HospitalInspections.org

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Based on the observation during the survey on 05/25/2016 the facility failed to maintain a miscellaneous opening. Findings include:

First Floor
The Pharmacy pass-through window was observed with an opening to speak through that was located at 5'-0" above the finished floor. The room ceiling was approximately 8'-6".

The deficiency impacted 1 of 8 smoke compartments.
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Review of 2000 NFPA 101, 19.3.6.5 In other than smoke compartments containing patient bedrooms, miscellaneous openings such as mail slots, pharmacy pass-through windows, laboratory pass-through windows, and cashier pass-through windows shall be permitted to be installed in vision panels or doors without special protection, provided that the aggregate area of openings per room does not exceed 20 in.2 (130 cm2), and the openings are installed at or below half the distance from the floor to the room ceiling.
Exception: For rooms protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, the aggregate area of openings per room shall not exceed 80 in.2 (520 cm2).
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* This tag is a repeat deficiency from the last survey.

Based on the observation of the smoke barriers on 05/25/2016 the facility failed to maintain a smoke barrier smoke resistive and with a thirty minute fire rating. Findings include:

Second Floor
1. The smoke barrier above the smoke doors for the entrance to the back side of I.C.U. was observed with an unsealed penetration of a conduit end with three red wires and one yellow wire.
2. The smoke barrier above the smoke doors by the elevator was observed with:
a. An unsealed penetration of blue and yellow wires
b. An unidentified white substance partially around the same blue and yellow wires

The deficiency impacted 2 of 8 smoke compartments.
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Review of 2000 NFPA 101, 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

Review of 2000 NFPA 101, 8.3.1* General. Where required by Chapters 12 through 42, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke.
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Based on the observation of the hazardous areas on 05/25/2016 the facility failed to maintain a hazardous area. Findings include:

First Floor
The Medical Records Storage Room off of the Scan Room was over 50 sq. ft. with combustibles the door did not have a self-closing device.

The deficiency impacted 1 of 8 smoke compartments.
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Review of 2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.
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A) Based on the observation of the exit signs on 05/25/2016 the facility failed to maintain the exit signs. Findings include:

The exit sign over the exit door by Resident Room 132, was not fully illuminated.

The deficiency impacted 1 of 8 smoke compartments.

NFPA 101, 7.10.5 Continuous illumination of exit signs.




27382

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B) Based on the observation of the exit signs on 05/25/2016 the facility failed to maintain the exit signs' directional indicators. Findings include:

First Floor
The following locations had exit signs with directional indicators indicating a false direction of travel to reach the nearest exit:
1. In the OR Suite between Recovery and the Clean Up Room
2. In the Behavioral Psych. Unit

The deficiency impacted 2 of 8 smoke compartments.
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Review of 2000 NFPA 101, 7.10.2 A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.

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Based on the observation during the survey on 05/25/2016 the facility failed to maintain the ceiling tiles for the automatic sprinkler system. Findings include:

First Floor
1. The "Old Administration Bathroom" was observed missing ceiling tiles:
a. The bathroom
b. The closet
2. EHR Nursing Office was observed with a ceiling tile with an approximately 6" in diameter hole

The deficiency impacted 2 of 8 smoke compartments.
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Review of 1999 NFPA 13, 5-8.4.2 Deflectors of sprinklers shall be aligned parallel to ceilings or roofs.

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Based on observation on 5/25/2016, the facility failed to maintain the designated smoking area. Findings include:

1. Excessive amount of smoking materials was observed discarded on the ground, in the designated smoking area for the Behavioral Unit.

2. Metal container with self-closing cover devices, was not provided in the designated smoking area for the Behavioral Unit.


NFPA 101, 19.7.4 Ashtrays of noncombustible material and safe design, and metal self-closing containers for disposing of cigarette butts and ashes from ashtrays, shall be provided.

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Based on observation on 5/25/2016, the facility failed to adequately perform testing and inspection of the dietary hood extinguishment system. Findings include:

During survey, the provided documentation for the monthly inspection of the hood system was the inspection card attached to the pull station of the hood extinguishing system. This card was observed with space on the reverse side to date and initial each month an inspection was conducted by facility staff. This side of the inspection card was blank. Last six month inspection was conducted 11/2015.

The deficiency impacted 8 of 8 smoke compartments.


NFPA 17, 9-2.1- On a monthly basis, inspection shall be conducted in accordance with the
manufacturer 's listed installation and maintenance manual or owner 's manual. As a minimum,
this "quick check " or inspection shall include verification of the following:
(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) The system shows no physical damage or condition that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blow-off caps, where provided, are intact and undamaged.
(h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.

