HospitalInspections.org

Based on observation and interview, the provider failed to ensure smoking regulations were adopted for areas where smoking was permitted to ensure the designated smoking areas did not increase the potential for fire. Findings include:

1. Observation at 10:30 a.m. on 3/22/16 near the north exit of the outpatient PT area revealed a bulk oxygen storage area and a large above ground diesel tank. Both the tank and oxygen storage were located within twenty feet of the exit door. Further observation revealed numerous disposed cigarettes on the ground of the oxygen storage area and near the exit door. A sign was affixed to the gate of the oxygen storage area indicating smoking was prohibited in that area. No sign was readily visible on the above ground diesel tank indicating any fire hazard of that combustible fuel.

Interview with the maintenance supervisor at the time of the above observation confirmed that condition. He indicated he had tried to get staff to dispose of cigarettes properly and to smoke in the proper designated smoking areas. He did not indicate if he was checking those smoking areas on a regular basis and provided no policy on where smoking was permitted.

This deficiency has the potential to affect one of five smoke compartments.

Based on observation and interview, the provider failed to ensure oxygen storage was in a location that met appropriate storage area requirements per NFPA 99 in one of one oxygen storage room. Findings include:

1. Observation at 1:30 p.m. on 3/22/16 revealed a clean linen storage room in the patient care wing. That room was also being used to store oxygen cylinders that amounted to less than 3000 cubic feet in total volume. Oxygen storage for nonflammable gas volumes less than 3000 cubic feet should have been stored in a location where there was a minimum distance of five feet from combustible storage. The oxygen cylinders were stored less than five feet from clean linen storage that would be considered combustible storage. The door to the room should have been secured to prevent unauthorized entry. The door to the room did not have any means to prevent unauthorized entry. A precautionary sign should have been conspicuously displayed indicating "Caution Oxidizing Gas Stored Within No Smoking." The room was not provided with any cautionary signage.

Interview with the maintenance supervisor at the time of the above observation confirmed that condition. He indicated he was unaware of those requirements and believed the current room was acceptable. No policy was provided indicating the proper means for storage of oxygen cylinder tanks.

This deficiency has the potential to affect one of five smoke compartments.

Based on document review and interview, the provider failed to ensure the emergency backup electrical service provided by an onsite diesel powered generator was properly inspected weekly and loaded monthly per NFPA 110 Standard for Emergency and Standby Power Systems. Findings include:

1. Document review at 8:30 a.m. on 2/22/16 of the generator inspections reports revealed no documentation for the weekly inspection and testing that was required for the type 1 essential electrical service. No documentation was provided indicating the generator was exercised under electrical load. The load test shall exercise the electrical transfer switch that transfers the building from normal electrical service to the backup generator and run under load condition for thirty minutes at least once per month.

Interview with the maintenance supervisor after review of the above generator inspection documentation revealed he was unaware of those weekly and monthly inspection and testing requirements. He believed the generator service company RDO Equipment Company was providing all the necessary inspections and testing. He revealed the generator was on a weekly automatic self-test. He indicated the self-test did not exercise the transfer switch from normal power to emergency power. No policy was provided indicating these inspections and testing requirements.

This deficiency has the potential to affect all 18 licensed beds.

Based on observation, testing, and interview, the provider failed to ensure the electrical wiring and equipment was maintained in accordance with the NFPA 70 The National Electrical Code in two randomly observed locations (men's and women's bathroom in the outpatient physical therapy area). Findings Include:

1. Observation at 8:50 a.m. on 3/22/16 in the men's public bathroom in the outpatient physical therapy area revealed a ground fault circuit interrupter (GFCI) outlet next to the hand sink. That GFCI outlet had a cracked test switch. Testing of the outlet with a GFCI tester revealed the circuit would trip but would remain in open neutral power. Observation in the women's bathroom of the same physical therapy area revealed a similar condition with a cracked test switch. It would sometimes trip to open neutral power or if you moved the circuit tester around it would show hot/neutral reverse.

Interview with the maintenance supervisor at the time of the above observation confirmed that condition. He indicated he had not noticed the GFCI in those bathrooms were not functioning correctly. I advised him to ensure other outlets within the hospital of similar manufacture and model are not doing the same thing. He did not indicate whether GFCI outlets were checked on a regular basis. No policy was provided indicating GFCI outlets were to be tested on a regular basis.

This deficiency has the potential to affect one of five smoke compartments
.

