HospitalInspections.org

Based on observations which were made during a tour of the building on September 10, 2012, it was determined that the facility did not ensure that all doors requiring self closing hardware were properly equipped and/or closed to positive latching.


Findings include:

In accordance with Section 19.2.2.2.6 of NFPA 101, 2000 edition, any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

At 9:45 a.m., the west door to the basement was observed to be held open by a wedge not allowing the self closing door to close to positive latching.

Based on a review of previous survey reports and a discussion with the maintenance supervisor on September 10, 2012, it was determined that the original hospital building is not protected by a complete automatic sprinkler system as required for a wood frame structure.

Findings include:

In accordance with NFPA 101 and Section 19.1.6.2, health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
Table 19.1.6.2 Construction Type Limitations

Construction
Type Stories
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)

The crawl space under the South Wing of the original hospital building is not sprinklered as required by NFPA 101 for Type V (111) construction. This crawl space is viewed as a concealed combustible space since the wood floor joists and wood deck are exposed. Although sprinkler mains run through this crawl space, sprinkler heads were apparently never installed.

Based on observations, interviews and record review made on September 10, 2012, the facility failed to provide for a functioning Type I Essential Electrical System due to failure to pass the generator load bank test.

Findings include:

In accordance with 3-6.3.1.1 of NFPA 99 (1999 Edition), the emergency electrical system shall have an alternate source of power separate and independent from the normal source that will be effective for a minimum of 1 and 1/2 hours after the loss of the normal source.

In accordance with 6-4.2.2 of NFPA 101 (1999 Edition), diesel powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

The generator is a 60 killowatts (Kw) Kohler and a contracted company provides inspections.

Interview with the maintenance supervisor at 9:20 a.m., "The generator head gasket leaks and did not pass the last load bank test."

Review of Generator LoadTest Report at 3:00 p.m. provided the following documentation:
2:00 p.m. at 25% (15 kw);
2:30 at 50% (30 kw); then at
3:00 p.m. the following was documented;
"Gen [generator] failed load bank testing
Coolant leak at head gasket."

Review of the Maintenance Check List:
2.0 Head Gasket Leaking.

Review of Additional notes:
"Head gasket leaking (exh side)
Could not complete load bank testing
No other problems found
Released to Service"

Interview with Interim Administrator at 3:50 p.m., "We are aware of the need to replace the generator and have applied for a grant to assist with funding."

On September 11, 2012 at 3:30 p.m., the facility administrator was presented with a letter of Significant Finding.

On September, 12, 2012, a letter was received from the Administrator of the facility stating the following:

"On September 12, 2012 at 12:40 p.m., [name of facility] has installed, load tested, and cut hospital power over to a 60 Kw portable generator. The load test documentation, and the rental agreement with [name of company] are included with this letter as evidence of compliance.

We performed a cut over of hospital power from the grid to the generator system at 12:40 p.m. The power was restored by our backup generator in 7 seconds. The cut over was observed by [surveyor names]. They also observed the installation and have taken pictures of the new system.

We plan to continue to load test and log the load test system on a Monthly basis."

The Significant Finding was abated at 12:40 p.m. on September 12, 2012.

Based on observations made on September 10, 2010, the facility failed to assure that a portable LPG tank attached to a barbecue was located an appropriate distance from any combustible materials.

Findings include:

Portable liquid petroleum gas (LPG) tanks used for such items as barbecues shall be located at least 3 feet from any building opening and at least 5 feet in any direction from an exterior source of ignition, direct-vent appliances or mechanical ventilation air intakes per section 3-2.2.2 of NFPA 58, 1998 Edition.

At 1:38 p.m., an outdoor propane cooking grill was observed sitting in a wooden gazebo approximately 4 feet from a combustible wooden structure.

Based on observations made on September 10, 2012, the facility did not maintain the electrical system and/or its components in accordance with the standards of the National Electrical Code, NFPA 70, 1999 Edition and/or interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings include:

Article 240-22 of NFPA 70 ,1999 Edition, states that no overcurrent device shall be connected in series with any conductor that is intentionally grounded. United Laboratories (UL) listing guidelines for relocatable power taps/power strips, being XBYS, notes that these strips are not intended to be series connected or daisy chained to other power strips or extension cords. Extension cords, including power strips or multiple adaptors used in health care, shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction, one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4 of NFPA 70, 1999 Edition and 7-5.1.2.6 & 7-6.2.1.5 of NFPA 99, 1999 Edition.

At 12:45 p.m., a refrigerator was observed to be plugged into a power strip that was hanging unsecured and plugged into another power strip (daisy chained) that was secured to the wall in the Emergency Department.

Based on observations made on September 10, 2012, the facility did not maintain the electrical system and/or its components in accordance with the standards of the National Electrical Code, NFPA 70, 1999 Edition and/or interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings include:

Extension cords (including power strips) or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4(b)(3) of NFPA 70.

Article 240-22 of NFPA 70 ,1999 edition, states that no overcurrent device shall be connected in series with any conductor that is intentionally grounded. United Laboratories (UL) listing guidelines for relocatable power taps/power strips, being XBYS, notes that these strips are not intended to be series connected or daisy chained to other power strips or extension cords. Extension cords, including power strips or multiple adaptors used in health care, shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction, one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4 of NFPA 70, 1999 edition and 7-5.1.2.6 & 7-6.2.1.5 of NFPA 99, 1999 edition.

1. At 9:25 a.m., a power strip was observed to be hanging unsecured below a desk in the Activities Room. The power strip had multiple cords plugged into it.

2. At 9:26 a.m., a microwave and small oven were observed to be plugged into a power strip in the Activities Room.

3. At 9:45 a.m., a standard size refrigerator and a microwave were observed to be plugged into a power strip in the staff break room.

