HospitalInspections.org

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Services Manager and Quality Regulatory Staff that the facility failed to maintain exit corridor doors resist the passage of smoke into the means of egress in the event of a hostile fire event (LSC 19.2.3.5, Table 19.3.2.1, 19.3.6.3, Exception 2; A19.3.6.3.3).
Findings include, but are not limited to:
1. On 3/10/2016, at 11:25 a.m., there was an unsealed wall penetration within the smoke barrier above the cross-corridor doors adjacent to the Pharmacy that measured approximately 3/4" in diameter.
Surveyor was accompanied by the Facilities Services Manager and Quality Regulatory Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Service Manager and Quality Regulatory Staff that the facility failed to install proper hold-open devices on non-required separation doors within the facility.
This resulted in the potential for smoke and fire to spread to other areas of the facility (LSC 19.3.6.3).
Findings include, but are not limited to:
1. On 3/9/2016, during the facility tour between 1:15 p.m. and 5:00 p.m., there were non-approved door hold open devices on the following doors but not limited to: courtesy cross-corridor doors adjacent to the ED, Environmental Services door adjacent to the ED and door(s) leading from the corridor into the OR area.
Surveyor was accompanied by the Facilities Service Manager and Quality Regulatory Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Services Manager and Quality Regulatory Staff that the facility failed to provide a one hour separation between hazardous areas and the corridor of the building.
This resulted in the potential for patients & staff to be exposed to hazardous products of fire during a hostile fire event (LSC 19.3.2, 8.4).
Findings include, but are not limited to:
1. On 3/9/2016, at 2:10 p.m., there was an unsealed ceiling penetration within the Boiler Room of the facility.
2. On 3/10/2016, at 10:54 a.m., there was a missing automatic door closure on Storage Rm. 23 that meets the requirements of a hazardous room as identified within NFPA 101.
Surveyor was accompanied by the Facilities Services Manager and Quality Regulatory Staff who acknowledged the existence of these conditions.

Based on observations and interview it was determined through on-going dialog with the Facilities Services Manager and Quality Regulatory Staff that the facility failed to ensure there were no dead ends exceeding 30' in the building.
This resulted in the potential for panic and injury during emergency evacuations and relocation (LSC 7.1, 19.2.1, 19.2.5.10).
Findings include, but are not limited to:
1. On 3/9/2016, during the facility tour between 1:00 p.m. and 5:00 p.m., the closing of the existing exit within the Family Birthing Wing, north end of the facility, created a dead end corridor within the Family Birthing Wing.
Surveyor was accompanied the Facilities Services Manager and Quality Regulatory Staff who acknowledge the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Services Manager and Quality Regulatory Staff that the facility failed to maintain accessible exits for patients, visitors and staff (NFPA 101, 19.2.2.2.4).
This resulted in the potential for panic and injury to occupants.
Findings include, but are not limited to:
1. On 3/9/2016, during the facility tour between 1:00 p.m. and 5:00 p.m., surveyor discovered that the exit at the north end of the Family Birthing Wing had been closed and there was not an alternate exit provided. Interviewing staff, staff mentioned that the exit was closed because of the construction that was happening outside of the exit and an alternate exit was not constructed or planned.
Staff also mentioned that they had reviewed the exiting with the Fire Chief with Jefferson County Fire District #1, but they did not contacted the Office of State Fire Marshal concerning the closing of exits as the Authority Having Jurisdiction.
Staff mentioned that an ILSM (Interim Life Safety Measures) was created for the exiting closure but had not been reviewed or submitted to the Office of State Fire Marshal for review and comments.
2. On 3/10/2016, at 11:20 a.m., the Green Hall Patio exterior exit, through the gate, was locked and would not allow staff and/or visitors from exiting properly to the public right of way. This exit was signed as an exit and was a part of the exiting plan of the hospital.
Surveyor was accompanied by the Facilities Services Manager and Quality Regulatory Staff who acknowledged the existence of these conditions.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Facilities Services Manager and Quality Regulatory Staff that the facility failed to provide fire drills for all staff affecting the entire building.
This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing residents to smoke and fire in the facility (LSC 19.7.1.2, A.19.7.1.2).
Findings include, but are not limited to:
1. On 3/8/2016, during record review between 2:00 p.m. and 5:00 p.m., facility documentation presented to the surveyor by the facility showed that fire drills for swing and night shift in 2014 and 2015 were not completed under varying conditions and random times throughout the shift.
Six of eight swing shift fire drills were conducted between 3:40 p.m. and 4:33 p.m. and eight of eight night shift fire drills were conducted between 5:00 a.m. and 6:30 a.m. which demonstrates that fire drills were conducted in a manner that created a pattern, instead of on different days and times and involving different locations and simulated circumstances.
2. On 3/8/2016, during record review between 2:00 p.m. and 5:00 p.m., facility documentation presented to the surveyor showed incomplete fire drill forms for the facility. Fire drill forms were missing items such as but not limited to the number of simulated evacuated occupants from the affected smoke compartment to an unaffected smoke compartment and the time for staff to perform the simulated evacuation of the patients during the fire drill as required and outlined within NFPA 101.
3. On 3/8/2016, during record review between 2:00 p.m. and 5:00 p.m., fire drill documentation presented to the surveyor from the facility showed that two fire drills were conducted outside the walls of the hospital.
The 3rd quarter swing shift fire drill in 2015 was conducted within the Laboratory which was a separate building, unattached from the hospital and the 3rd quarter swing shift drill in 2014 was conducted within the Facilities Shop. These drills did not simulate the evacuation of any patients within the hospital as required by NFPA 101.
Surveyor was accompanied by the Facilities Services Manager and Quality Regulatory Staff who acknowledged the existence of these conditions.

