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Based on observation and interview, the facility failed to ensure 2 of 2 generators were in accordance with NFPA 99, 2012 Edition, Health Care Facilities Code Section 6.4.1.1.6.1 (see tag 709), failed to ensure 2 of 2 generators were in accordance with NFPA 99, 2012 Edition, Health Care Facilities Code Section 6.4.1.1.6. and failled to ensure all circuits on the life safety branch supply power to circuits essential for life safety in accordance with NFPA 99. NFPA 99, Health Care Facilities Code, 2012 Edition, Section 6.4.2.2.3.2(see tag 702).

The cumulative effect of these systemic problems resulted in the facility's inability to ensure that all locations from which it provides services are constructed, arranged and maintained to ensure the provision of quality health care in a safe environment.

Based on document review, observation, and interview, the condition of the hospital environment failed to be maintained in a manner to ensure the safety and well-being of patients in three instances.

Findings included:

1. Review of manufacturer's instructions for the "Phillips HeartStart Automated External Defibrillator" (AED) "Edition 3" read: "By visually checking the status indicator daily, the user can verify that the AED has passed a self-test within the last 24 hours and is ready to use....The HeartStart AED will automatically perform periodic self-tests every 24 hours to ensure the device remains ready for use..."

2. On 11-13-2019 at 9:00 AM, while on tour of the computer tomography (CT) room at off-site #1, accompanied by SP50, Vice President of Clinical Services, a HeartStart AED was observed.

3. In interview on 11/14/2019 at approximately 10:20 AM, A # 14, Operations Manager, confirmed the AED located in the CT room at off-site #1 was "checked twice a year."

4. In interview on 11/14/2019 at approximately 10:22 AM, A # 1, Director of Nursing Operations, confirmed there wasn't a log indicating that the AED located in the CT room at off-site #1 was visually inspected daily by staff to ensure the systems self-check passed.

5. In interview on 11/14/2019 at approximately 2:30 PM, A # 4, Director of Quality, confirmed the facility did not have a policy related to AED monitoring by staff.

6. On 11-12-2019 at 12:44 PM, while on tour of the outpatient draw station, accompanied by SP51, Laboratory Director, the cord to the bathroom pull cord alarm was observed to be wrapped around the bathroom grab bar, next to the toilet. The cord did not activate the alarm when pulled, while wrapped around the grab bar.

7. On 11-13-2019 at 9:35 AM, while on tour of the electrocardiogram (EKG) room at off-site #1, accompanied by SP50, the cord to the bathroom pull cord alarm was observed to be wrapped around the bathroom grab bar, next to the toilet. The cord did not activate the alarm when pulled, while wrapped around the grab bar.

8. On 11-23-2019 at 12:44 PM, SP51 acknowledged the cord to the bathroom pull cord alarm was wrapped around the bathroom grab bar, next to the toilet and didn't activate the alarm when pulled while wrapped around the grab bar in the outpatient draw station bathroom.

9. On 11-13-2019 at 9:35 AM, SP50 acknowledged the cord to the bathroom pull cord alarm was wrapped around the bathroom grab bar, next to the toilet and didn't activate the alarm when pulled while wrapped around the grab bar in the EKG room bathroom at off-site #1.

