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Based on observation and staff interview, the facility failed to provide doors that positively latched in 1 of 2 smoke compartments. This condition had the potential to allow super-heated gasses from a fire to push open the doors and allow smoke and fire to migrate from the Operating Room (OR) Suite to the exit corridor, which had the potential to affect all patients. The facility census was 3.

Findings are:
Observations during the facility tour on 11/14/12, at 1:20 pm revealed the double doors that separated the OR Suite from the exit corridor failed to latch when swung shut by the automatic closure.
In an interview conducted at the time of observations (11/14/12, at 1:20 pm), Maintenance A agreed the doors did not latch.

Based on observation, record review and staff interview, the facility failed to install and maintain battery backup emergency lighting in accordance with the National Fire Protection Association 101 and 99 in the Operating Room (OR) and the Generator Room. This condition would leave the Operating Room in darkness during the 1-10 second gap from loss of power until the emergency generator restored power, or would leave the Generator Room in darkness during generator failure, which would affect all patients. The facility census was 3.

Findings are:
Observation during the facility tour on 11/14/12, at 11:45 am revealed the Operating Room failed to have battery backup emergency lighting/task illumination installed in the room.
Record review revealed that the Generator Room battery backup emergency light failed to be tested monthly and annually.
In an interview conducted at the time of observations (11/14/12, at 11:45 am), Maintenance A acknowledged the findings.

Actual NFPA Standard:
NFPA 99, 3-3.2.1.2.5e Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

NFPA 101, 7.9.3, Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 ? hours. Equipment shall be fully operation for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Based on observation and staff interview, the facility failed to maintain an exit sign in 1 of 2 smoke compartments. This condition had the potential to slow the evacuation of staff from the Ambulance Bay, which would not affect any patients. The facility census was 3.

Findings are:
Observation during the facility tour on 11/14/12, at 1:18 pm revealed the internally illuminated exit sign above the walk-out exit door in the Ambulance Bay failed to be lit during the survey.
In an interview conducted at the time of observation, (11/14/12, at 1:18 pm), Maintenance A confirmed that the exit sign failed to be illuminated.

Based on record review and staff interview, the facility failed to conduct a fire drill quarterly for each shift for 2 of 3 shifts. This condition would not provide the necessary training for staff to respond to a fire emergency, which would affect all patients. The facility census was 3.

Findings are:
Record review of fire drills revealed:
1. The facility failed to document a fire drill for the 1st shift in the 3rd quarter of 2012.
2. The facility failed to document a fire drill for the 3rd shift in the 3rd quarter of 2012.
In an interview conducted at the time of record review (11/14/12, at 11:05 am), Maintenance A acknowledged the missing fire drills.

Based on observation and staff interview, the facility failed to maintain the sprinkler system in accordance with the National Fire Protection Association, 13. This condition had the potential of fire sprinklers not activating as listed, which had the potential affect all patients. The facility census was 3.

Findings are:
Observations during the facility tour on 11/14/12, at 1:02 pm revealed the facility failed to replace the missing sprinkler escutcheon ring in the hallway of the Mammography Suite.
In an interview conducted at the time of observation, (11/14/12, at 1:02 pm), Maintenance A acknowledged the missing escutcheon.

Actual NFPA Standard:
NFPA 13, 3-2.7.2*
Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

Based on observation, record review and staff interview, the facility failed to install a line isolation monitor or ground-fault circuit interrupter outlets in the Operating Room in accordance with NFPA 99. This condition had the potential to allow a patient to receive electrical shock during a surgery. The facility census was 3.

Findings are:
Observations during the facility tour on 11/14/12, at 11:42 am revealed GFCI outlets or a line isolation monitor failed to be installed in the Operating Room.
Record review revealed no written specifics of which type of procedures would normally take place in the operating room to determine if any special protection against electric shock had to be provided if wet procedures are likely to be performed or not.
In an interview conducted at the time of observation, (11/14/12, at 11:42 am), Maintenance A verified that GFCI outlets or line isolation monitoring failed to be installed and that a policy of normally conducted procedures with what, if any, special protection needed did not exist.