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Based on the observation during the survey on 05/25/2016 the facility failed to maintain freestanding cylinders. Findings include:

First Floor
Oxygen cylinders were observed unsecured in the following locations:
1. The Doctors' Lounge (ER Sleep Room) - one unsecured oxygen cylinder.
2. X-ray Room 2 - three unsecured oxygen cylinders.

The deficiency impacted 1 of 8 smoke compartments.
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Review of 1999 NFPA 99, 4-3.5.2.1 Gases in Cylinders and Liquefied Gases in Containers - Level 1.
(a) * Handling of Gases. Administrative authorities shall provide regulations to ensure that standards for safe practice in the specifications for cylinders; marking of cylinders, regulators, and valves; and cylinder connections have been met by vendors of cylinders containing compressed gases supplied to the facility.
(b) Special Precautions - Oxygen Cylinders and Manifolds. Great care shall be exercised in handling oxygen to prevent contact of oxygen under pressure with oils, greases, organic lubricants, rubber, or other materials of an organic nature. The following regulations, based on those of the CGA Pamphlet G-4, Oxygen, shall be observed:
27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

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Based on observation during the survey on 04/19/2016, the facility failed to maintain the electrical wiring and equipment in accordance with the National Electrical Code (NFPA 70). Findings include:

Based on observation on 04/19/2016 the facility failed to maintain an adequate number and/or location of electrical receptacles in the business office. As examples see:

First Floor
1. The Business Office Manager's Office was observed with:
a. A refrigerator plugged into a power strip
b. A microwave plugged into a different power strip
2. The QA Office was observed missing an electrical cover plate for an electrical outlet by the desk
3. The X-ray Breakroom was observed with a refrigerator plugged into a power strip

The deficiency imapcted 2 of 8 smoke compartments.
______________

Review of the printed statement on the 2567 for K- 147, Electrical wiring and equipment shall be in accordance with National Electrical Code (NFPA 70).

Review of 2000 NFPA 101, 9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

Review of 1999 NFPA 70, 370-25. Covers and Canopies
In completed installations, each box shall have a cover, faceplate, or fixture canopy.

Review of 1999 NFPA 70, 400-7 (b) Attachment Plugs. Where used as permitted in subsections (a)(3), (a)(6), and (a)(8), each flexible cord shall be equipped with an attachment plug and shall be energized from a receptacle outlet.

Review of 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

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Based on the observation during the survey on 05/25/2016 the facility failed to maintain a miscellaneous opening. Findings include:

First Floor
The Pharmacy pass-through window was observed with an opening to speak through that was located at 5'-0" above the finished floor. The room ceiling was approximately 8'-6".

The deficiency impacted 1 of 8 smoke compartments.
______________

Review of 2000 NFPA 101, 19.3.6.5 In other than smoke compartments containing patient bedrooms, miscellaneous openings such as mail slots, pharmacy pass-through windows, laboratory pass-through windows, and cashier pass-through windows shall be permitted to be installed in vision panels or doors without special protection, provided that the aggregate area of openings per room does not exceed 20 in.2 (130 cm2), and the openings are installed at or below half the distance from the floor to the room ceiling.
Exception: For rooms protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, the aggregate area of openings per room shall not exceed 80 in.2 (520 cm2).
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* This tag is a repeat deficiency from the last survey.

Based on the observation of the smoke barriers on 05/25/2016 the facility failed to maintain a smoke barrier smoke resistive and with a thirty minute fire rating. Findings include:

Second Floor
1. The smoke barrier above the smoke doors for the entrance to the back side of I.C.U. was observed with an unsealed penetration of a conduit end with three red wires and one yellow wire.
2. The smoke barrier above the smoke doors by the elevator was observed with:
a. An unsealed penetration of blue and yellow wires
b. An unidentified white substance partially around the same blue and yellow wires

The deficiency impacted 2 of 8 smoke compartments.
______________

Review of 2000 NFPA 101, 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

Review of 2000 NFPA 101, 8.3.1* General. Where required by Chapters 12 through 42, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke.
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Based on the observation of the hazardous areas on 05/25/2016 the facility failed to maintain a hazardous area. Findings include:

First Floor
The Medical Records Storage Room off of the Scan Room was over 50 sq. ft. with combustibles the door did not have a self-closing device.

The deficiency impacted 1 of 8 smoke compartments.
______________

Review of 2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.
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A) Based on the observation of the exit signs on 05/25/2016 the facility failed to maintain the exit signs. Findings include:

The exit sign over the exit door by Resident Room 132, was not fully illuminated.

The deficiency impacted 1 of 8 smoke compartments.

NFPA 101, 7.10.5 Continuous illumination of exit signs.