Based on record review and interview during the survey, it was determined through on-going dialog with the Facilities Services Manager and Quality Regulatory Staff that the facility failed to test and maintain fire alarm in accordance with NFPA 72 for the entire building.
This resulted in the potential for system and device failure during fire emergencies (LSC 4.6.12.1, 9.6.1.4, NFPA 70, NFPA 72).
Findings include, but are not limited to:
1. On 3/9/2016, during record review between 8:00 a.m. and 12:45 p.m., documentation provided by the facility showed quarterly fire alarm testing and maintenance being conducted on a semi-annual basis. Quarterly fire alarm testing and maintenance was being performed by a third party vendor.
Surveyor was accompanied by the Facilities Services Manager and Quality Regulatory Staff who acknowledged the existence of these conditions.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Facilities Services Manager and Quality Regulatory Staff that the facility failed to ensure the sprinkler system was continuously maintained & in reliable operating condition for the entire building.
This resulted in the potential for system failure during fire emergencies (LSC 4.6.12.1, NFPA 13 3-2.91, .2, .3, NFPA 25 9.6.2.1, .2 & 8.17.4.6).
Findings include, but are not limited to:
1. On 3/8/2016, during record review between 2:00 p.m. and 5:00 p.m., weekly and monthly testing and maintenance was being performed by staff and there was no documentation showing technician competence in maintaining the sprinklers to the adopted 1998 edition of NFPA 25 standards.
2. On 3/9/2016, during record review between 8:00 a.m. and 12:45 p.m., documentation provided by the facility showed quarterly fire sprinkler testing and maintenance being conducted on a semi-annual basis. Quarterly fire alarm testing and maintenance was being performed by a third party vendor.
3. On 3/9/2016, at 1:54 p.m., there was a damaged automatic sprinkler head within the Administration Entrance that shall be replaced.
4. On 3/10/2016, during the facility tour between 10:00 a.m. and 3:30 p.m., there were damaged automatic sprinkler heads that shall be replaced within the following locations but not limited to: adjacent to the House Keeping Closet, Door 29 and alcove of the Sane Room.
5. On 3/10/2016, during the facility tour between 10:00 a.m. and 3:30 p.m., there were painted automatic sprinkler heads that shall be replaced within the following locations but not limited to: adjacent to Quality Improvement, (Door 8) and Service Corridor outside of OR #1.
6. On 3/10/2016, during the facility tour between 10:00 a.m. and 3:30 p.m., there were missing escutcheon plates around the automatic sprinkler heads within the following locations but not limited to: Bathroom of Patient Rm. 121 and within the "Old Vault" near the kitchen of the facility.
7. On 3/10/2016, at 10:58 a.m., there was a corroded automatic sprinkler head at the north end of the building outside of the Administration Entrance/Exit that shall be replaced.
8. On 3/10/2016, at 2:11 p.m., there was a large gap between the automatic sprinkler head escutcheon plate and ceiling within ED Doctor's Sleep Room Restroom.
9. On 3/10/2016, at 2:32 p.m., there was a missing spare sprinkler head for the concealed sprinkler heads that were within the facility. NFPA 25 requires a minimum of 2 spare sprinkler heads of each type and temperature to be stored within the spare sprinkler cabinet.
Surveyor was accompanied by the Facilities Services Manager and Quality Regulatory Staff who acknowledged the existence of these conditions.