Based on observation and interview, the facility failed to ensure 2 of 2 generators were in accordance with NFPA 99, 2012 Edition, Health Care Facilities Code Section 6.4.1.1.6.1. Section 6.4.1.1.6.1 states that Type 1 and Type 2 essential electrical system power sources shall be classified as Type 10, Class X, Level 1 generator sets per NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110 Section 7.3.1 states the Level 1 or Level 2 EPS equipment location(s) shall be provided with battery-powered emergency lighting. This requirement shall not apply to units located outdoors in enclosures that do not include walk-in access. NFPA 110 7.3.2 states the emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switched and failed to ensure all circuits on the life safety branch supply power to circuits essential for life safety in accordance with NFPA 99. NFPA 99, Health Care Facilities Code, 2012 Edition, Section 6.4.2.2.3.2 states the life safety branch shall supply power for lighting, receptacles, and equipment as follows:
(1) Illumination of means of egress in accordance with NFPA 101, Life Safety Code.
(2) Exit signs and exit directional signs in accordance with NFPA 101, Life Safety Code.
(3) Hospital communication systems, where used for issuing instruction during emergency conditions.
(4) Generator set location as follows:
(a) Task illumination
(b) Battery charger for emergency battery-powered lighting unit(s)
(c) Select receptacles at the generator set location and essential electrical system transfer switch locations
(5) Elevator cab lighting, control, communications, and signaling systems.
(6) Electrically powered doors used for building egress.
(7) Fire alarms and auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm and Signaling Code.
Section 6.4.2.2.3 states alarm and alerting systems (other than fire alarm systems) shall be connected to the life safety branch or the critical branch. Section 6.4.2.2.3.4 states loads dedicated to a specific generator, including the fuel transfer pump(s), ventilation fans, electrically operated louvers, controls, cooling systems, and other generator accessories essential for generator operation, shall be connected to the life safety branch or the output terminals of the generator with over-current protective devices. Section 6.4.2.2.3.5 states no functions other than those in 6.4.2.2.3.2, 6.4.2.2.3.3, and 6.4.2.2.3.4 shall be connected to the life safety branch, except as specifically permitted in 6.4.2.2.3. Section 6.4.2.2.6.1 states the life safety branch shall be kept independent of all other wiring and equipment. This deficient practice could affect all patients, staff and visitors.

Findings include:

During a facility tour with the Facility Manager on 11/14/19 at 9:42 a.m., it was found that Automatic Transfer Switch, Banks 6-11, which included Critical, Life Safety, and Equipment circuits, was not protected by battery powered emergency lighting. Based on interview at the time of observation, the Facility Manager agreed that the Automatic Transfer Switch was not protected by battery powered emergency lighting.

Based on observations with the Director of Engineering & Facilities and the Purchasing Manager for the Surgery Center during a tour of the facility from 8:30 a.m. to 10:20 a.m. on 11/14/19, it could not be assured all life safety branch circuits were separated from non-life safety branch circuits. The facility has one diesel fired emergency generator rated at 400 kW and the facility has three transfer switches located in the main electrical room. The electrical panels in the main electrical room were connected to the emergency generator and to the normal source. The electrical panel identified as "EQ1" had equipment branch circuits contained within the panel and had a circuit identified as "Generator Feed". Based on interview at the time of the observations, the Director of Engineering & Facilities checked with Hospital staff who informed him the "Generator Feed" circuit is for the generator block heater and the battery charger for the generator and agreed this life safety branch circuit was not separated from non-life safety branch circuits.

Based on record review, observation and interview, the facility to maintain the limited noncombustible rating in accordance with LSC Table 19.1.6.1. This deficient practice could affect all occupants.

Findings include:

During record review with the Facility Manager on 11/13/19 between 11:00 a.m. and 12:00 p.m., the Life Safety Plans indicated the 5th Floor "Interstitial Space" was constructed to I (332) rating. During a subsequent tour of the 5th floor on the same date, the following were observed:
a) At 1:41 p.m. a steel support beam above an air handler unit had a location measuring approximately four inches by four inches where the protective coating was removed. Based on an interview at the time of observation, the Facility Manager agreed that protective coating had been removed.
b) At 1:51 p.m. 2 cross braces were found to be missing the protective coating. The remaining visible cross braces were protected by a protective coating. Based on interview at the time of observation, the Facility Manager agreed that two cross-braces were missing the protective coating.

Based on document review, observation and interview, the facility failed to provide a sanitary environment in 7 of 17 units (Central Processing, Emergency Department, Obstetrics and Progressive Care Unit in facility, Radiology and Laboratory at off-site Diagnostic Services and Outpatient Therapy off-site) toured and failed to properly store biohazard waste at off-site #1 in one instance..

