HospitalInspections.org

Based on observations, the facility failed to maintain illumination at the exit discharges.

The findings included:

Observation on 8/16/17 at 12:00 PM, revealed 1 bulb light fixtures at the following exit discharges:
a. 200 hall exit.

b. 300 hall exit.

c. 400 hall exit.
National Fire Protection Association (NFPA) 101, 19.2.8 (2012 Ed.)
NFPA 101, 7.8.1.4 (2012 Ed.)

The maintenance supervisor was present when the deficiency was identified and the quality assurance director acknowledged the deficiency during the exit conference on 7/16/17.

Based on observations, the facility failed to maintain the kitchen vent and hood system.

The findings included:

Observation on 8/16/17 at 11:48 AM, revealed the filters and baffles were coated in grease. The cleaning label stated the last cleaning was performed on 9/8/16 and the next cleaning was scheduled for 12/2016. There were no records or evidence of a system cleaning in 12/2016.
National Fire Protection Association (NFPA) 101, 19.3.2.5.1 (2012 Ed.)
NFPA 101, 9.2.3 (2012 Ed.)
NFPA 96, 11.6.1 (2011 Ed.)

This finding was verified by the maintenance supervisor and acknowledged by the quality assurance director during the exit conference on 8/16/17.

Based on records review, the facility failed to maintain the sprinkler system.

The findings included:

During the records review on 8/16/17 from 9:10 AM until 10:30 AM, the facility could not provide documentation on replacement of pressure gauges every 5 years and the 5 year internal sprinkler line inspection.
National Fire Protection Association (NFPA) 101, 19.3.5.1 (2012 Ed.)
NFPA 101, 9.7.5 (2012 Ed.)
NFPA 25, 5.3.2 (2011 Ed.)
NFPA 25, 6.1.5 (2011 Ed.)
NFPA 25, 14.2.1 (2011 Ed.)

This finding was verified and acknowledged during the records review and exit conference by the quality assurance director on 8/16/17.

National Fire Protection Association (NFPA) 99, 5.1.14.2 (2012 Ed.) Maintenance of Medical Gas, Vacuum, WAGD, and Medical Support Gas Systems.
5.1.14.2.1* General. Health care facilities with installed medical gas, vacuum,WAGD, or medical support gas systems, or combinations thereof, shall develop and document periodic maintenance programs for these systems and their subcomponents as appropriate to the equipment installed.
5.1.14.2.2 Maintenance Programs.
5.1.14.2.2.1 Inventories. Inventories of medical gas, vacuum, WAGD, and medical support gas systems shall include at least
all source subsystems, control valves, alarms, manufactured assemblies containing patient gases, and outlets.
5.1.15* Category 1 Maintenance. Facilities shall have a routine
maintenance program for their piped medical gas and vacuum
systems.

Based on records review and interview, the facility could not provide a risk assessment of the medical gas and vacuum systems.

The findings included:

During the document review on 8/16/17 from 9:10 AM until 10:15 AM, the facility could not provide a preventive maintenance or testing schedule assessment for the complete medical gas and vacuum systems.
NFPA 99, 5.1.14.2.1, 5.1.14.2.2, 5.1.15 (2012 Ed.)

This finding was verified and acknowledged during the records review and exit conference by the quality assurance director on 8/16/17.

National Fire Protection Association (NFPA) 99, 5.1.14.2.3 (2012 Ed.) Inspection and Testing Operations.
NFPA 90, 5.1.14.2.3.1 General. The elements in 5.1.14.2.2.2 through 5.1.15 shall be inspected or tested as part of the maintenance
program as follows:
(1)*Medical air source, as follows:
(a) Room temperature
(b) Shaft seal condition
(c) Filter condition
(d) Presence of hydrocarbons
(e) Room ventilation
(f) Water quality, if so equipped
(g) Intake location
(h) Carbon monoxide monitor calibration
(i) Air purity
(j) Dew point
GAS AND VACUUM SYSTEMS 99-55
(2)*Medical vacuum source - exhaust location
(3) WAGD source - exhaust location
(4)*Instrument air source - filter condition
(5)*Manifold sources (including systems complying with
5.1.3.5.10, 5.1.3.5.11, 5.1.3.5.12, and 5.1.3.5.13), as follows:
(a) Ventilation
(b) Enclosure labeling
(6) Bulk cryogenic liquid source inspected in accordance
with NFPA 55, Compressed Gases and Cryogenic Fluids Code
(7) Final line regulation for all positive pressure systems -
delivery pressure
(8)*Valves - labeling
(9)*Alarms and warning systems-lamp and audio operation
(10) Alarms and warning systems, as follows:
(a) Master alarm signal operation
(b) Area alarm signal operation
(c) Local alarm signal operation
(11)*Station outlets/inlets, as follows:
(a) Flow
(b) Labeling
(c) Latching/delatching
(d) Leaks

Based on records review and interview, the facility failed to provide inspection and testing of the medical gas and vacuum systems.

The findings included:

During the document review on 8/16/17 from 9:10 AM until 10:15 AM, the facility could not provide records of testing the complete medical gas and vacuum system.
NFPA 99, 5.1.14.2.3.1 (2012 Ed.)

This finding was verified and acknowledged during the records review and exit conference by the quality assurance director on 8/16/17

National Fire Protection Association (NFPA) 110, 7.3.1 (2010 Ed.)
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.
7.3.2 The emergency lighting charging system and the normal service room lighting shall be supplied from the load side
of the transfer switch.

Based on observations, the facility failed to maintain the transfer switch room.

The findings included:

Observation on 3/19/17 at 12:30 PM, revealed the transfer switch room did not have a battery back up emergency light.
National Fire Protection Association (NFPA) 110, 7.3.1 (2010 Ed.)

The maintenance supervisor was present when the deficiency was identified and the quality assurance director acknowledged the deficiency during the exit conference on 8/16/17.

Based on observations, the facility failed to maintain oxygen cylinder storage.

The findings included:

Observation on 8/16/17 at 12:20 PM, revealed the following oxygen cylinders in the storage room were not stored per cylinder storage requirements:
a. were not segregated or labeled as "empty" or "full".
National Fire Protection Association (NFPA) 99, 11.6.5.2 (2012 Ed.)

b. 1 of 2 cylinder racks were constructed of wood.
(NFPA) 99, 11.3.2.1 (2012 Ed.)

c. 3 of 11 oxygen cylinders were not secured.
National Fire Protection Association 99, 11.6.2.3. (11) (2012 Ed.)

The maintenance supervisor was present when the deficiencies were identified and the quality assurance director acknowledged the deficiencies during the exit conference on 8/16/17.