HospitalInspections.org

Based on document review and staff interview it was determined the facility failed to maintain emergency lighting in accordance with National Fire Protection Association 101. Facility census 1.

Findings include:

1. Document review on 04/16/18 at 2:50 p.m. revealed no evidence of the required monthly or annual emergency light testing.

2. The Facilities Director and Environmental Services Coordinator were both present on 04/16/18 and agreed the testing would need completed per code.

Based on observation and staff interview it was determined the facility failed to provide exit lighting in accordance with National Fire Protection Association 19.2.10.1. Facility census 1.

Findings include:

1. Facility tour on 04/17/18 at 3:00 p.m. revealed exit directional lighting was missing upon leaving radiology in both directions. Exit lighting needs added to direct the flow of traffic toward the emergency department and front entrance. This needs to be accomplished by adding four (4) exit lights. One (1) will need placed in the clinic approach hallway directing traffic toward the front of the building. The other three (3) will need added in the emergency department hallway directing traffic from the radiology exit toward the front entrance and the emergency department.

2. The Facilities Director and Environmental Services Coordinator were both present on 04/17/18 and agreed the additional lighting would need to be added.

Based on observation and staff interview it was determined the facility failed to maintain hazardous areas according to the National Fire Protection Association. Facility census 1.

Findings include:

1. Facility tour on 04/17/18 at 1:02 p.m. revealed two (2) doors not closing and latching from dirty laundry to the hall.

2. Facility tour on 04/17/18 at 1:05 p.m. revealed the housekeeping storage room was open at the top approximately eighteen (18) inches and sharing sprinkler protection with the employee break room. All storage rooms must be sealed with automatic closing doors.

3. Facility tour on 04/17/18 at 1:39 p.m. revealed a storage room door near the main nurse station that did not close and latch.

4. Facility tour on 04/17/18 at 1:59 p.m. revealed a storage room near the beauty shop that did not close and latch.

5. Facility tour on 04/17/18 at 2:16 p.m. revealed the phone/storage room near the main electrical room did not have an automatic closer.

6. The Facilities Director and Environmental Services Coordinator were both present on 04/17/18 and agreed the aforementioned deficiencies would need to be corrected.

Based on document review and staff interview it was determined the facility failed to ensure appropriate emergency forces notification of the fire alarm system in accordance with National Fire Protection Association 101. Facility census 1.

Findings include:

1. Document review on 04/16/18 at 1:08 p.m. revealed there was no entry in the fire drill documentation that alarms were being successfully received by the fire alarm monitoring company.

2. The Facilities Director and Environmental Services Coordinator were both present on 04/16/18 and agreed the above deficiency would need to be corrected.

Based on observation and staff interview it was determined the facility failed to maintain the sprinkler system according to National Fire Protection Association. Facility census 1.

Findings include:

1. An inspection above the suspended ceiling on 04/18/18 at 9:10 a.m. revealed wires being supported by the sprinkler piping near the radiology sleep room.

2. An inspection above the suspended ceiling on 04/18/18 at 9:16 a.m. revealed wires being supported by the sprinkler piping near mammography.

3. An inspection above the suspended ceiling on 04/18/18 at 9:21 a.m. revealed wires and ceiling tile being supported by the sprinkler piping near the radiology manager's area.

4. An inspection above the suspended ceiling on 04/18/18 at 9:28 a.m. revealed wires being supported by the sprinkler piping above the emergency room corridor.

5. An inspection above the suspended ceiling on 04/18/18 at 9:32 a.m. revealed wires being supported by the sprinkler piping near the laboratory.

6. An inspection above the suspended ceiling on 04/18/18 at 9:34 a.m. revealed wires being supported by the sprinkler piping near the clinic entrance.

7. An inspection above the suspended ceiling on 04/18/18 at 9:47 a.m. revealed wires being supported by the sprinkler piping near the Director of Nursing's office.

8. An inspection above the suspended ceiling on 04/18/18 at 9:49 a.m. revealed wires being supported by the sprinkler piping near the nurse's station.

9. An inspection above the suspended ceiling on 04/18/18 at 9:51 a.m. revealed wires being supported by the sprinkler piping near Room 405.

10. The Facilities Director and Environmental Services Coordinator were both present on 04/18/18 and agreed the aforementioned deficiencies would need to be corrected.

Based on observation and staff interview it was determined the facility failed to maintain fire extinguishers according to National Fire Protection Association 10. Facility census 1.

Findings include:

1. Facility tour on 04/17/18 at 2:14 p.m. revealed there was a fire extinguisher in the shredder room blocked by storage.

2. Facility tour on 04/18/18 at 3:14 p.m. revealed there was a fire extinguisher in the Radiology Department mounted with the top of the extinguisher exceeding five (5) feet.

3. The Facilities Director and Environmental Services Coordinator were both present on 04/17/18 and 04/18/18 and agreed the extinguishers would need to be maintained per code.

Based on observation and staff interview it was determined the facility failed to provide the correct door assembly to accommodate a two (2) hour rated wall as required by the National Fire Protection Association. Facility census 1.

Findings include:

1. Facility tour on 04/18/18 at 9:40 a.m. revealed the double doors leading into the clinic was lacking the required ninety (90) minute rated assembly.

2. Facility tour on 04/18/18 at 9:41 a.m. revealed the bathroom door near the clinic double doors was lacking the required ninety (90) minute rated assembly.