Actual NFPA Standard:
NFPA 99, 3-3.2.1.2 All Patient Care Areas.
(f) Wet Locations.
1. * Wet location patient care areas shall be provided with special protection against electric shock. This special protection shall be provided by a power distribution system that inherently limits the possible ground-fault current due to a first fault to a low value, without interrupting the power supply; or by a power distribution system in which the power supply is interrupted if the ground-fault current does, in fact, exceed a value of 6 mA.
2. The use of an isolated power system (IPS) shall be permitted as a protective means capable of limiting ground fault current without power interruption. When installed, such a power system shall conform to the requirements of 3-3.2.2.
3. Where power interruption under first fault condition (line-to-ground fault) is tolerable, the use of a ground-fault circuit interrupter (GFCI) shall be permitted as the protective means that monitors the actual ground fault current and interrupts the power when that current exceeds 6 mA.

Based on observation and staff interview, the facility failed to use electrical wiring in accordance with NFPA 70 in 2 of 2 smoke compartments. This condition had the potential to cause an electrical fire, which would affect all patients. The facility census was 3.

Findings are:
Observation during the facility tour on 11/14/12 from 1:08 pm to 1:43 pm revealed:
1. An extension cord was run underneath a door for the processor in the Dark Room. The facility failed to prohibit the use of extension cords in lieu of permanent wiring.
2. The facility failed to replace the missing outlet plate in the Ambulance Bay near the security camera at the ceiling.
3. A microwave was plugged into a 3-outlet power tap in the Kitchen. The facility failed to plug the heat producing appliance directly into a wall outlet.
In an interview conducted at the time of observation (11/14/12 from 1:08 pm to 1:43 pm), Maintenance A acknowledged the use of the electrical equipment.

Based on observation and staff interview, the facility failed to provide doors that positively latched in 1 of 2 smoke compartments. This condition had the potential to allow super-heated gasses from a fire to push open the doors and allow smoke and fire to migrate from the Operating Room (OR) Suite to the exit corridor, which had the potential to affect all patients. The facility census was 3.

Findings are:
Observations during the facility tour on 11/14/12, at 1:20 pm revealed the double doors that separated the OR Suite from the exit corridor failed to latch when swung shut by the automatic closure.
In an interview conducted at the time of observations (11/14/12, at 1:20 pm), Maintenance A agreed the doors did not latch.

Based on observation, record review and staff interview, the facility failed to install and maintain battery backup emergency lighting in accordance with the National Fire Protection Association 101 and 99 in the Operating Room (OR) and the Generator Room. This condition would leave the Operating Room in darkness during the 1-10 second gap from loss of power until the emergency generator restored power, or would leave the Generator Room in darkness during generator failure, which would affect all patients. The facility census was 3.

Findings are:
Observation during the facility tour on 11/14/12, at 11:45 am revealed the Operating Room failed to have battery backup emergency lighting/task illumination installed in the room.
Record review revealed that the Generator Room battery backup emergency light failed to be tested monthly and annually.
In an interview conducted at the time of observations (11/14/12, at 11:45 am), Maintenance A acknowledged the findings.

Actual NFPA Standard:
NFPA 99, 3-3.2.1.2.5e Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

NFPA 101, 7.9.3, Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 ? hours. Equipment shall be fully operation for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Based on observation and staff interview, the facility failed to maintain an exit sign in 1 of 2 smoke compartments. This condition had the potential to slow the evacuation of staff from the Ambulance Bay, which would not affect any patients. The facility census was 3.

Findings are:
Observation during the facility tour on 11/14/12, at 1:18 pm revealed the internally illuminated exit sign above the walk-out exit door in the Ambulance Bay failed to be lit during the survey.
In an interview conducted at the time of observation, (11/14/12, at 1:18 pm), Maintenance A confirmed that the exit sign failed to be illuminated.

