HospitalInspections.org

Surveyor: Compton, Robert
Based on observation, the facility failed to maintain the walls and ceiling of the building in a condition that would resist the passage of smoke and fire. This was evidenced by observed unsealed penetrations. This affected staff and patients in four of five smoke compartments within the facility and could potentially result in the spread of smoke and/or fire from one area to another.

Findings:

During a tour of the facility with the Director of Plant Operations on 4/16/13, penetrations were observed in the walls.

1. At 12:35 p.m., there was an approximately one-half inch unsealed penetration in the southwest corner of the ceiling in the Conference Room. Blue data cables were traveling through the penetration.

2. At 12:53 p.m., there was an approximately three inch round damaged area behind the door in the south wall of the Auxiliary Storage Room. This damaged portion of the wall was where the doorknob hit the wall when the door was fully opened.

3. At 1:20 p.m., the sprinkler escutcheon rings were not flush to the ceiling in the Utility Room across from the Nurses' Station. This caused an approximately one-half inch unsealed penetration around the sprinkler pipe.

4. At 1:23 p.m., there were two unsealed penetrations in the ceiling in the Pharmacy. One penetration was in the southeast corner of the room and the other penetration was in southeast corner of the Refrigerator Room in the Pharmacy.

5. At 1:36 p.m., there were two approximately one-quarter inch unsealed penetrations in the west corner of the ceiling of the Central Supply Room.

6. At 1:52 p.m., there was an approximately one-quarter inch unsealed penetration in the ceiling of the Emergency Room near the clock.

7. At 2:05 p.m., the Generator Room had three unsealed penetrations in a wall and the ceiling.
One penetration was located in the ceiling near the attic access door and was approximately four by eight inches in size.
The other penetrations were located in the northwest corner of the room and were one and one-half inch and one inch in size, respectively.

Based on observation, the facility failed to maintain corridor doors free from obstructions to closing. This was evidenced by corridor doors that failed to close and latch when tested. It is critical that corridor doors close and latch to prevent the spread of smoke and/or fire into other areas of the facility. This deficient practice affected staff and patients in one of five smoke compartments.


Findings:

During a tour of the facility with the Director of Plant Operations, doors were observed.

1. At 1:20 p.m., the Hepa Filter Room corridor door did not positively latch when tested by releasing the door from an open position.

Surveyor: Compton, Robert
Based on observation, the facility failed to maintain all exit signs. This was evidenced by a photoluminescent exit sign that was past its replacement date. This affected all staff and patients in two of five smoke compartments within the facility and could potentially result in confusion or a delay in evacuation in the event of an emergency.

NFPA 101 Life Safety Code, 2000 edition
7.10.5.2 Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.

Findings:

During a tour of the facility with the Director of Plant Operations on 4/16/13, exit signs were observed.

At 1:00 p.m., the photoluminescent exit sign located in the corridor above the cross-corridor doors near the Dining Room had a replacement date of 4/2000. When asked, Staff stated that the sign did still produce illumination.

Based on observation and staff interview, the facility failed to maintain the fire-rated construction of its smoke/fire barrier walls. This was evidenced by an observed unsealed penetration. This affected two of five smoke compartments and could potentially result in smoke and/or fire spreading from one smoke compartment to another.

NFPA 101 Life Safety Code, 2000 edition
8.3.6.1: Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
1. The space between the penetrating item and the smoke barrier shall meet one following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
2. Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b It shall be protected by an approved device that is designed for the specific purpose.
3. Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with the Director of Plant Operations on 4/16/13, smoke/fire barrier walls were observed.

1. Between 2:45 and 3:30 p.m., the smoke/fire barrier wall in the attic above the Human Resources Office had an approximately two inch by four inch unsealed penetration through the concrete wall. This penetration was located in the wall to the right of center. Staff stated that the penetration was going to be sealed with a cableway fire stop unit. Staff stated that it was ordered but had not been received yet.

Based on observation and interview, the facility failed to protect its hazardous area enclosures. This was evidenced by rooms which contained combustible materials that posed a degree of hazard greater than that normal to the general occupancy of the building that were not equipped with self-closing mechanisms on the doors. This deficient practice affected all staff and patients in two of four smoke compartments within the facility and could potentially result in the spread of smoke and/or fire.


