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Based on observation, the facility failed to ensure doors in the path of egress did not require the use of a key, a tool, or special knowledge or effort for operation from the egress side in accordance with NFPA 101-2012, Section 7.2.1.5.3, 7.2.1.5.10, and 7.2.1.6. Facilities can only lock doors and gates in the case of clinical need such as a special care unit.

Findings include:

1. During an observation on 3/18/24 at 12:40 p.m., the marked exit doors going into the OR area were found to be maglocked, with an electronic badge-in device. Egress from the door was with an electronic device using a card to unlock the doors and enter. The system is set up as an "access-controlled" egress special locking arrangement. The motion detector was not a part of the system.

Whatever type of special locking arrangement they want to utilize throughout the facility, either delayed egress, or access-controlled egress, the facility must then apply all the features the code requires in NFPA 101-2012 Section 7.2.1.6. The locked doors in the lighted path of egress must also unlock and be open to occupants in the event the sprinkler or fire detection systems are activated.

Based on observation, the facility failed to ensure all exit passageways were marked in accordance with NFPA 101 2012 Edition, Section 7.10.1.2.2..

Findings include:

1. During an observation on 3/18/24 at 12:48 p.m., the lab and phlebotomy area was inspected. There was no exit signage guiding occupants in phlebotomy back out to the egress corridor. there were three doors visible in the area and the egress path was not obvious.

Based on observation, the facility failed to ensure all exit passageways were marked in accordance with NFPA 101 2012 Edition, Section 7.10.1.2.2..

Findings include:

1. During an observation on 3/18/24 at 1:25 p.m., the egress path and exit sign leading occupants to the birthing area was inspected. The birthing area is a locked unit as clinical needs dictate. The exit sign was leading occupants to a magnetically locked door. There was an exit to the outside of the building immediately to the right of the locked door, the exit sign should lead occupants to the exterior exit with a chevron to the right.

2. During an observation on 3/18/24 at 1:35 p.m., the ER was inspected. There was only one exit sign visible to occupants of the ER, and there were other ways that could be seen as egress pathways. There needed to be a second marked egress from the area.

Based on observation, the facility failed to ensure hazardous rooms/areas had doors which were able to close, and latch under the power of a self-closing device, in accordance with NFPA 101, 2012 Edition, Sections 19.3.2.1 and 19.3.2.1.3.

Findings include:

1. During an observation on 3/18/24 at 1:45 p.m., the MRI future room was inspected. This is a room where the the MRI machine will be, but for now was being used as a work room and storage area. It is considered a hazardous area. The corridor door to the room was found to not close and latch under the power of the self-closer.

Based on observation the facility failed to ensure sprinkler heads were installed clear of ceiling mounted fixtures in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.6.5.2 and Table 8.6.5.1.2.

Findings Include:

1. During an observation on 3/18/24 at 12:55 p.m., the imaging locker room was inspected. A ceiling mounted light fixture was observed, obstructing a sprinkler head. The head was within 12 inches of the light, and the light was lower than the deflector on the sprinkler head.

2. During an observation on 3/18/24 at 1:10 p.m., resident room 118 was inspected. The curtain rail in the room was found to be obstructing a sprinkler head in the room. The sprinkler was very close to the rail and the rail was lower than the deflector on the head.

Based on observation, the facility failed to ensure proper sprinkler maintenance in accordance with NFPA 101-2012 and NFPA 25-2011, Section 5.2.1.1.1.

Findings include:

1. During an observation on 3/18/24 at 1:33 p.m., ER triage room was inspected. There was a sprinkler head in the room which was found to be choked with debris.

Based on observation, the facility failed to inspect and maintain the sprinkler system in accordance with NFPA 13, 2010 Edition, Section 6.2.7.2.

Findings include:

1. During an observation on 3/18/24 at 12:30 p.m., the sleep room was inspected, an escutcheon ring was missing from a sprinkler head in the bathroom.

Based on observation, the facility failed to maintain corridor doors in accordance with NFPA 101-2012, Section 19.3.6.3.5.

