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Based on observations as referenced in the Life Safety Report of Survey completed on 01/13/2016, and staff interviews and observations conducted on 01/12/2016 through 01/13/2016, the facility failed to develop and maintain the facilities in a manner to ensure the safety of patients.

The findings include:

1. The facility failed to ensure all preventative maintenance programs (mechanical, electrical, and patient-care equipment) are maintained in a safe operating manner.

~cross refer to 485.623(b)(1) - Maintenance Standard Tag C0222

2. The facility failed to ensure proper ventilation, lighting, and temperature control in all pharmaceutical, patient care, and food preparation areas.

~cross refer to 485.623(b)(5) - Maintenance Standard Tag C0226

3. The facility failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association (NFPA).

~cross refer to 485.623(d)(1) - Life Safety from Fire Standard Tag C0231

Based on observations as referenced in the Life Safety Report of Survey completed on 01/13/2016, and staff interviews and observations conducted on 01/12/2016 through 01/13/2016, the facility failed to ensure all preventative maintenance programs (mechanical, electrical, and patient-care equipment) are maintained in a safe operating manner.

The findings include:

1. Based on observation and staff interview conducted on 01/12/2016 through 01/13/2016 at approximately 12:00 PM onward, the following deficiencies were noted:

A. Facility at the time of the survey were not familiar on how to test the emergency generator with loss of normal power to the Life Safety Transfer switch .
B. Facility was not able to provide a Low fuel alarm when the main fuel storage tank contains less than a 3-hour operating supply for the emergency generator.
NFPA 99: 3.4.1

Failure to comply with minimum standards as referenced increases the risk of death or injury due to loss of normal power.

~cross refer to Life Safety Code Standard-NFPA 101, Tag K0144.

Based on observations as referenced in the Life Safety Report of Survey completed on 01/13/2016, and staff interviews and observations conducted on 01/12/2016 through 01/13/2016, the facility failed to ensure proper ventilation, lighting, and temperature control in all pharmaceutical, patient care, and food preparation areas.

The findings include:

1. Based on observation and staff interview on 01/12/2016 through 01/13/2016, at approximately 12:00 PM onward, the following deficiency was noted:

A. At the time of the survey the facility was not able to provide a log of the relative humidity for the operating rooms since the end of December of 2015. Failure to comply with minimum standards as referenced increases the risk of death or injury due to improper humidity.

~cross refer to Life Safety Code Standard-NFPA 101, Tag K0078.

Based on observations as referenced in the Life Safety Report of Survey completed on 01/13/2016, and staff interviews and observations conducted on 01/12/2016 through 01/13/2016, the facility failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association (NFPA).

The findings include:

Based on observations on 01/12/2016 through 01/13/2016, at approximately 12:00 PM onward, the following deficiencies were noted:

1. Ceiling radiation dampers were not provided for in the supply and return HVAC duct located in the Fire Alarm Control Panel (FACP) room. Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~cross refer to Life Safety Code Standard-NFPA 101, Tag K0012.

2. The one hour fire rated wall separating the clean supply room and the machine room has HVAC ducts penetrating the one hour fire rated wall and the facility could not verify the penetrations were equipped with UL rate fire dampers in order to maintain the required fire resistance rating of the wall. Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~cross refer to Life Safety Code Standard-NFPA 101, Tag K0029.

3. The main supply storage room has HVAC ducts penetrating the 1 hour fire rated wall and the facility could not verify the the penetrations were equipped with UL rate fire dampers in order to maintain the required fire resistance rating of the wall. Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~cross refer to Life Safety Code Standard-NFPA 101, Tag K0029.

4. The automatic sprinkler system tamper supervisory signal could be silenced permanently. Supervisory signals shall not be silenced permanently except by reopening/restoration of the valve. Reference NFPA 101, 19.7.6, 4.6.12, NFPA 13, NFPA 25, NFPA 72; 9.7.5. Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~cross refer to Life Safety Code Standard-NFPA 101, Tag K0061.

5. In the Kitchen there are mixed sprinkler heads in the facility rated for Intermediate Temperature Classification, Glass Bulb Color of Green temperature rating of 200° (degrees) F (Fahrenheit) and Ordinary Temperature Classification, Glass Bulb Color of Red temperature rating of 155°F in the same space. The kitchen is an air conditioned space classified as ordinary environment. Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~cross refer to Life Safety Code Standard-NFPA 101, Tag K0062.

6. 1. The portable fire extinguishers for the Heli-pad was not readably accessible. The fire extinguishers were located in the fire extinguisher shed and at the time of the survey the shed was pad locked shut. Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~cross refer to Life Safety Code Standard-NFPA 101, Tag K0064.

7. The large wheeled portable fire extinguisher for the heli-pad was not hydrostatic tested in the last six years. Last hydrostatic test was conducted in 2006. Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~cross refer to Life Safety Code Standard-NFPA 101, Tag K0064.

8. The following Heating, Ventilating, and Air Conditioning systems (HVAC) were non-compliant; specific findings include:

A. The HVAC system for the laundry room above door (BCH2-105) did not shut down with fire alarm activation.
NFPA 90A, 4-2
B. No access door for the smoke duct detectors for unit M1-152, and M1-147 above door (BCH1-105) was not provided for in order to clean inspect and maintain the device. NFPA 90A, 2-3.4.1
C. In patient room 156 the HVAC duct penetrating the smoke wall (next to the outside wall) is not equipped with a smoke damper.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~cross refer to Life Safety Code Standard-NFPA 101, Tag K0067.

9. The following smoke dampers were non-compliant; specific findings include:

A. The smoke damper located in the smoke wall above corridor door BCH-1-033 did not close upon activation of the fire alarm system.
B. The smoke damper located in the smoke wall above door BCH2-105 did not close upon activation of the fire alarm system.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~cross refer to Life Safety Code Standard-NFPA 101, Tag K0104

Based on hospital policy review, observation during tour, and staff interview, the hospital failed to follow a system to control infections by storing clean equipment per hospital policy.

The findings include:

Review of hospital policy titled, "Cleaning and Disinfecting of Patient Care Equipment", effective date 03/05/2014, revealed, "Purpose: This policy serves as a guideline for the recognition of clean or soiled equipment and for storage... Procedural Guidelines... A. Clean equipment is stored in the clean equipment area... B. Soiled equipment is stored in the soiled or 'dirty' area..."

Observation during tour of the Emergency Department, conducted on 01/12/2016 at 1215, revealed empty sharps containers (containers designed to safely store sharp medical equipment after use), paper towels, rolls of toilet paper, containers of hand sanitizer, an Environmental Services cleaning cart, and medical equipment container trays wrapped in plastic stored in a soiled utility room.

Interview conducted on 01/12/2016 at 1215, with the Emergency Department Manager, revealed the equipment was ready for use and/or transport to patient rooms for use.

Interview conducted on 01/12/2016 at 1415, with the Director of Infection Control, revealed clean equipment should not be stored in a soiled utility room. Interview revealed hospital policy was not followed.