NFPA 99 Health Care Facilities, 1999 edition
10.5.1
Laboratories employing quantities of flammable, combustible, or hazardous materials that are considered a severe hazard are protected in accordance with NFPA 99. (Laboratories that are not considered to be a severe hazard meet the provisions of K29.) Laboratories in health care occupancies and medical and dental offices are in accordance with NFPA 99, Standard for Health Care Facilities.


Findings:

During a tour of the facility with the Director of Plant Operations, hazardous area enclosures were observed.

1. At 12:57 p.m., the storage room near Purchasing did not have a self-closing door. This room was approximately six feet wide by ten feet long and contained combustible storage.

2. At 1:56 p.m., the Laboratory corridor door did not have a self-closure on the door.

Based on observation, the facility failed to ensure that exits are readily accessible at all times as evidenced by exit doors that were equipped with a double-action fastening device, more than one fastening device, and fastening devices that were located 48 inches above the floor. This deficient practice affected all staff and patients in one of one outpatient building and could potentially result in injury or a delay in egress in the event of an emergency.


NFPA 101 Life Safety Code, 2000 edition
3.3.121* Means of Egress. A continuous and unobstructed way of travel from any point in a building or structure to a public way consisting of three separate and distinct parts: (1) the exit access, (2) the exit, and (3) the exit discharge.

39.2.2.2 Doors.
39.2.2.2.1 Doors complying with 7.2.1 shall be permitted.
39.2.2.2.2* Locks complying with Exception No. 2 to 7.2.1.5.1 shall be permitted only on principal entrance/exit doors.

7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
Exception No. 1: This requirement shall not apply where otherwise provided in Chapters 18 through 23.
Exception No. 2: Exterior doors shall be permitted to have key-operated locks from the egress side, provided that the following criteria are met:
(a) Permission to use this exception is provided in Chapters 12 through 42 for the specific occupancy.
(b) On or adjacent to the door, there is a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high on a contrasting background that reads as follows:

THIS DOOR TO REMAIN UNLOCKED WHEN THE BUILDING IS OCCUPIED

(c) The locking device is of a type that is readily distinguishable as locked.
(d) A key is immediately available to any occupant inside the building when it is locked.
Exception No. 2 shall be permitted to be revoked by the authority having jurisdiction for cause.
Exception No. 3: Where permitted in Chapters 12 through 42, key operation shall be permitted, provided that the key cannot be removed when the door is locked from the side from which egress is to be made.

7.2.1.5.4* A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable
with not more than one releasing operation.

Findings:

Physical Therapy at Healing Hands Close to Home

1. At 2:41 p.m., the northwest exit door had a double-action fastening device as well as a fastening device located 58 inches above the floor.

2. At 2:43 p.m., the front Lobby exit had a double-action fastening device as well as a fastening device located 58 inches above the floor.

Based on observation, the facility failed to provide battery-powered emergency illumination. This was evidenced by the failure to provide a battery-powered emergency lighting unit in an anesthetizing location. This deficient practice affected one of one operating room and could potentially result in a loss of lighting in the operating room during the ten seconds of time (or longer if the generator fails to start) that is allowed for the back-up generator to transfer power during power outages.

NFPA 101 Life Safety Code, 2000 edition
19.3.2.3 Anesthetizing Locations. Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99 3-3.2.1.2, 5 (e)
5. Wiring in Anesthetizing Locations
e. Battery-powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e)

NFPA 70, National Electrical Code
NFPA 700-12 (e)
(e) Unit Equipment. Individual unit equipment for emergency illumination shall consist of the following:
(1) A rechargeable battery
(2) A battery charging means
(3) Provisions for one or more lamps mounted on the equipment, or shall be permitted to have terminals for remote lamps, or both, and
(4) A relaying device arranged to energize the lamps automatically upon failure of the supply to the unit equipment.

Findings:.

During a tour of the facility with the Director of Plant Operations on 4/16/13, at 1:36 p.m., there was no battery-powered back-up lighting unit in Operating Room 1. This room had a window that covered approximately 40 percent of the west wall. When asked, Staff stated that that facilities do approximately two surgeries per month, that no surgeries are performed in the late afternoon, and that there are no emergency surgeries performed: they are all scheduled surgeries because the anesthesiologist is not from the area.

