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Based on observation and staff interview the facility failed to maintain the building fire and smoke wall separations. This deficient practice affects all smoke compartments, all staff, visitors and residents.

The findings included:

On 04/03/19, between 12:30 PM and 1:00 PM, and on 04/04/19, between 10:35 AM and 10:45 AM, while accompanied by the facilities director, observations were made of improper and/or unsealed fire/smoke-stop penetrations in numerous areas of the facility. Areas checked as examples include, but are not limited to, the following:

1. On 04/03/19, at 12:30 PM, in the main Air Conditioning room (A/C) room, there was an improperly sealed penetration through the fire wall.
2. On 04/03/19, at 12:35 PM, in the Main Switch Gear room, there was an improperly sealed penetration through the fire wall.
3. On 04/03/19, at 12:38 PM, in the generator room, there were multiple improperly sealed penetrations through the fire wall.
4. On 04/03/19, at 12:57 PM, in the first floor medical gas room, there was an improperly sealed penetration through the fire wall.
5. On 04/04/2019, at 10:35 AM, in the second floor equipment room, there were multiple improperly sealed penetrations through the fire wall.

An interview with the facilities director at the time of observation(s) revealed he could not produce documentation showing the fire stopping was installed per the manufacturer's specifications for the fire walls. No additional written documentation to support the fire rated protection by fire-stopping of the fire-stop penetrations was provided at the time of exit.

These findings were acknowledged with the Chief Executive Officer, Chief Financial Officer, Chief Operating Officer, Director of Facilities Management, and Plant Operations Manager during the exit conference on 04/04/19 at 4:15 PM.

NFPA 101 LSC (2012) Chapters, 8 and 19.7.

Based on observation, record review and staff interview, the facility failed to inspect and maintain fire doors in accordance with the applicable provisions of NFPA 101 and NFPA 80. This may cause the doors to fail as designed and in the event of a fire would allow the passage of fire, smoke and fire gasses to travel to multiple parts of the building.

The findings included:

On 04/03/2018 at 11:55 AM, during review of the facility maintenance logs, the records for door inspections included 190 total doors inspected and 149 doors did not pass inspection. The facility was not able to provide a floor plan or a list of all of the fire doors in the facility. Interview with the Facilities Director stated " the facility was in the process of repairing the doors that were identified and interim life safety measures were put into place unit the work was completed."

These findings were acknowledged with the Chief Executive Officer, Chief Financial Officer, Chief Operating Officer, Director of Facilities Management, and Plant Operations Manager during the exit conference on 04/04/19 at 4:15 PM.


NFPA 101 (2012 edition) 19.7.6, 8.3.3.1, NFPA 80 (2010 edition) 5.2, 5.2.3

Based on interview, observations and record review, the facility failed to maintain the proper use of equipment and devices of portable air conditioning (A/C) units with regard to the installation of the devices with proper exhausting means per manufacturer instructions. Failure to properly install the exhausting means of the devices results in the improper functioning of the equipment which can lead to failure of the devices endangering the patients, staff, and other building occupants.

The findings included:

On 04/04/19 at 10:30 AM while on tour of facility it was observed in the 2nd Floor Data Room, the use of portable ac units. These units were in use to maintain safe temperatures given the heat produced within the space due to the data equipment. The units exhaust was being directed up into the dropped ceiling grid. This space above the dropped grid ceiling is not provided with exhaust to the outside. Interview with the Director of Facilities, at time of finding, revealed the installation of the portable AC units were not continuously maintained in accordance with the Manufacturer's Installation Instructions.

These findings were acknowledged with the Chief Executive Officer, Chief Financial Officer, Chief Operating Officer, Director of Facilities Management, and Plant Operations Manager during the exit conference on 04/04/19 at 4:15 PM.

NFPA 101 (2012) 9.2
NFPA 99 (2012) 9.3.1

Based on observations and staff interviews, the facility failed to maintain the medical gas equipment and system. Improper use and management of medical gas systems could result in failure of the system to perform as designed. This could result in failure of the system, creating the potential for harm to patients and staff and increasing the risks associated with anesthetizing medical gasses.

The findings included:

On 04/04/19 between 3:00 PM and 4:00 PM, during inspection of the operating rooms (ORs) the following was observed. The anesthesia equipment in the operating rooms had a color coded white vacuum gas receptacle connector leading to a white hose to a one-into-two adapter with the white vacuum hose line and purple hose line with field modified white connector to the scavenger container. This hose is not dedicated to Waste Anesthetic Gas Disposal (WAGD). The current connectors are field modifications to connect to a vacuum inlet which is prohibited.

The original anesthesia machines installed when the facility opened, piped the WAGD gas to vacuum and would be considered an existing situation and acceptable, however the facility has upgraded to new anesthesia equipment that requires a WAGD inlet. Unauthorized field modifications were made by changing the purple hose (dedicated to WAGD Gas) to a distinct connector for a vacuum inlet as opposed to a WAGD inlet.

These findings were acknowledged with the Chief Operating Officer, Director of Facilities Management, Plant Operations Manager, Chief Medical Officer, and Chief Executive Officer during the exit conference 04/04/2019 at 4:15 PM.

NFPA 99 (2012 edition) 5.1.5.16.1 and 5.1.10.2.3.1.

Based on observation and staff interview the facility failed to maintain the electrical equipment used for care, treatment or diagnostic of patients or residents to code requirements. This deficient practice has the ability to affect all residents requiring physician ordered continuous oxygen or other life support electrical equipment.

The findings included:

On 04/04/19 at 9:50 AM, during the document review, the facility was not able to produce current documentation that the main feeder breaker had been exercised annually. Interview with the Facilities Manager he stated "The test had been done in January 2018 but had not been done for this year yet." No additional written documentation to substantiate compliance was received at the exit conference.

These findings were acknowledged with the Chief Executive Officer, Chief Financial Officer, Chief Operating Officer, Director of Facilities Management, and Plant Operations Manager during the exit conference on 04/04/19 at 4:15 PM.


NFPA LSC 101 (2012) Chapter 4 & 19.7.6. NFPA 110.