Findings include:

1. During an observation on 3/18/24 at 1:39 p.m., the corridor door to the imaging storage room was unable to open fully due to storage behind the door blocking it from opening. Corridor doors must be able to swing open the full length of the swing.

2. During an observation on 3/18/24 at 1:53 p.m., the corridor door to the middle room for materials management was unable to open fully due to storage behind the door blocking it from opening. Corridor doors must be able to swing open the full length of the swing.

Based on record review, the facility failed to maintain documentation of inspections on all Patient-Care Related Electrical Equipment (PCREE). The deficient practice affected all smoke compartments.

Findings include:

1. Review of facility records on 3/18/24 reflected a lack of documentation for the electric beds in the facility having been electrically tested for continuity, resistance, leakage, physical integrity, etc.

Actual NFPA Standard: NFPA 99, Health Care Facilities Code (2012)
3.3.137 Patient-Care-Related Electrical Equipment.
Electrical equipment appliance that is intended to be used for diagnostic, therapeutic, or monitoring purposes in a patient care vicinity.
10.3 Testing Requirements - Fixed and Portable.
10.3.1* Physical Integrity. The physical integrity of the power cord assembly composed of the power cord, attachment plug, and cord-strain relief shall be confirmed by visual inspection.
10.3.2* Resistance.
10.3.2.1 For appliances that are used in the patient care vicinity, the resistance between the appliance chassis, or any exposed conductive surface of the appliance, and the ground pin of the attachment plug shall be less than 0.50 ohm under the following conditions:
(1) The cord shall be flexed at its connection to the attachment plug or connector.
(2) The cord shall be flexed at its connection to the strain relief on the chassis.
10.3.2.2 The requirement of 10.3.2.1 shall not apply to accessible metal parts that achieve separation from main parts by double insulation or metallic screening or that are unlikely to become energized (e.g., escutcheons or nameplates, small screws).
10.3.3* Leakage Current Tests.
10.3.3.1 General.
10.3.3.1.1 The requirements in 10.3.3.2 through 10.3.3.4 shall apply to all tests.
10.3.3.1.2 Tests shall be performed with the power switch ON and OFF.
10.3.3.2 Resistance Test. The resistance tests of 10.3.3.3 shall be conducted before undertaking any leakage current measurements.
10.3.3.3* Techniques of Measurement. The test shall not be made on the load side of an isolated power system or separable isolation transformer.
10.3.3.4* Leakage Current Limits. The leakage current limits in 10.3.4 and 10.3.5 shall be followed.
10.3.4 Leakage Current - Fixed Equipment.
10.3.4.1 Permanently wired appliances in the patient care vicinity shall be tested prior to installation while the equipment is temporarily insulated from ground.
10.3.4.2 The leakage current flowing through the ground conductor of the power supply connection to ground of permanently wired appliances installed in general or critical care areas
shall not exceed 10.0 mA (ac or dc) with all grounds lifted.
10.3.5 Touch Current - Portable Equipment.
10.3.5.1* Touch Current Limits. The touch current for cord connected equipment shall not exceed 100 ?A with the ground wire intact (if a ground wire is provided) with normal polarity and shall not exceed 500 ?A with the ground wire disconnected.
10.3.5.2 If multiple devices are connected together and one power cord supplies power, the leakage current shall be measured as an assembly.
10.3.5.3 When multiple devices are connected together and more than one power cord supplies power, the devices shall be separated into groups according to their power supply cord, and the leakage current shall be measured independently for each group as an assembly.
10.3.5.4 Touch Leakage Test Procedure. Measurements shall be made using the circuit, as illustrated in Figure 10.3.5.4, with the appliance ground broken in two modes of appliance operation as follows:
(1) Power plug connected normally with the appliance on
(2) Power plug connected normally with the appliance off (if equipped with an on/off switch)
10.3.5.4.1 If the appliance has fixed redundant grounding (e.g., permanently fastened to the grounding system), the touch leakage current test shall be conducted with the redundant