Based on observation, the facility failed to maintain its portable fire extinguishers. This was evidenced by a fire extinguisher that was sitting on the floor and a fire extinguisher that was mounted on a wall too high above the floor. This deficient practice affected staff and patients in two of five smoke compartments and could potentially cause a delay in access to the fire extinguishers resulting in the spread of smoke and/or fire.

NFPA 10, 1998 edition
1-6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.

1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

Findings:

During a tour of the facility with the Director of Plant Operations on 4/16/13, fire extinguishers were observed.

1. At 1:56 p.m., the fire extinguisher located in the Laboratory was mounted to the wall 72 inches above the floor.

2. At 2:07 p.m., the fire extinguisher located in the Generator Room was sitting on the floor.

Based on observation, the facility failed to ensure that all means of egress are continuously maintained free of obstructions to full, instant use in the case of fire or other emergency. This was evidenced by items stored in the exit corridor. This deficient practice affected all staff and patients in two of five smoke compartments at the main hospital and one of one offsite building and could potentially result in injury or a delayed evacuation in the event of an emergency.


Findings:

Main Hospital
During a tour of the facility with the Director of Plant Operations on 4/16/13, exit corridors were observed.

1. At 12:38 p.m., the exit corridor from the Business Office portion of the wing had a copy machine and a recycle bin located in the corridor. The clear width between the copy machine and the wall was 37 inches.

Physical Therapy at Healing Hands Close to Home
2. At 2:42 p.m., there was a chest freezer used for cold packs located in the corridor leading to the northwest exit. The clear width between the corridor and the wall was 31 inches

Based on observation and interview, the facility failed to protect its medical compressed gas cylinders as evidenced by cylinders which were stored against a potential source of heat. This deficient practice affected one of five smoke compartments at the hospital and one of one offsite location and could potentially result in the cylinder rupturing, damage to the cylinders or surrounding equipment, and the acceleration of fire.


1999 NFPA 99
4-3.1.1.1 Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

4-3.1.1.2 (3) Provisions shall be made for racks or fastenings to protect cylinders from damage or dislocation.

4-5.1.1.2* Storage Requirements (Location, Construction, Arrangement).
6. Cylinders containing compressed gases and containers for volatile liquids shall be kept away from radiators, steam piping, and like sources of heat.

During a tour of the facility with the Director of Plant Operations on 4/16/13, compressed gas cylinders were observed.

Main Hospital
1. At 1:38 p.m., the Operating Room had one H size oxygen and one H size nitrous compressed gas cylinder that were chained together near the top and bottom of the tanks. The tanks were not individually secured to prevent one from falling during handling.

Physical Therapy at Healing Hands Close to Home
2. At 2:38 p.m., the Physical Therapy Office had items stored in front of a flush mount electric radiant wall heater. There were two E size oxygen cylinders stored directly in front of, and leaning against, the front of the heater. There was also a cork board bulletin board partially in front of the heater, leaning against the wall four inches from the heater, and a full size filing cabinet that was partially in front of the heater six inches away.
Engineering Staff removed the oxygen tanks from the area.
When asked, Staff stated that the breaker to the heater should be off. When asked to test the heater, the heater came on and began heating up. Engineering Staff shut off the breaker to the heaters at that time.

Based on document review and interview, the facility failed to protect its anesthetizing location as evidenced by the failure to maintain the relative humidity to insure that it was equal to, or greater than, 35 percent. This affected one of five smoke compartments and could potentially result in the ignition of fire due to electrostatic charges or other heat-generating equipment in an oxygen-rich environment.

NFPA 99 Health Care Facilities, 1999 edition
19.3.2.3 Anesthetizing Locations.
Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

5-4.1.1 Ventilation in anesthetizing locations
The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Findings:

During record review at on 4/16/13, documentation was requested for monitoring humidity levels in areas where general anesthesia was used.

Main Hospital Building
At 8:45 p.m., documentation for humidity levels in the Operating Room indicated that humidity levels dropped below 35 percent for the following days.