Based on observation and interview, the provider failed to ensure smoking regulations were adopted for areas where smoking was permitted to ensure the designated smoking areas did not increase the potential for fire. Findings include:

1. Observation at 10:30 a.m. on 3/22/16 near the north exit of the outpatient PT area revealed a bulk oxygen storage area and a large above ground diesel tank. Both the tank and oxygen storage were located within twenty feet of the exit door. Further observation revealed numerous disposed cigarettes on the ground of the oxygen storage area and near the exit door. A sign was affixed to the gate of the oxygen storage area indicating smoking was prohibited in that area. No sign was readily visible on the above ground diesel tank indicating any fire hazard of that combustible fuel.

Interview with the maintenance supervisor at the time of the above observation confirmed that condition. He indicated he had tried to get staff to dispose of cigarettes properly and to smoke in the proper designated smoking areas. He did not indicate if he was checking those smoking areas on a regular basis and provided no policy on where smoking was permitted.

This deficiency has the potential to affect one of five smoke compartments.

Based on observation and interview, the provider failed to ensure oxygen storage was in a location that met appropriate storage area requirements per NFPA 99 in one of one oxygen storage room. Findings include:

1. Observation at 1:30 p.m. on 3/22/16 revealed a clean linen storage room in the patient care wing. That room was also being used to store oxygen cylinders that amounted to less than 3000 cubic feet in total volume. Oxygen storage for nonflammable gas volumes less than 3000 cubic feet should have been stored in a location where there was a minimum distance of five feet from combustible storage. The oxygen cylinders were stored less than five feet from clean linen storage that would be considered combustible storage. The door to the room should have been secured to prevent unauthorized entry. The door to the room did not have any means to prevent unauthorized entry. A precautionary sign should have been conspicuously displayed indicating "Caution Oxidizing Gas Stored Within No Smoking." The room was not provided with any cautionary signage.

Interview with the maintenance supervisor at the time of the above observation confirmed that condition. He indicated he was unaware of those requirements and believed the current room was acceptable. No policy was provided indicating the proper means for storage of oxygen cylinder tanks.

This deficiency has the potential to affect one of five smoke compartments.

Based on document review and interview, the provider failed to ensure the emergency backup electrical service provided by an onsite diesel powered generator was properly inspected weekly and loaded monthly per NFPA 110 Standard for Emergency and Standby Power Systems. Findings include:

1. Document review at 8:30 a.m. on 2/22/16 of the generator inspections reports revealed no documentation for the weekly inspection and testing that was required for the type 1 essential electrical service. No documentation was provided indicating the generator was exercised under electrical load. The load test shall exercise the electrical transfer switch that transfers the building from normal electrical service to the backup generator and run under load condition for thirty minutes at least once per month.

Interview with the maintenance supervisor after review of the above generator inspection documentation revealed he was unaware of those weekly and monthly inspection and testing requirements. He believed the generator service company RDO Equipment Company was providing all the necessary inspections and testing. He revealed the generator was on a weekly automatic self-test. He indicated the self-test did not exercise the transfer switch from normal power to emergency power. No policy was provided indicating these inspections and testing requirements.

This deficiency has the potential to affect all 18 licensed beds.

Based on observation, testing, and interview, the provider failed to ensure the electrical wiring and equipment was maintained in accordance with the NFPA 70 The National Electrical Code in two randomly observed locations (men's and women's bathroom in the outpatient physical therapy area). Findings Include:

1. Observation at 8:50 a.m. on 3/22/16 in the men's public bathroom in the outpatient physical therapy area revealed a ground fault circuit interrupter (GFCI) outlet next to the hand sink. That GFCI outlet had a cracked test switch. Testing of the outlet with a GFCI tester revealed the circuit would trip but would remain in open neutral power. Observation in the women's bathroom of the same physical therapy area revealed a similar condition with a cracked test switch. It would sometimes trip to open neutral power or if you moved the circuit tester around it would show hot/neutral reverse.

Interview with the maintenance supervisor at the time of the above observation confirmed that condition. He indicated he had not noticed the GFCI in those bathrooms were not functioning correctly. I advised him to ensure other outlets within the hospital of similar manufacture and model are not doing the same thing. He did not indicate whether GFCI outlets were checked on a regular basis. No policy was provided indicating GFCI outlets were to be tested on a regular basis.

This deficiency has the potential to affect one of five smoke compartments
.