HospitalInspections.org

Based on observation, testing, and interview, the provider failed to maintain self-closing smoke barrier doors on two sets of randomly observed cross-corridor smoke barrier doors (near administration suite and near patient room 36). Findings include:

1. Observation at 10:20 a.m. on 1/27/15 revealed a set of cross-corridor 3/4 inch solid bond wood smoke barrier doors being held open with a magnetic hold open device near the administration suite. Testing of those doors revealed those doors had become warped at the top and did not provide a smoke tight seal. An approximate 3/4 inch gap was observed. Interview with the maintenance technician at the time of the observation confirmed that condition. That condition was also observed at the cross-corridor door located near patient room 36.

This deficiency has the potential to affect three of four smoke compartment corridors.

Based on observation and interview, the provider failed to maintain proper separation of hazardous areas in one randomly observed location (laundry room). Findings include:

1. Observation at 3:10 p.m. on 1/27/15 revealed a corridor door to the laundry room was equipped with a self-closing device. The door would not close and latch into the door frame under power of the self-closing device. Further observation revealed the ventilation from the dryers were creating a strong negative air pressure in the laundry room. The air pressure was not allowing the door to fully close. Interview with the maintenance technician at the time of the observation confirmed that condition. He did not indicate if that door was checked on a regular basis to ensure it was functioning properly.

This deficiency has the potential to affect one of four smoke compartments.

Based on observation and interview, the provider failed to provide emergency lighting in two randomly observed exit discharge locations (west exits from patient care wing). Findings include:

1. Observation at 11:20 a.m. on 1/27/15 revealed an exit door from the west end north door of the patient care wing. Further observation outside of that exit revealed a single utility light pole was located near the parking area that provided egress lighting from that exit. Interview with the maintenance technician at the time of the observation revealed that utility light was not tied to emergency power. Failure of power would leave that exit discharge without light. That condition was also observed for the west end south door exit of the patient care wing.

This deficiency has the potential to affect exit discharge from two of eight exits.

Based on record review and interview, the provider failed to furnish two means for transmitting the fire alarm system signal to an approved central station. The fire alarm system's communication device only had one phone line connected to it to signal the monitoring agency. A minimum of two means (two phone lines) for transmitting a signal offsite is required per NFPA 72, section 5-5.3.2.1.6.1. Findings include:

1. Record review at 9:30 a.m. on 1/27/15 revealed the provider had contracted Automatic Building Controls Inc. to conduct annual fire alarm system inspections. Review of the inspection report dated 4/28/14 revealed the representative of Automatic Building Controls had indicated a second phone line should be installed to the main fire alarm panel in accordance with NFPA 72. Further review indicated the same comment was found on the 4/16/13 report. Interview with the maintenance technician and environmental services director at the time of the exit interview confirmed that finding and revealed they were unfamiliar with that requirement.

This deficiency has the potential to affect the entire facility.

Based on record review and interview, the provider failed to ensure the automatic sprinkler system was continuously maintained in reliable operating condition and inspected and tested periodically in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Findings include:

1. Document review at 9:30 a.m. on 1/27/15 of the provider's automatic sprinkler system inspection report prepared by Total Fire Protection Inc. revealed no documentation of required testing. The automatic sprinkler was installed with original construction in 1975. Review of all of the provided quarterly inspection reports for last three years provided no indication a five year internal obstruction investigation had been ever been completed for the sprinkler system.

Interview with the plant operations supervisor at the time of the record review confirmed that condition. He indicated he was unaware of the five year internal obstruction investigation.

This deficiency has the potential to affect the entire facility.

Based on observation and interview, the provider failed to secure and maintain storage locations of nonflammable gases with gas volumes that were less 3000 cubic feet in accordance with NFPA 99 in one randomly observed oxygen cylinder storage room (in the patient care wing near room 27) Findings include:

1. Observation at 11:50 a.m. on 1/27/15 revealed a converted shower room being used to store approximately 15 e-cylinder oxygen tanks. That room was also being used to store combustible material. Fire sprinkler protection was not provided in that room and a minimum of 20 feet of separation should have been provided from combustible materials. Further observation revealed the door to that room was not provided with hardware that would prevent unauthorized entry. Interview with the maintenance technician at the time of observation revealed he was unaware of the oxygen storage requirements.

