HospitalInspections.org

Based upon documentation review, observations and staff interviews on November 4, 2021 between approximately 0900 hours and 1400 hours the facility has failed to maintain the facility in accordance with NFPA 101 (2012) 19.1. Failure to maintain in accordance with 2012 NFPA 101 may place patients, staff, and visitors at a greater risk of exposure to heat, fire, and smoke.

The findings include:

The facility was unable to provide documentation of carbon monoxide alarm testing and maintenance.
NFPA 101 (2012) 19.1.1.1.3, NFPA 101 4.6.1.2, NFPA 720 (2012) 9.8.1, 8.7.1.

The above was discussed and acknowledged by the maintenance staff.

Based upon observations and staff interviews on November 4, 2021 between approximately 0900 and 1400 hours the facility has failed to maintain all means of egress continuously free of obstructions. This could inhibit the orderly exit of patients, staff, and visitors out of the building during an emergency and may prevent emergency responders from entering.

The findings include:

Lower level - a Genie lift was obstructing an egress corridor.

NFPA 101 (2012) 19.2.3.4

The above was discussed and acknowledged by the maintenance staff.

Based on documentation review and staff interviews on November 4, 2021 between approximately 0900 and 1400 hours the facility has failed to maintain the ability of doors to be held open only by devices arranged to automatically close upon activation of the fire alarm. This could result in the passage of smoke or fire from one compartment into another compartment thereby exposing patient, staff and/or visitors to the toxic products of combustion.

The findings include:

Kitchen - door was blocked in the open position. Corrected during inspection.
NFPA 101 (2012) 19.3.6.3.1

Rural Health Clinic - doors does not latch when closed.

Elevator #2 - roll down door does not roll down when fire alarm activates.

Acute Care Nursing Supply Room - door does not latch when closed.

NFPA 101 (2012) 19.3.6.3.1

The above was discussed and acknowledged by the maintenance staff.

Based upon documentation review, observation and staff interviews on November 2, 2021 between approximately 0900 and 1400 hours the facility has failed to conduct testing/maintenance of the hood and duct fire suppression equipment protecting the commercial cooking equipment. This could result in the failure of the system to operate properly which would endanger the patients, staff and/or visitors within the facility.

The findings include:

The facility was unable to provide two semi-annual hood cleaning reports within the past twelve months.

NFPA 101 (2012 ed) 19.1.1.1.1, 19.3.2.5.1, 9.2.3, 2.1, NFPA 96 (2011 ed) 1.1.1, 11.4
Inspections reports must be free of deviancies.
The above was discussed and acknowledged by the maintenance staff.

Based on documentation review and staff interviews on November 4, 2021 between approximately 0900 and 1400 hours the facility has failed to have their fire alarm system installed in accordance with the references NFPAs and in a manner that is approved. This could result in a fire not being detected by the fire alarm system, possible leading to harm and delayed evacuation of patients, staff, and visitors.

The findings include:

The panel which houses the circuit and the circuit to the fire alarm panel was not identified.
NFPA 101 (2012 ed) 19.1.1.1.1, 19.3.4.1, 9.6.1.3, 2.1, NFPA 72 (2010 ed) 1.1.1, 10.5.5.2

The above was discussed and acknowledged by the maintenance staff.

Based on documentation review, observation and staff interview on November 4, 2021 between approximately 0900 and 1400 hours the facility has failed to have appropriate testing of the fire alarm system which result in the failure to notify staff of a problem with the fire alarm system. This could lead to the system not functioning as intended and lead patients, staff, and visitors within the building not being notified of a fire.

The findings include:

The facility was unable to provide documentation of annual fire alarm service.
NFPA 101 (2012) 19.1.1.1.1, 19.3.4.1, 9.6.1.3, 2.1, NFPA 72 (2010) 1.1.1, 14.4.5
Inspections reports must be free of deviancies.

Front Entrance - manual pull station access was obstructed by wheelchairs.
NFPA 101 (2012) 19.1.1.1.1, 19.3.4.1, 9.6.1.3, 2.1, NFPA 72 (2010) 1.1.1, 17.14.5

Fire alarm control panel serving the administration office is in trouble status.
NFPA 101 (2012) 19.1.1.1.1, 19.3.4.1, 9.6.1.3, 2.1, NFPA 72 (2010) 1.1.1, 14.2.1.2

The above was discussed and acknowledged by the maintenance staff.