grounding intact.
10.3.5.4.2 Test shall be made with Switch A in Figure 10.3.5.4 closed.
10.3.6* Lead Leakage Current Tests and Limits - Portable Equipment.
10.3.6.1 The leakage current between all patient leads connected together and ground shall be measured with the power plug connected normally and the device on.
10.3.6.2 An acceptable test configuration shall be as illustrated in Figure 10.3.5.4.
10.3.6.3 The leakage current shall not exceed 100 ?A for ground wire closed and 500 ?A ac for ground wire open.
10.5.2.1 Testing Intervals.
10.5.2.1.1 The facility shall establish policies and protocols for the type of test and intervals of testing for patient care-related electrical equipment.
10.5.2.1.2 All patient care-related electrical equipment used in patient care rooms shall be tested in accordance with 10.3.5.4 or 10.3.6 before being put into service for the first time and after any repair or modification that might have compromised electrical safety.
10.5.2.5* System Demonstration. Any system consisting of several electric appliances shall be demonstrated to comply with this code as a complete system.
10.5.3 Servicing and Maintenance of Equipment.
10.5.3.1 The manufacturer of the appliance shall furnish documents containing at least a technical description, instructions for use, and a means of contacting the manufacturer.
10.5.3.1.1 The documents specified in 10.5.3.1 shall include the following, where applicable:
(1) Illustrations that show the location of controls
(2) Explanation of the function of each control
(3) Illustrations of proper connection to the patient or other equipment, or both
(4) Step-by-step procedures for testing and proper use of the appliance
(5) Safety considerations in use and servicing of the appliance
(6) Precautions to be taken if the appliance is used on a patient simultaneously with other electric appliances
(7) Schematics, wiring diagrams, mechanical layouts, parts
lists, and other pertinent data for the appliance
(8) Instructions for cleaning, disinfection, or sterilization
(9) Utility supply requirements (electrical, gas, ventilation, heating, cooling, and so forth)
(10) Explanation of figures, symbols, and abbreviations on
the appliance
(11) Technical performance specifications
(12) Instructions for unpacking, inspection, installation, adjustment,
and alignment
(13) Preventive and corrective maintenance and repair
procedures
10.5.3.1.2 Service manuals, instructions, and procedures provided by the manufacturer shall be considered in the development of a program for maintenance of equipment.
10.5.6 Record Keeping - Patient Care Appliances.
10.5.6.1 Instruction Manuals.
10.5.6.1.1 A permanent file of instruction and maintenance manuals shall be maintained and be accessible.
10.5.6.1.2 The file of manuals shall be in the custody of the engineering group responsible for the maintenance of the appliance.
10.5.6.1.3 Duplicate instruction and maintenance manuals shall be available to the user.
10.5.6.1.4 Any safety labels and condensed operating instructions on an appliance shall be maintained in legible condition.
10.5.6.2* Documentation.
10.5.6.2.1 A record shall be maintained of the tests required by this chapter and associated repairs or modifications.
10.5.6.2.2 At a minimum, the record shall contain all of the following:
(1) Date
(2) Unique identification of the equipment tested
(3) Indication of which items have met or have failed to meet the performance requirements of 10.5.6.2
10.5.6.3 Test Logs. A log of test results and repairs shall be maintained and kept for a period of time in accordance with a health care facility's record retention policy.
10.5.8 Qualification and Training of Personnel.
10.5.8.1* Personnel concerned for the application or maintenance of electric appliances shall be trained on the risks associated with their use.
10.5.8.1.1 The health care facilities shall provide programs of continuing education for its personnel.
10.5.8.1.2 Continuing education programs shall include periodic review of manufacturers' safety guidelines and usage requirements for electrosurgical units and similar appliances.
10.5.8.2 Personnel involved in the use of energy-delivering devices including, but not limited to, electrosurgical, surgical laser, and fiberoptic devices shall receive periodic training in fire suppression.
10.5.8.3 Equipment shall be serviced by qualified personnel only.