This deficiency has the potential to affect one of four smoke compartments.

Based on document review, observation, and interview, the provider failed to conduct required testing and maintain the generator of the emergency power system in accordance with NFPA 99 and NFPA 110. Findings include:

1. Document review at 9:45 a.m. on 1/27/15 revealed the 150 KW diesel generator providing emergency power supply to the essential electrical system was serviced semi-annually by Dak Generators. Review of the service reports revealed a load bank had not been conducted at any time over the past year. Interview with the maintenance technician revealed the loading on the generator during the required monthly thirty minute load test was approximately 24-28% of the nameplate power rating. An annual load bank test shall be conducted on diesel generators that are not loaded to at least 30% of the nameplate power rating. The maintenance technician revealed he was unaware of that requirement.

2. Observation at 9:55 a.m. on 1/27/15 revealed the generator battery was dated as being replaced on December 2011. Generator batteries should have been scheduled for replacement every twenty-four to thirty months. Approximately thirty-seven months had lapsed since the last battery had been installed. Weekly specific gravity tests are required to be performed. Interview with the maintenance supervisor at the time of the observation revealed he was unaware that battery should have been replaced, and that specific gravity testing was required.

This deficiency has the potential to affect the entire facility.

Based on observation and interview, the provider failed to maintain the clearance space around the electrical equipment in accordance with NFPA 70 in two randomly observed locations (mechanical room in the patient wing and the janitor ' s closet in the kitchen). Findings include:

1. Observation at 11:05 a.m. on 1/27/15 revealed a mechanical room in the patient wing where electrical circuit breaker panels were housed. Miscellaneous parts and materials were being stored on the top of the panels. Working space for electrical equipment shall be maintained free of storage to permit ready and safe operation and maintenance of such equipment. Interview with the maintenance technician at the time of observation confirmed that condition. That same condition was also found at the electrical circuit breaker panels in the janitor ' s closet in the kitchen.

This deficiency has the potential to affect two of four smoke compartments.

Based on observation, testing, and interview, the provider failed to maintain self-closing smoke barrier doors on two sets of randomly observed cross-corridor smoke barrier doors (near administration suite and near patient room 36). Findings include:

1. Observation at 10:20 a.m. on 1/27/15 revealed a set of cross-corridor 3/4 inch solid bond wood smoke barrier doors being held open with a magnetic hold open device near the administration suite. Testing of those doors revealed those doors had become warped at the top and did not provide a smoke tight seal. An approximate 3/4 inch gap was observed. Interview with the maintenance technician at the time of the observation confirmed that condition. That condition was also observed at the cross-corridor door located near patient room 36.

This deficiency has the potential to affect three of four smoke compartment corridors.

Based on observation and interview, the provider failed to maintain proper separation of hazardous areas in one randomly observed location (laundry room). Findings include:

1. Observation at 3:10 p.m. on 1/27/15 revealed a corridor door to the laundry room was equipped with a self-closing device. The door would not close and latch into the door frame under power of the self-closing device. Further observation revealed the ventilation from the dryers were creating a strong negative air pressure in the laundry room. The air pressure was not allowing the door to fully close. Interview with the maintenance technician at the time of the observation confirmed that condition. He did not indicate if that door was checked on a regular basis to ensure it was functioning properly.

This deficiency has the potential to affect one of four smoke compartments.

Based on observation and interview, the provider failed to provide emergency lighting in two randomly observed exit discharge locations (west exits from patient care wing). Findings include:

1. Observation at 11:20 a.m. on 1/27/15 revealed an exit door from the west end north door of the patient care wing. Further observation outside of that exit revealed a single utility light pole was located near the parking area that provided egress lighting from that exit. Interview with the maintenance technician at the time of the observation revealed that utility light was not tied to emergency power. Failure of power would leave that exit discharge without light. That condition was also observed for the west end south door exit of the patient care wing.

This deficiency has the potential to affect exit discharge from two of eight exits.