Based on documentation review, observation and staff interview on November 4, 2021 between approximately 0900 and 1400 hours the facility has failed to maintain the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire and allow the fire to increase in size and intensity which would endanger the patients, staff, and/or visitors within the facility.

The findings include:

The facility was unable to provide documentation of quarterly inspections of the fire sprinkler system.
NFPA 101 (2012) 19.1.1.1.1, 19.3.5.1, 9.7.5, 2.1, NFPA 25 (2011) 1.1, 5.1.1.2
Inspections reports must be free of deviancies.

The facility was unable to provide documentation of five year internal pipe inspection.
NFPA 101 (2012 ed) 19.1.1.1.1, 19.3.5.1, 9.7.5, 2.1, NFPA 25 (2011 ed) 1.1, 14.2.1
Inspections reports must be free of deviancies.

The above was discussed and acknowledged by the maintenance staff.

Based on observation and staff interviews on November 4, 2021 between approximately 0900 and 1400 hours the facility failed to maintain their fire extinguishers in accordance with NFPA 10. This potentially delays a quick response to contain a fire from spreading which could expose and endanger patients, staff, and/or visitors within the facility.

The findings include:

Maintenance Shop - two fire extinguishers were not secured
NFPA 101 (2012 ed) 19.1.1.1.1, 19.3.4.12, 9.7.4.1, 2.1, NFPA 10 (2010 ed) 1.1, 6.1.3.4

IT Room - fire extinguishers tags indicated they had not had annual service performed within the past twelve months.
NFPA 101 (2012 ed) 19.1.1.1.1, 19.3.4.12, 9.7.4.1, 2.1, NFPA 10 (2010 ed) 1.1, 7.3.1.3.2

The above was discussed and acknowledged by the facility plant operations staff.

Based on observation and staff interview on November 4, 2021 between approximately 0900 to 1400 hours the facility has failed to maintain electric equipment in a safe manner and in accordance with NFPA 70. This could endanger patients, staff, and visitors in the building by risk of fire, electrocution, or other harm.

The findings include:

Exposed wires were observed in the following locations:
Training Room - two open electrical boxes
Director of Business Services - an open electrical box
NFPA 101 (2012 ed) 19.1.1.1.1, 19.5.1.1, 9.1.2, 2.1, NFPA 70 (2011 ed) 90.2 (A), 314.20

Kitchen Dry Storage Room - electrical panel blocked. Corrected during inspection.
NFPA 101 (2012 ed) 19.1.1.1.1, 19.5.1.1, 9.1.2, 2.1, NFPA 70 (2011 ed) 90.2 (A), 110.26(A)(2)

The above was discussed and acknowledged by the maintenance staff.

Based on documentation review, observation and staff interview on November 4, 2021 between approximately 0900 and 1400 hours the facility has failed to ensure dampers in the facility were inspected and provided necessary maintenance at least every four years in accordance with NFPA 90A. LSC 9.2.1 requires heating, ventilating and air conditioning (HVAC), ductwork and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems.

NFPA 90A, 2012 Edition, Section 5.4.8.1 states fire dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. NFPA 80, 2010 Edition, Section 19.4.1 states each damper shall be tested and inspected 1 year after installation. The test and inspection frequency shall be every 4 years. If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in-place if so equipped. The damper shall not be blocked from closure in any way. All inspections and testing shall be documented, indicating the location of the fire damper, date of inspection, name of inspector and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected. This deficient practice could affect all patients, staff, and visitors.

The findings include:

The facility was unable to provide documentation of damper testing within the past six years.

NFPA 101 (2012 ed) 19.1.1.1.1, 19.2.1, 7.2.1.15.2, NFPA 80 (2010 ed) 1.1, 19.4.1.1

Inspections reports must be free of deviancies.

The above was discussed and acknowledged by the maintenance staff.

Based upon documentation review, observations and staff interviews on November 4, 2021 between approximately 0900 and 1400 hours the facility has failed to test all fire rated doors in accordance with NFPA 80. This could lead to the doors not functioning as required in a fire, endangering patients, visitors, and staff inside the building.

The findings include:

The facility was unable to provide documentation of annual fire door inspection.

Report must be free of deficiencies.