In March of 2012, the relative humidity was 30.7 and 32.6.
In June of 2012, the relative humidity was 31.0 and 32.7.
In July of 2012, the relative humidity was 27, 32, and 31.0.
In August of 2012, the relative humidity was 21.2 and 25.7.
In September of 2012, the relative humidity was 28.2, 30.0, 32.6, 31.6, and 34.
In October of 2012, the relative humidity was 30.
In November of 2012, the relative humidity was 26, 26, 28, and 30.
In December of 2012, the relative humidity was 32.
In January of 2013, the relative humidity was 29, 30, and 30.
In February of 2013, the relative humidity was 28,29,34, and 34.
In March of 2013, the relative humidity was 19, 21, 23, and 26.
In April of 2013, the relative humidity was 28.


Documentation did not indicate what actions were taken to adjust the humidity levels or if the levels had changed.

During the exit conference on 4/16/13 at 4:45 p.m., Engineering Staff stated that they may request a waiver to lower the humidity requirements.

Based on document review and interview, the facility failed to provide a written policy to insure that if the automatic sprinkler system or fire alarm system was out of service for four or more hours in a 24 hour period that the authority having jurisdiction (AHJ) would be notified. This was evidenced by a lack of documentation and knowledge of these requirements. This affected all staff and patients in five of five smoke compartments within the facility and could potentially result in the AHJ (both the Department of Public Health and Local Fire Authority) being unable to exercise oversight and first responders being unaware that the building was left unprotected by the shut down.

NFPA 101 Life Safety Code, 2000 edition
21.3.4.1 General. Ambulatory health care facilities shall be provided with fire alarm systems in accordance with Section 9.6, except as modified by 21.3.4.2 through 21.3.4.5.

9.6.1.8 Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

9.7.6.1 Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.

Findings:

During a review of the facility's records on 4/16/13, the fire watch policy was reviewed.

At 8:45 a.m., the facility fire watch procedure did not include guidance to contact the AHJ in the event that the fire alarm system or the automatic sprinkler system was out of service for four or more hours in a 24 hour period. Documentation did not specify notification of the State Department of Public Health and Local Fire Authority (AHJ). When asked, Staff was unsure of the four hour time period required to contact the AHJ.

Based on observation and interview, the facility failed to comply with the regulations regarding electrical wiring and utilities. This was evidenced by high wattage devices which were plugged into power strips and the permanent use of power strips in patient care areas. This deficient practice affected all staff and residents in three of seven smoke compartments and could potentially result in the ignition of fire.

National Electric Code, 1998 edition
400.8 Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors.

NFPA 99 3-3.2.1.2, All patient care areas.
(d)(2) Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings:


Main Hospital
During a tour of the facility with the Director of Plant Operations, electrical wiring and equipment were observed.

1. Between 1:04 p.m. and 1:10 p.m., Patient Rooms 3-2, 3-4, and 3-6 had hospital grade power strips that were attached to the walls between the patient room beds.

2. At 1:25 p.m., the Recovery Room had a hospital grade power strip that had a suction machine, a portable electro-cardiogram monitor, a blood pressure monitor, and a blood oxygen monitor plugged into it. The wall had one outlet with two duplex outlets that were being used by other devices.

3. At 1:26 p.m., Patient Room 2-6 had a power strip attached to the wall near the bed.

4. At 1:28 p.m., the Nursery infant warmer was plugged into a hospital grade power strip.

5. At 1:31 p.m., the Ultra Sound/Radiology room had a ultra sound machine and bed that were plugged into a hospital grade power strip. This room had two outlets available. Staff stated that the outlet could have been used in place of the power strips.

6. At 1:38 p.m., the Operating Room had a suction pump that was plugged into a hospital grade power strip.

7. At 1:52 p.m., the Emergency Room had a blood pressure monitor, a suction machine, and an I.V. pump plugged into a power strip.

When asked about the use of power strips in patient care areas, Staff stated that most walls in the patient care areas had a single gang outlet (two places to plug in devices) or a single double gang outlet ( four places to plug devices in) and that there were not enough outlets on the walls.

Physical Therapy at Healing Hands Close to Home
8. At 2:15 p.m., In the location identified as the Staff Kitchen, there was an electric skillet which had approximately one-quarter inch of cooking oil in it, an electric hot plate with range type heating elements, a toaster oven, a microwave oven, and a small refrigerator that were plugged into a power strip attached to the wall. Engineering Staff stated that the cooking equipment would be removed.