3. The Facilities Director and Environmental Services Coordinator were both present on 04/18/18 and agreed the door assemblies would need to be corrected to the required rating.

Based on observation and staff interview, the facility failed to maintain smoke barrier construction to a 1/2-hour fire resistance rating. Facility census 1.

Findings include:

1. An inspection above the suspended ceiling near the IT closet in the main hallway on 04/17/18 at 1:22 p.m. revealed there was orange foam sealing the smoke wall. The foam was not approved for healthcare use and will need replaced with an approved fire caulk.

2. An inspection above the suspended ceiling near the Radiology Manager's area on 04/18/18 at 9:23 a.m. revealed there was space around the sprinkler piping and wires that need to be sealed.

3. An inspection above the suspended ceiling on 04/18/18 at 9:53 a.m. revealed there was a hole in the smoke wall near Physical Therapy that needs to be sealed.

4. The Facilities Director and Environmental Services Coordinator were both present on 04/17/18 and 04/18/18 and agreed the aforementioned deficiencies would need to be corrected.

Based on document review and staff interview it was determined the facility failed to test fire door assemblies on an annual basis according to National Fire Protection Association 80. Facility census 1.

Findings include:

1. Document review on 04/18/18 at 1:04 p.m. revealed there was no evidence of fire door assembly testing.

2. The Facilities Director and Environmental Services Coordinator were both present on 04/18/18 and agreed the testing has not been performed.

Based on observation and staff interview it was determined the facility failed to prohibit portable space heating devices. Facility census is 1.

Findings include:

1. Facility tour on 04/18/18 at 1:31 p.m. revealed there was a portable electric space heater in use in the Occupational Therapy Department. The heater utilized an element exceeding two hundred and twelve (212) degrees Fahrenheit.

2. Facility tour on 04/18/18 at 2:03 p.m. revealed there was a portable electric space heater in use in the Cardiopulmonary Waiting Area. The heater utilized an element exceeding two hundred and twelve (212) degrees Fahrenheit.

3. The Environmental Services Coordinator was present on 04/18/18 and agreed the heaters were not allowed and would be removed.

Based on document review and staff interview and staff interview it was determined the facility failed to provide inspection and testing of the gas and vacuum piped systems as required by the National Fire Protection Association 99. Facility census 1.

Findings include:

1. Document review on 04/16/18 at 12:48 p.m. revealed the last annual gas certification performed was in December 2016.

2. The Facilities Director was present on 04/16/18 and agreed the inspection would need to be completed.

Based on observation and staff interview it was determined the facility failed to maintain electrical wiring per National Fire Protection Association 70. Facility census 1.

Findings include:

1. Facility tour of the electric room near the generator on 04/17/18 at 2:18 p.m. revealed there was storage in front of electrical panels.

2. Facility tour of the new hire orientation room on 04/17/18 at 2:37 p.m. revealed there was storage in front of electrical panels.

3. A tour of the boiler room on 04/17/18 at 3:28 p.m. revealed there were two (2) junction boxes needing connectors removed and knock out covers added. Additionally, there was a six by six (6x6) inch junction box missing three (3) of the four (4) screws, allowing a gap between the cover and box, exposing wires.

4. Facility tour of the administrative meeting room on 04/16/18 at 2:50 p.m. revealed there was a computer monitor in use behind the wall mounted television missing the entire side panel cover, allowing wiring and components to be exposed.

5. A tour above the suspended ceiling in the corridor between radiology and the clinic on 04/18/18 at 8:50 a.m. revealed there was a flexible metal conduit separated from the junction box, allowing wiring to be exposed.

6. A tour above the suspended ceiling on 04/18/18 at 9:22 a.m. revealed there was a junction box cover missing above the Radiology Manager's desk.

7. A tour above the suspended ceiling on 04/18/18 at 9:29 a.m. revealed there was a wire exiting a junction box between the cover and box and then wrapped around the conduit in the emergency department corridor.

8. A tour above the suspended ceiling on 04/18/18 at 9:11 a.m. revealed there was electric wiring open ended without the correct termination, allowing conductors to be exposed near the radiology sleep room.

9. The Facilities Director and Environmental Services Coordinator were both present on 04/18/18 and agreed the aforementioned deficiencies would need to be corrected.

Based on observation and staff interview it was determined the facility failed to provide ground fault circuit interrupters within six (6) feet of a sink. Facility census 1.

Findings include:

1. A facility tour on 04/17/18 at 10:30 a.m. revealed there were three (3) receptacles within six (6) feet of a sink in the food preparation line lacking ground fault protection.

2. The Environmental Services Coordinator was present on 04/17/18 and agreed the aforementioned citations would need to be corrected.

Based on document review and staff interview it was determined the facility failed to maintain and test electrical receptacles at patient bed locations in accordance with National Fire Protection Association 101. Facility census 1.

Findings include:

1. Document review on 04/16/18 at 1:50 p.m. revealed receptacle testing was incomplete. All areas must be tested annually and damaged receptacles must show replace/retest.

2. The Facilities Director was present on 04/16/18 and agreed the aforementioned deficiency would need to be corrected.

Based on document review and staff interview it was determined the facility failed to complete electrical testing for portable patient-care related equipment. Facility census 1.

Findings include:

1. Document review on 04/16/18 at 2:02 p.m. revealed the facility could not provide evidence of electrical safety testing for all patient-care related equipment.

2. The Facilities Director was present on 04/16/18 and agreed the aforementioned deficiency would need to be corrected.