27382

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B) Based on the observation of the exit signs on 05/25/2016 the facility failed to maintain the exit signs' directional indicators. Findings include:

First Floor
The following locations had exit signs with directional indicators indicating a false direction of travel to reach the nearest exit:
1. In the OR Suite between Recovery and the Clean Up Room
2. In the Behavioral Psych. Unit

The deficiency impacted 2 of 8 smoke compartments.
______________

Review of 2000 NFPA 101, 7.10.2 A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.

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Based on the observation during the survey on 05/25/2016 the facility failed to maintain the ceiling tiles for the automatic sprinkler system. Findings include:

First Floor
1. The "Old Administration Bathroom" was observed missing ceiling tiles:
a. The bathroom
b. The closet
2. EHR Nursing Office was observed with a ceiling tile with an approximately 6" in diameter hole

The deficiency impacted 2 of 8 smoke compartments.
______________

Review of 1999 NFPA 13, 5-8.4.2 Deflectors of sprinklers shall be aligned parallel to ceilings or roofs.

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Based on observation on 5/25/2016, the facility failed to maintain the designated smoking area. Findings include:

1. Excessive amount of smoking materials was observed discarded on the ground, in the designated smoking area for the Behavioral Unit.

2. Metal container with self-closing cover devices, was not provided in the designated smoking area for the Behavioral Unit.


NFPA 101, 19.7.4 Ashtrays of noncombustible material and safe design, and metal self-closing containers for disposing of cigarette butts and ashes from ashtrays, shall be provided.

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Based on observation on 5/25/2016, the facility failed to adequately perform testing and inspection of the dietary hood extinguishment system. Findings include:

During survey, the provided documentation for the monthly inspection of the hood system was the inspection card attached to the pull station of the hood extinguishing system. This card was observed with space on the reverse side to date and initial each month an inspection was conducted by facility staff. This side of the inspection card was blank. Last six month inspection was conducted 11/2015.

The deficiency impacted 8 of 8 smoke compartments.


NFPA 17, 9-2.1- On a monthly basis, inspection shall be conducted in accordance with the
manufacturer 's listed installation and maintenance manual or owner 's manual. As a minimum,
this "quick check " or inspection shall include verification of the following:
(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) The system shows no physical damage or condition that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blow-off caps, where provided, are intact and undamaged.
(h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.

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Based on the observation during the survey on 05/25/2016 the facility failed to maintain freestanding cylinders. Findings include:

First Floor
Oxygen cylinders were observed unsecured in the following locations:
1. The Doctors' Lounge (ER Sleep Room) - one unsecured oxygen cylinder.
2. X-ray Room 2 - three unsecured oxygen cylinders.

The deficiency impacted 1 of 8 smoke compartments.
______________

Review of 1999 NFPA 99, 4-3.5.2.1 Gases in Cylinders and Liquefied Gases in Containers - Level 1.
(a) * Handling of Gases. Administrative authorities shall provide regulations to ensure that standards for safe practice in the specifications for cylinders; marking of cylinders, regulators, and valves; and cylinder connections have been met by vendors of cylinders containing compressed gases supplied to the facility.
(b) Special Precautions - Oxygen Cylinders and Manifolds. Great care shall be exercised in handling oxygen to prevent contact of oxygen under pressure with oils, greases, organic lubricants, rubber, or other materials of an organic nature. The following regulations, based on those of the CGA Pamphlet G-4, Oxygen, shall be observed:
27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

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Based on observation during the survey on 04/19/2016, the facility failed to maintain the electrical wiring and equipment in accordance with the National Electrical Code (NFPA 70). Findings include:

Based on observation on 04/19/2016 the facility failed to maintain an adequate number and/or location of electrical receptacles in the business office. As examples see:

First Floor
1. The Business Office Manager's Office was observed with:
a. A refrigerator plugged into a power strip
b. A microwave plugged into a different power strip
2. The QA Office was observed missing an electrical cover plate for an electrical outlet by the desk
3. The X-ray Breakroom was observed with a refrigerator plugged into a power strip

The deficiency imapcted 2 of 8 smoke compartments.
______________

Review of the printed statement on the 2567 for K- 147, Electrical wiring and equipment shall be in accordance with National Electrical Code (NFPA 70).

Review of 2000 NFPA 101, 9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

Review of 1999 NFPA 70, 370-25. Covers and Canopies
In completed installations, each box shall have a cover, faceplate, or fixture canopy.

Review of 1999 NFPA 70, 400-7 (b) Attachment Plugs. Where used as permitted in subsections (a)(3), (a)(6), and (a)(8), each flexible cord shall be equipped with an attachment plug and shall be energized from a receptacle outlet.

Review of 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.