Surveyor: Compton, Robert
Based on observation, the facility failed to maintain the walls and ceiling of the building in a condition that would resist the passage of smoke and fire. This was evidenced by observed unsealed penetrations. This affected staff and patients in four of five smoke compartments within the facility and could potentially result in the spread of smoke and/or fire from one area to another.

Findings:

During a tour of the facility with the Director of Plant Operations on 4/16/13, penetrations were observed in the walls.

1. At 12:35 p.m., there was an approximately one-half inch unsealed penetration in the southwest corner of the ceiling in the Conference Room. Blue data cables were traveling through the penetration.

2. At 12:53 p.m., there was an approximately three inch round damaged area behind the door in the south wall of the Auxiliary Storage Room. This damaged portion of the wall was where the doorknob hit the wall when the door was fully opened.

3. At 1:20 p.m., the sprinkler escutcheon rings were not flush to the ceiling in the Utility Room across from the Nurses' Station. This caused an approximately one-half inch unsealed penetration around the sprinkler pipe.

4. At 1:23 p.m., there were two unsealed penetrations in the ceiling in the Pharmacy. One penetration was in the southeast corner of the room and the other penetration was in southeast corner of the Refrigerator Room in the Pharmacy.

5. At 1:36 p.m., there were two approximately one-quarter inch unsealed penetrations in the west corner of the ceiling of the Central Supply Room.

6. At 1:52 p.m., there was an approximately one-quarter inch unsealed penetration in the ceiling of the Emergency Room near the clock.

7. At 2:05 p.m., the Generator Room had three unsealed penetrations in a wall and the ceiling.
One penetration was located in the ceiling near the attic access door and was approximately four by eight inches in size.
The other penetrations were located in the northwest corner of the room and were one and one-half inch and one inch in size, respectively.

Based on observation, the facility failed to maintain corridor doors free from obstructions to closing. This was evidenced by corridor doors that failed to close and latch when tested. It is critical that corridor doors close and latch to prevent the spread of smoke and/or fire into other areas of the facility. This deficient practice affected staff and patients in one of five smoke compartments.


Findings:

During a tour of the facility with the Director of Plant Operations, doors were observed.

1. At 1:20 p.m., the Hepa Filter Room corridor door did not positively latch when tested by releasing the door from an open position.

Surveyor: Compton, Robert
Based on observation, the facility failed to maintain all exit signs. This was evidenced by a photoluminescent exit sign that was past its replacement date. This affected all staff and patients in two of five smoke compartments within the facility and could potentially result in confusion or a delay in evacuation in the event of an emergency.

NFPA 101 Life Safety Code, 2000 edition
7.10.5.2 Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.

Findings:

During a tour of the facility with the Director of Plant Operations on 4/16/13, exit signs were observed.

At 1:00 p.m., the photoluminescent exit sign located in the corridor above the cross-corridor doors near the Dining Room had a replacement date of 4/2000. When asked, Staff stated that the sign did still produce illumination.

Based on observation and staff interview, the facility failed to maintain the fire-rated construction of its smoke/fire barrier walls. This was evidenced by an observed unsealed penetration. This affected two of five smoke compartments and could potentially result in smoke and/or fire spreading from one smoke compartment to another.

NFPA 101 Life Safety Code, 2000 edition
8.3.6.1: Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
1. The space between the penetrating item and the smoke barrier shall meet one following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
2. Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b It shall be protected by an approved device that is designed for the specific purpose.
3. Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with the Director of Plant Operations on 4/16/13, smoke/fire barrier walls were observed.

1. Between 2:45 and 3:30 p.m., the smoke/fire barrier wall in the attic above the Human Resources Office had an approximately two inch by four inch unsealed penetration through the concrete wall. This penetration was located in the wall to the right of center. Staff stated that the penetration was going to be sealed with a cableway fire stop unit. Staff stated that it was ordered but had not been received yet.

Based on observation and interview, the facility failed to protect its hazardous area enclosures. This was evidenced by rooms which contained combustible materials that posed a degree of hazard greater than that normal to the general occupancy of the building that were not equipped with self-closing mechanisms on the doors. This deficient practice affected all staff and patients in two of four smoke compartments within the facility and could potentially result in the spread of smoke and/or fire.