Based on observations which were made during a tour of the building on September 10, 2012, it was determined that the facility did not ensure that all doors requiring self closing hardware were properly equipped and/or closed to positive latching.


Findings include:

In accordance with Section 19.2.2.2.6 of NFPA 101, 2000 edition, any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

At 9:45 a.m., the west door to the basement was observed to be held open by a wedge not allowing the self closing door to close to positive latching.

Based on a review of previous survey reports and a discussion with the maintenance supervisor on September 10, 2012, it was determined that the original hospital building is not protected by a complete automatic sprinkler system as required for a wood frame structure.

Findings include:

In accordance with NFPA 101 and Section 19.1.6.2, health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
Table 19.1.6.2 Construction Type Limitations

Construction
Type Stories
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)

The crawl space under the South Wing of the original hospital building is not sprinklered as required by NFPA 101 for Type V (111) construction. This crawl space is viewed as a concealed combustible space since the wood floor joists and wood deck are exposed. Although sprinkler mains run through this crawl space, sprinkler heads were apparently never installed.

Based on observations, interviews and record review made on September 10, 2012, the facility failed to provide for a functioning Type I Essential Electrical System due to failure to pass the generator load bank test.

Findings include:

In accordance with 3-6.3.1.1 of NFPA 99 (1999 Edition), the emergency electrical system shall have an alternate source of power separate and independent from the normal source that will be effective for a minimum of 1 and 1/2 hours after the loss of the normal source.

In accordance with 6-4.2.2 of NFPA 101 (1999 Edition), diesel powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

The generator is a 60 killowatts (Kw) Kohler and a contracted company provides inspections.

Interview with the maintenance supervisor at 9:20 a.m., "The generator head gasket leaks and did not pass the last load bank test."

Review of Generator LoadTest Report at 3:00 p.m. provided the following documentation:
2:00 p.m. at 25% (15 kw);
2:30 at 50% (30 kw); then at
3:00 p.m. the following was documented;
"Gen [generator] failed load bank testing
Coolant leak at head gasket."

Review of the Maintenance Check List:
2.0 Head Gasket Leaking.

Review of Additional notes:
"Head gasket leaking (exh side)
Could not complete load bank testing
No other problems found
Released to Service"

Interview with Interim Administrator at 3:50 p.m., "We are aware of the need to replace the generator and have applied for a grant to assist with funding."

On September 11, 2012 at 3:30 p.m., the facility administrator was presented with a letter of Significant Finding.

On September, 12, 2012, a letter was received from the Administrator of the facility stating the following:

"On September 12, 2012 at 12:40 p.m., [name of facility] has installed, load tested, and cut hospital power over to a 60 Kw portable generator. The load test documentation, and the rental agreement with [name of company] are included with this letter as evidence of compliance.

We performed a cut over of hospital power from the grid to the generator system at 12:40 p.m. The power was restored by our backup generator in 7 seconds. The cut over was observed by [surveyor names]. They also observed the installation and have taken pictures of the new system.

We plan to continue to load test and log the load test system on a Monthly basis."

The Significant Finding was abated at 12:40 p.m. on September 12, 2012.

Based on observations made on September 10, 2010, the facility failed to assure that a portable LPG tank attached to a barbecue was located an appropriate distance from any combustible materials.

Findings include:

Portable liquid petroleum gas (LPG) tanks used for such items as barbecues shall be located at least 3 feet from any building opening and at least 5 feet in any direction from an exterior source of ignition, direct-vent appliances or mechanical ventilation air intakes per section 3-2.2.2 of NFPA 58, 1998 Edition.

At 1:38 p.m., an outdoor propane cooking grill was observed sitting in a wooden gazebo approximately 4 feet from a combustible wooden structure.

Based on observations made on September 10, 2012, the facility did not maintain the electrical system and/or its components in accordance with the standards of the National Electrical Code, NFPA 70, 1999 Edition and/or interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings include:

Article 240-22 of NFPA 70 ,1999 Edition, states that no overcurrent device shall be connected in series with any conductor that is intentionally grounded. United Laboratories (UL) listing guidelines for relocatable power taps/power strips, being XBYS, notes that these strips are not intended to be series connected or daisy chained to other power strips or extension cords. Extension cords, including power strips or multiple adaptors used in health care, shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction, one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4 of NFPA 70, 1999 Edition and 7-5.1.2.6 & 7-6.2.1.5 of NFPA 99, 1999 Edition.

At 12:45 p.m., a refrigerator was observed to be plugged into a power strip that was hanging unsecured and plugged into another power strip (daisy chained) that was secured to the wall in the Emergency Department.

Based on observations made on September 10, 2012, the facility did not maintain the electrical system and/or its components in accordance with the standards of the National Electrical Code, NFPA 70, 1999 Edition and/or interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings include:

Extension cords (including power strips) or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4(b)(3) of NFPA 70.

Article 240-22 of NFPA 70 ,1999 edition, states that no overcurrent device shall be connected in series with any conductor that is intentionally grounded. United Laboratories (UL) listing guidelines for relocatable power taps/power strips, being XBYS, notes that these strips are not intended to be series connected or daisy chained to other power strips or extension cords. Extension cords, including power strips or multiple adaptors used in health care, shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction, one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4 of NFPA 70, 1999 edition and 7-5.1.2.6 & 7-6.2.1.5 of NFPA 99, 1999 edition.

1. At 9:25 a.m., a power strip was observed to be hanging unsecured below a desk in the Activities Room. The power strip had multiple cords plugged into it.

2. At 9:26 a.m., a microwave and small oven were observed to be plugged into a power strip in the Activities Room.

3. At 9:45 a.m., a standard size refrigerator and a microwave were observed to be plugged into a power strip in the staff break room.