NFPA 101 (2012 ed) 19.1.1.1.1, 19.2.1, 7.2.1.15.2, NFPA 80 (2010 ed) 1.1, 5.2.4.1

The above was discussed and acknowledged by the maintenance staff.

Based on observation and staff interview on November 4, 2021 between approximately 0900 to 1400 hours the facility failed to maintain their medical gas identification and labeling in accordance with NFPA 99. Failure to maintain medical gas identification as required could place patients, staff, and visitors to the threat of misused gases or using open flames around gases.

The findings include:

The medical gas storage room containing positive pressure gases other than just oxygen and medical air did not have the following signage:

Positive Pressure Gases
NO Smoking or Open Flame
Room May Have Insufficient Oxygen
Open Door and Allow Room to
Ventilate Before Entering


NFPA 99 (2012) 5.1.3.1.8
The above was discussed and acknowledged by the maintenance staff.

Based on documentation review, observation and staff interviews on November 4, 2021 between approximately 0900 and 1400 hours the facility failed to properly maintain medical gas equipment through testing and inspection possible leading to a problem not being detected, and thus place patients, staff, and visitors to the threat of an accelerated fire.

The findings include:

The facility was unable to provide documentation periodic testing and after adjustments or repairs of medical gas administration system.

NFPA 99 (2012) 5.1.14.2.3

Inspection reports must be free of deficiencies.

The above was discussed and acknowledged by the maintenance staff.

Based on documentation review and staff interviews on November 4, 2021 between approximately 0900 and 1400 hours the facility failed to keep records or conduct maintenance on their hospital grade receptacles, non-hospital grade receptacles, and Line Isolation Monitors. This could cause an increased risk of fire due to the non-maintenance of the electrical system, and place patients, staff, and visitors of electrical shock or ham.

The findings include:

The facility was unable to provide documentation of testing neither hospital grade or non-hospital grade electrical receptacles.

NFPA 99 (2012) 1.1.1, 6.3.4.1.3 and 6.3.4.1.1

Reports must be free of deficiencies.

The above was discussed and acknowledged by the maintenance staff.

Based on documentation review, observation and staff interview on November 4, 2021 between approximately 0900 and 1400 hours the facility has failed to maintain and test the emergency generator in accordance with NFPA 110. This could result in a failure of the emergency power system which would leave the facility without egress and task lighting in the event of a power failure which would endanger the patients, staff, and/or visitors within the facility.

The findings include:

The facility was unable to provide documentation of annual generator fuel testing within the past twelve months.

NFPA 99 (2012 ed) 6.4.4.1.1.3, 2.1, NFPA 110 (2010 ed)1.1, 8.3.8, 8.1.1

Reports must be free of deficiencies.

The facility was unable to provide documentation of tri-annual 4 hours continuous load test of the emergency generator.

NFPA 99 (2012 ed) 6.4.4.1.1.3, 2.1, NFPA 110 (2010 ed)1.1, 8.4.9

Reports must be free of deficiencies.

The above was discussed and acknowledged by the maintenance staff.

Based on observation and staff interviews on November 4, 2021 between approximately 0900 and 1400 hours the facility failed to restrict the use of extension cords and non-approved power strips in their facility. This could endanger patients, staff, and visitors in the facility due to the increased fire risk.

The findings include:

Endoscopy Suite - a non-medical grade powerstrip was in use.
COVID Vaccine Refrigerator - plugged into a non-medical grade power cord.

Business Office - a non-fused multiplug adapters was plugged into other multiplug adapters under the desk in the back on the right side.

NFPA 101 (2012 ed) 19.1.1.1.1, 19.5.1.1, 9.1.2, 2.1, NFPA 70 (2011 ed) 90.2 (A), 10.2.3.1.1

The above was discussed and acknowledged by the maintenance staff.

Based on documentation review, observation and staff interview on November 4, 2021 between approximately 0900 and 1400 hours the facility has failed to provide documentation of personnel concerned with the application, maintenance, and handling of medical gases and cylinders that are trained on the risk and provide continuing education. Failure to provide training and continuing education on the safe handling and use of gases and cylinders could place patients, visitors, and staff at risk of oxygen malfunctions.

The findings include:

The facility was unable to provide documentation of training for medical gas equipment use.

NFPA 99 (2012 ed) 1.1.1, 11.5.2.1, 11.5.2.1.2

The above was discussed and acknowledged by the maintenance staff.