NFPA 99 Health Care Facilities, 1999 edition
10.5.1
Laboratories employing quantities of flammable, combustible, or hazardous materials that are considered a severe hazard are protected in accordance with NFPA 99. (Laboratories that are not considered to be a severe hazard meet the provisions of K29.) Laboratories in health care occupancies and medical and dental offices are in accordance with NFPA 99, Standard for Health Care Facilities.


Findings:

During a tour of the facility with the Director of Plant Operations, hazardous area enclosures were observed.

1. At 12:57 p.m., the storage room near Purchasing did not have a self-closing door. This room was approximately six feet wide by ten feet long and contained combustible storage.

2. At 1:56 p.m., the Laboratory corridor door did not have a self-closure on the door.

Based on observation, the facility failed to ensure that exits are readily accessible at all times as evidenced by exit doors that were equipped with a double-action fastening device, more than one fastening device, and fastening devices that were located 48 inches above the floor. This deficient practice affected all staff and patients in one of one outpatient building and could potentially result in injury or a delay in egress in the event of an emergency.


NFPA 101 Life Safety Code, 2000 edition
3.3.121* Means of Egress. A continuous and unobstructed way of travel from any point in a building or structure to a public way consisting of three separate and distinct parts: (1) the exit access, (2) the exit, and (3) the exit discharge.

39.2.2.2 Doors.
39.2.2.2.1 Doors complying with 7.2.1 shall be permitted.
39.2.2.2.2* Locks complying with Exception No. 2 to 7.2.1.5.1 shall be permitted only on principal entrance/exit doors.

7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
Exception No. 1: This requirement shall not apply where otherwise provided in Chapters 18 through 23.
Exception No. 2: Exterior doors shall be permitted to have key-operated locks from the egress side, provided that the following criteria are met:
(a) Permission to use this exception is provided in Chapters 12 through 42 for the specific occupancy.
(b) On or adjacent to the door, there is a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high on a contrasting background that reads as follows:

THIS DOOR TO REMAIN UNLOCKED WHEN THE BUILDING IS OCCUPIED

(c) The locking device is of a type that is readily distinguishable as locked.
(d) A key is immediately available to any occupant inside the building when it is locked.
Exception No. 2 shall be permitted to be revoked by the authority having jurisdiction for cause.
Exception No. 3: Where permitted in Chapters 12 through 42, key operation shall be permitted, provided that the key cannot be removed when the door is locked from the side from which egress is to be made.

7.2.1.5.4* A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable
with not more than one releasing operation.

Findings:

Physical Therapy at Healing Hands Close to Home

1. At 2:41 p.m., the northwest exit door had a double-action fastening device as well as a fastening device located 58 inches above the floor.

2. At 2:43 p.m., the front Lobby exit had a double-action fastening device as well as a fastening device located 58 inches above the floor.

Based on observation, the facility failed to provide battery-powered emergency illumination. This was evidenced by the failure to provide a battery-powered emergency lighting unit in an anesthetizing location. This deficient practice affected one of one operating room and could potentially result in a loss of lighting in the operating room during the ten seconds of time (or longer if the generator fails to start) that is allowed for the back-up generator to transfer power during power outages.

NFPA 101 Life Safety Code, 2000 edition
19.3.2.3 Anesthetizing Locations. Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99 3-3.2.1.2, 5 (e)
5. Wiring in Anesthetizing Locations
e. Battery-powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e)

NFPA 70, National Electrical Code
NFPA 700-12 (e)
(e) Unit Equipment. Individual unit equipment for emergency illumination shall consist of the following:
(1) A rechargeable battery
(2) A battery charging means
(3) Provisions for one or more lamps mounted on the equipment, or shall be permitted to have terminals for remote lamps, or both, and
(4) A relaying device arranged to energize the lamps automatically upon failure of the supply to the unit equipment.

Findings:.

During a tour of the facility with the Director of Plant Operations on 4/16/13, at 1:36 p.m., there was no battery-powered back-up lighting unit in Operating Room 1. This room had a window that covered approximately 40 percent of the west wall. When asked, Staff stated that that facilities do approximately two surgeries per month, that no surgeries are performed in the late afternoon, and that there are no emergency surgeries performed: they are all scheduled surgeries because the anesthesiologist is not from the area.

