacking a Remote Stop Switch (per NFPA 110 3-5.5.6)

Discussion with the Facilities Supervisor revealed that he was of the understanding that this requirement was forthcoming at a later date and that the facility has already been taking bids for a remote stop switch installation to move the switches outside of the Gen-set room. At the exit interview, with the Facilities Supervisor and Facilities Director, it was stated that the facility will move ahead with the installation process ASAP.

During the survey tour on 07/20/2015, at 1515, while accompanied by the Facilities Supervisor and Building Operator 2, through observation and staff interview, it was discovered that the facility failed to comply with NFPA 70, also known as the National Electric Code (NEC). This could allow for electrical arcing starting a fire, placing patients, staff and visitors at risk. The findings were acknowledged by the Facilities Supervisor.
The findings include, but are not limited to:
1. Basement level UPS Server Room - open junction box discovered in the overhead.
Facilities Supervisor was unaware that the junction box was not covered and ordered for correction immediately.