Based on record review and interview, the provider failed to furnish two means for transmitting the fire alarm system signal to an approved central station. The fire alarm system's communication device only had one phone line connected to it to signal the monitoring agency. A minimum of two means (two phone lines) for transmitting a signal offsite is required per NFPA 72, section 5-5.3.2.1.6.1. Findings include:

1. Record review at 9:30 a.m. on 1/27/15 revealed the provider had contracted Automatic Building Controls Inc. to conduct annual fire alarm system inspections. Review of the inspection report dated 4/28/14 revealed the representative of Automatic Building Controls had indicated a second phone line should be installed to the main fire alarm panel in accordance with NFPA 72. Further review indicated the same comment was found on the 4/16/13 report. Interview with the maintenance technician and environmental services director at the time of the exit interview confirmed that finding and revealed they were unfamiliar with that requirement.

This deficiency has the potential to affect the entire facility.

Based on record review and interview, the provider failed to ensure the automatic sprinkler system was continuously maintained in reliable operating condition and inspected and tested periodically in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Findings include:

1. Document review at 9:30 a.m. on 1/27/15 of the provider's automatic sprinkler system inspection report prepared by Total Fire Protection Inc. revealed no documentation of required testing. The automatic sprinkler was installed with original construction in 1975. Review of all of the provided quarterly inspection reports for last three years provided no indication a five year internal obstruction investigation had been ever been completed for the sprinkler system.

Interview with the plant operations supervisor at the time of the record review confirmed that condition. He indicated he was unaware of the five year internal obstruction investigation.

This deficiency has the potential to affect the entire facility.

Based on observation and interview, the provider failed to secure and maintain storage locations of nonflammable gases with gas volumes that were less 3000 cubic feet in accordance with NFPA 99 in one randomly observed oxygen cylinder storage room (in the patient care wing near room 27) Findings include:

1. Observation at 11:50 a.m. on 1/27/15 revealed a converted shower room being used to store approximately 15 e-cylinder oxygen tanks. That room was also being used to store combustible material. Fire sprinkler protection was not provided in that room and a minimum of 20 feet of separation should have been provided from combustible materials. Further observation revealed the door to that room was not provided with hardware that would prevent unauthorized entry. Interview with the maintenance technician at the time of observation revealed he was unaware of the oxygen storage requirements.

This deficiency has the potential to affect one of four smoke compartments.

Based on document review, observation, and interview, the provider failed to conduct required testing and maintain the generator of the emergency power system in accordance with NFPA 99 and NFPA 110. Findings include:

1. Document review at 9:45 a.m. on 1/27/15 revealed the 150 KW diesel generator providing emergency power supply to the essential electrical system was serviced semi-annually by Dak Generators. Review of the service reports revealed a load bank had not been conducted at any time over the past year. Interview with the maintenance technician revealed the loading on the generator during the required monthly thirty minute load test was approximately 24-28% of the nameplate power rating. An annual load bank test shall be conducted on diesel generators that are not loaded to at least 30% of the nameplate power rating. The maintenance technician revealed he was unaware of that requirement.

2. Observation at 9:55 a.m. on 1/27/15 revealed the generator battery was dated as being replaced on December 2011. Generator batteries should have been scheduled for replacement every twenty-four to thirty months. Approximately thirty-seven months had lapsed since the last battery had been installed. Weekly specific gravity tests are required to be performed. Interview with the maintenance supervisor at the time of the observation revealed he was unaware that battery should have been replaced, and that specific gravity testing was required.

This deficiency has the potential to affect the entire facility.

Based on observation and interview, the provider failed to maintain the clearance space around the electrical equipment in accordance with NFPA 70 in two randomly observed locations (mechanical room in the patient wing and the janitor ' s closet in the kitchen). Findings include:

1. Observation at 11:05 a.m. on 1/27/15 revealed a mechanical room in the patient wing where electrical circuit breaker panels were housed. Miscellaneous parts and materials were being stored on the top of the panels. Working space for electrical equipment shall be maintained free of storage to permit ready and safe operation and maintenance of such equipment. Interview with the maintenance technician at the time of observation confirmed that condition. That same condition was also found at the electrical circuit breaker panels in the janitor ' s closet in the kitchen.

This deficiency has the potential to affect two of four smoke compartments.