Findings Include:

1. Review of policy titled: Cleaning of the Storing Processing, Distributing (S.P.D.) Department Policy last reviewed 03/12/19, indicated the purpose was to provide a sanitary environment for the decontamination, laundering, packing and sterilizing, process stores, corridors, lifts and the offices.

2. Review of policy titled: Dusting: High and Low Procedure last reviewed 04/02/19, indicated high dusting of ledges over 6 feet and low dusting (below waist) to be done on a routine basis, refer to Duty List which indicated high dusting to be done weekly.

3. Tour of Emergency Department on 11/12/19 at 12:10 pm with A#1 (Director of Nursing Operations) and A#16 (Emergency Department Nursing Manager); observed copious amount of visible, wipeable dust on top of linen cart by exam room #5, bottom of pediatric code cart and top of the Emergency Medical Services linen cart in the hallway.

4. Tour of Obstetrics on 11/12/19 at 12:40 pm with A#1 (Director of Nursing Operations) and A#17 (Obstetrics Nursing Manager); observed visible, wipeable dust on top of ice machine in the Nourishment Room.

5. On 11-13-2019 at 9:35 am during a tour of offsite #1, while accompanied by A#12 (Vice-President Clinical Services) visible, wipeable dust was observed in the X-Ray room on the top of the sharps container, X-Ray head, and the X-Ray control panel. On the same date at 9:53 am, while accompanied by A#19 (Phlebotomy Supervisor) and A#12, visible, wipeable dust was observed in the laboratory on the top ledge of the corkboard.

6. On 11-13-2019 at 10:00 am during a tour of offsite #2, while accompanied by A#20 (Manager of Outpatient Therapy Services) and A#12 (Vice-President of Clinical Services), visible, wipeable dust was observed in the following areas:
a. Treatment room #1: on top ledge of the picture frame and on the underside of the treatment table.
b. Treatment room #7: on the underside of the treatment table.
c. Treatment room #8: on the underside of the treatment table.
d. Lymphedema room: on top of shelving
e. Gym area: on the underside of treatment table, asset number

7. Tour of Progressive Cardiac Care on 11/13/19 at 11:30 am with A#1 (Director of Nursing Operations) and NP#2 (Progressive Cardiac Care Nursing Manager); observed visible, wipeable dust on top of the ice machine in the west side Nourishment Room.

8. Tour of Central Processing on 11/13/19 at 1:00 pm with A#1 (Director of Nursing Operations) and A#18 (Central Processing Tech); observed copious amount of visible, wipeable dust on top of Sterilizer #7.

9. On 11-13-2019 at 9:35 am and 9:53 am, A#12 (Vice-President Clinical Services) acknowledged the dust observed in the X-Ray room and laboratory (refer #5).

10. On 11-13-2019 at 10:00 am, A#12 (Vice-President Clinical Services) acknowledged the dust observed in the outpatient therapy services offsite (refer #6).

11. Interview with A#1 (Director of Nursing Operations) on 11/13/19 at 3:00 pm confirmed the presence of visible, wipeable dust in:
a. Emergency Department (refer #3).
b. Obstetrics Department (refer#4).
c. Progressive Cardiac Care Department (refer #7).
d. Central Processing Department (refer#8).

12. On 11-13-2019 at 9:35 AM, while on tour of off-site #1 and accompanied by SP50, Vice President of Clinical Services, one full sharps container and six empty biohazard boxes were observed to be stored in a soiled utility room. The door to the room opened into a hallway with public access and did not contain a lock.

13. On 11-13-2019 at 9:35 PM SP50 acknowledged biohazard waste was stored in the soiled utility room. SP50 further acknowledged the door to the soiled utility room did not have a lock and the door opened into a public access hallway.