Based on observation, the facility failed to maintain its portable fire extinguishers. This was evidenced by a fire extinguisher that was sitting on the floor and a fire extinguisher that was mounted on a wall too high above the floor. This deficient practice affected staff and patients in two of five smoke compartments and could potentially cause a delay in access to the fire extinguishers resulting in the spread of smoke and/or fire.

NFPA 10, 1998 edition
1-6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.

1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

Findings:

During a tour of the facility with the Director of Plant Operations on 4/16/13, fire extinguishers were observed.

1. At 1:56 p.m., the fire extinguisher located in the Laboratory was mounted to the wall 72 inches above the floor.

2. At 2:07 p.m., the fire extinguisher located in the Generator Room was sitting on the floor.

Based on observation, the facility failed to ensure that all means of egress are continuously maintained free of obstructions to full, instant use in the case of fire or other emergency. This was evidenced by items stored in the exit corridor. This deficient practice affected all staff and patients in two of five smoke compartments at the main hospital and one of one offsite building and could potentially result in injury or a delayed evacuation in the event of an emergency.


Findings:

Main Hospital
During a tour of the facility with the Director of Plant Operations on 4/16/13, exit corridors were observed.

1. At 12:38 p.m., the exit corridor from the Business Office portion of the wing had a copy machine and a recycle bin located in the corridor. The clear width between the copy machine and the wall was 37 inches.

Physical Therapy at Healing Hands Close to Home
2. At 2:42 p.m., there was a chest freezer used for cold packs located in the corridor leading to the northwest exit. The clear width between the corridor and the wall was 31 inches

Based on observation and interview, the facility failed to protect its medical compressed gas cylinders as evidenced by cylinders which were stored against a potential source of heat. This deficient practice affected one of five smoke compartments at the hospital and one of one offsite location and could potentially result in the cylinder rupturing, damage to the cylinders or surrounding equipment, and the acceleration of fire.


1999 NFPA 99
4-3.1.1.1 Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

4-3.1.1.2 (3) Provisions shall be made for racks or fastenings to protect cylinders from damage or dislocation.

4-5.1.1.2* Storage Requirements (Location, Construction, Arrangement).
6. Cylinders containing compressed gases and containers for volatile liquids shall be kept away from radiators, steam piping, and like sources of heat.

During a tour of the facility with the Director of Plant Operations on 4/16/13, compressed gas cylinders were observed.

Main Hospital
1. At 1:38 p.m., the Operating Room had one H size oxygen and one H size nitrous compressed gas cylinder that were chained together near the top and bottom of the tanks. The tanks were not individually secured to prevent one from falling during handling.

Physical Therapy at Healing Hands Close to Home
2. At 2:38 p.m., the Physical Therapy Office had items stored in front of a flush mount electric radiant wall heater. There were two E size oxygen cylinders stored directly in front of, and leaning against, the front of the heater. There was also a cork board bulletin board partially in front of the heater, leaning against the wall four inches from the heater, and a full size filing cabinet that was partially in front of the heater six inches away.
Engineering Staff removed the oxygen tanks from the area.
When asked, Staff stated that the breaker to the heater should be off. When asked to test the heater, the heater came on and began heating up. Engineering Staff shut off the breaker to the heaters at that time.

Based on document review and interview, the facility failed to protect its anesthetizing location as evidenced by the failure to maintain the relative humidity to insure that it was equal to, or greater than, 35 percent. This affected one of five smoke compartments and could potentially result in the ignition of fire due to electrostatic charges or other heat-generating equipment in an oxygen-rich environment.

NFPA 99 Health Care Facilities, 1999 edition
19.3.2.3 Anesthetizing Locations.
Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

5-4.1.1 Ventilation in anesthetizing locations
The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Findings:

During record review at on 4/16/13, documentation was requested for monitoring humidity levels in areas where general anesthesia was used.

Main Hospital Building
At 8:45 p.m., documentation for humidity levels in the Operating Room indicated that humidity levels dropped below 35 percent for the following days.