Based on record review and staff interview, the facility failed to conduct a fire drill quarterly for each shift for 2 of 3 shifts. This condition would not provide the necessary training for staff to respond to a fire emergency, which would affect all patients. The facility census was 3.

Findings are:
Record review of fire drills revealed:
1. The facility failed to document a fire drill for the 1st shift in the 3rd quarter of 2012.
2. The facility failed to document a fire drill for the 3rd shift in the 3rd quarter of 2012.
In an interview conducted at the time of record review (11/14/12, at 11:05 am), Maintenance A acknowledged the missing fire drills.

Based on observation and staff interview, the facility failed to maintain the sprinkler system in accordance with the National Fire Protection Association, 13. This condition had the potential of fire sprinklers not activating as listed, which had the potential affect all patients. The facility census was 3.

Findings are:
Observations during the facility tour on 11/14/12, at 1:02 pm revealed the facility failed to replace the missing sprinkler escutcheon ring in the hallway of the Mammography Suite.
In an interview conducted at the time of observation, (11/14/12, at 1:02 pm), Maintenance A acknowledged the missing escutcheon.

Actual NFPA Standard:
NFPA 13, 3-2.7.2*
Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

Based on observation, record review and staff interview, the facility failed to install a line isolation monitor or ground-fault circuit interrupter outlets in the Operating Room in accordance with NFPA 99. This condition had the potential to allow a patient to receive electrical shock during a surgery. The facility census was 3.

Findings are:
Observations during the facility tour on 11/14/12, at 11:42 am revealed GFCI outlets or a line isolation monitor failed to be installed in the Operating Room.
Record review revealed no written specifics of which type of procedures would normally take place in the operating room to determine if any special protection against electric shock had to be provided if wet procedures are likely to be performed or not.
In an interview conducted at the time of observation, (11/14/12, at 11:42 am), Maintenance A verified that GFCI outlets or line isolation monitoring failed to be installed and that a policy of normally conducted procedures with what, if any, special protection needed did not exist.

Actual NFPA Standard:
NFPA 99, 3-3.2.1.2 All Patient Care Areas.
(f) Wet Locations.
1. * Wet location patient care areas shall be provided with special protection against electric shock. This special protection shall be provided by a power distribution system that inherently limits the possible ground-fault current due to a first fault to a low value, without interrupting the power supply; or by a power distribution system in which the power supply is interrupted if the ground-fault current does, in fact, exceed a value of 6 mA.
2. The use of an isolated power system (IPS) shall be permitted as a protective means capable of limiting ground fault current without power interruption. When installed, such a power system shall conform to the requirements of 3-3.2.2.
3. Where power interruption under first fault condition (line-to-ground fault) is tolerable, the use of a ground-fault circuit interrupter (GFCI) shall be permitted as the protective means that monitors the actual ground fault current and interrupts the power when that current exceeds 6 mA.

Based on observation and staff interview, the facility failed to use electrical wiring in accordance with NFPA 70 in 2 of 2 smoke compartments. This condition had the potential to cause an electrical fire, which would affect all patients. The facility census was 3.

Findings are:
Observation during the facility tour on 11/14/12 from 1:08 pm to 1:43 pm revealed:
1. An extension cord was run underneath a door for the processor in the Dark Room. The facility failed to prohibit the use of extension cords in lieu of permanent wiring.
2. The facility failed to replace the missing outlet plate in the Ambulance Bay near the security camera at the ceiling.
3. A microwave was plugged into a 3-outlet power tap in the Kitchen. The facility failed to plug the heat producing appliance directly into a wall outlet.
In an interview conducted at the time of observation (11/14/12 from 1:08 pm to 1:43 pm), Maintenance A acknowledged the use of the electrical equipment.