In March of 2012, the relative humidity was 30.7 and 32.6.
In June of 2012, the relative humidity was 31.0 and 32.7.
In July of 2012, the relative humidity was 27, 32, and 31.0.
In August of 2012, the relative humidity was 21.2 and 25.7.
In September of 2012, the relative humidity was 28.2, 30.0, 32.6, 31.6, and 34.
In October of 2012, the relative humidity was 30.
In November of 2012, the relative humidity was 26, 26, 28, and 30.
In December of 2012, the relative humidity was 32.
In January of 2013, the relative humidity was 29, 30, and 30.
In February of 2013, the relative humidity was 28,29,34, and 34.
In March of 2013, the relative humidity was 19, 21, 23, and 26.
In April of 2013, the relative humidity was 28.


Documentation did not indicate what actions were taken to adjust the humidity levels or if the levels had changed.

During the exit conference on 4/16/13 at 4:45 p.m., Engineering Staff stated that they may request a waiver to lower the humidity requirements.

Based on document review and interview, the facility failed to provide a written policy to insure that if the automatic sprinkler system or fire alarm system was out of service for four or more hours in a 24 hour period that the authority having jurisdiction (AHJ) would be notified. This was evidenced by a lack of documentation and knowledge of these requirements. This affected all staff and patients in five of five smoke compartments within the facility and could potentially result in the AHJ (both the Department of Public Health and Local Fire Authority) being unable to exercise oversight and first responders being unaware that the building was left unprotected by the shut down.

NFPA 101 Life Safety Code, 2000 edition
21.3.4.1 General. Ambulatory health care facilities shall be provided with fire alarm systems in accordance with Section 9.6, except as modified by 21.3.4.2 through 21.3.4.5.

9.6.1.8 Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

9.7.6.1 Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.

Findings:

During a review of the facility's records on 4/16/13, the fire watch policy was reviewed.

At 8:45 a.m., the facility fire watch procedure did not include guidance to contact the AHJ in the event that the fire alarm system or the automatic sprinkler system was out of service for four or more hours in a 24 hour period. Documentation did not specify notification of the State Department of Public Health and Local Fire Authority (AHJ). When asked, Staff was unsure of the four hour time period required to contact the AHJ.

Based on observation and interview, the facility failed to comply with the regulations regarding electrical wiring and utilities. This was evidenced by high wattage devices which were plugged into power strips and the permanent use of power strips in patient care areas. This deficient practice affected all staff and residents in three of seven smoke compartments and could potentially result in the ignition of fire.

National Electric Code, 1998 edition
400.8 Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors.

NFPA 99 3-3.2.1.2, All patient care areas.
(d)(2) Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings:


Main Hospital
During a tour of the facility with the Director of Plant Operations, electrical wiring and equipment were observed.

1. Between 1:04 p.m. and 1:10 p.m., Patient Rooms 3-2, 3-4, and 3-6 had hospital grade power strips that were attached to the walls between the patient room beds.

2. At 1:25 p.m., the Recovery Room had a hospital grade power strip that had a suction machine, a portable electro-cardiogram monitor, a blood pressure monitor, and a blood oxygen monitor plugged into it. The wall had one outlet with two duplex outlets that were being used by other devices.

3. At 1:26 p.m., Patient Room 2-6 had a power strip attached to the wall near the bed.

4. At 1:28 p.m., the Nursery infant warmer was plugged into a hospital grade power strip.

5. At 1:31 p.m., the Ultra Sound/Radiology room had a ultra sound machine and bed that were plugged into a hospital grade power strip. This room had two outlets available. Staff stated that the outlet could have been used in place of the power strips.

6. At 1:38 p.m., the Operating Room had a suction pump that was plugged into a hospital grade power strip.

7. At 1:52 p.m., the Emergency Room had a blood pressure monitor, a suction machine, and an I.V. pump plugged into a power strip.

When asked about the use of power strips in patient care areas, Staff stated that most walls in the patient care areas had a single gang outlet (two places to plug in devices) or a single double gang outlet ( four places to plug devices in) and that there were not enough outlets on the walls.

Physical Therapy at Healing Hands Close to Home
8. At 2:15 p.m., In the location identified as the Staff Kitchen, there was an electric skillet which had approximately one-quarter inch of cooking oil in it, an electric hot plate with range type heating elements, a toaster oven, a microwave oven, and a small refrigerator that were plugged into a power strip attached to the wall. Engineering Staff stated that the cooking equipment would be removed.