Based on record review and interview during the survey, it was determined through on-going dialog with the Facilities Service Manager and Quality Regulatory Staff that the facility failed to ensure the sprinkler system is continuously maintained & in reliable operating condition for the entire building.
This resulted in the potential for system failure during fire emergencies (LSC 4.6.12.1, NFPA 13 3-2.91, .2, .3, NFPA 25 9.6.2.1, .2 & 8.17.4.6).
Findings include, but are not limited to:
1. On 3/9/2016, during record review between 8:00 a.m. and 12:45 p.m., the facility had not conducted the required annual forward flow test of the sprinkler system, last test was conducted on 7/27/2011 and was past due since 7/27/2012.
Surveyor was accompanied by the Facilities Service Manager and Quality Regulatory Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Services Manager and Quality Regulatory Staff that the facility failed to maintain fire extinguishers in accordance with adopted standards for the extinguishers of the facility.
This resulted in the potential for fires to progress beyond incipient stage (LSC 19.3.5.6, 4.6.12.1, 9.7.4.1, NFPA 10).
Findings include, but are not limited to:
1. On 3/9/2016, at 2:36 p.m., there was a missing minimum sized 4A 40B:C fire extinguisher within the kitchen as required by NFPA 10.
2. On 3/10/2016, at 3:17 p.m., there was a missing minimum sized 10A 120B:C fire extinguisher for the heliport as required by NFPA 418 for helicopters measured between 50' and 80'.
Surveyor was accompanied by the Facilities Services Manager and Quality Regulatory Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Service Manager and Quality Regulatory Staff that the facility failed to properly install building service equipment.
This resulted in the potential for a gas leak and unexpected fire (LSC 19.5.2.1, 19.5.2.2, 9.2, NFPA 90A).
Findings include, but are not limited to:
1. On 3/9/2016, at 1:35 p.m., the water heaters within the basement did not have a seismic strap installed on the heater to prevent the water heater from tipping over during a seismic event.
2. On 3/10/2016, at 11:31 a.m., the water heater within Rehab did not have a seismic strap installed on the heater to prevent the water heater from tipping over during a seismic event.
Surveyor was accompanied by the Facilities Service Manager and Quality Regulatory Staff who acknowledged these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Service Manager and Quality Regulator Staff that the facility failed to provide safe storage for compressed gas in the facility.
This resulted in the potential for injury to staff and patients from a damaged compressed gas cylinder releasing unexpectedly. (LSC 19.3.2.4, NFPA 99 4.3.1.1.2).
Findings include, but were not limited to:
1. On 3/10/2016, at 2:30 p.m., there were multiple compressed gas cylinders that were not properly secured by evidence of the cylinders standing in a free non-restrained fashion that would allow the bottoms of the cylinders to kick out and strike other cylinders or fencing within the Exterior Liquid Oxygen storage area during a seismic event.
Surveyor was accompanied by the Facilities Service Manager and Quality Regulator Staff who acknowledged the existence of these conditions.

Based on observations and interviews it was determined through on-going dialog with the Facilities Service Manager and Quality Regulator Staff that the facility failed to provide safe storage for compressed gas.
This resulted in the potential for damage to electrical switches and receptacles during the movement of oxygen tanks in the facility. (LSC 19.3.2.4, NFPA 99 4.3.1.1.2).
Findings include, but were not limited to:
1. On 3/10/2016, at 2:50 p.m., there was oxygen cylinders stored within the Med Surge Blue Storeroom that had electrical within 60" of the finish floor.
Surveyor was accompanied by the Facilities Service Manager and Quality Regulator Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Service Manager and Quality Regulatory Staff that the facility failed to ensure that piped in medical gas systems comply with NFPA 99.
This resulted in the potential for injury to patients during medical procedures.
Findings include but are not limited to:
1. On 3/9/2016, at 2:30 p.m., the temporary exterior location for the facilities Liquid Oxygen was not properly protected for vehicle impact. The temporary location was located on the south side of the building within the vehicular parking lot.
2. On 3/9/2016, at 2:30 p.m., the temporary exterior location for the facilities Liquid Oxygen system was not properly signed according to NFPA 704 standards.
Surveyor was accompanied by the Facilities Service Manager and Quality Regulatory Staff who acknowledged the existence these conditions.

Based on record review and interview during the survey, it was determined through on-going dialog with the Facilities Services Manager and Quality Regulatory Staff that the facility failed to ensure that piped-in medical gas complied with NFPA 99, 5-4.1.1.
This resulted in the potential for injury to patients during medical procedures.
Findings include, but are not limited to:
1. On 3/9/2016, during record review between 8:00 a.m. and 12:45 p.m., the facility could not provide any Humidity Logs for the hospitals anesthetizing areas prior to April 2014.
2. On 3/9/2016, during record review between 8:00 a.m. and 12:45 p.m., the facility could not provide IFU's (Instructions for Use) for the equipment utilized within the anesthetizing location to show that the equipment could tolerate humidity down to 20% as outlined within CMS S&C Letter 15-27
Surveyor was accompanied by the Facilities Services Manager and Quality Regulatory Staff who acknowledged the existence of these conditions.

Based on observations, record review and interviews it was determined through on-going dialog with the Facilities Service Manager and Quality Regulatory Staff that the facility failed to properly maintain the generator affecting the entire facility.
This resulted in the potential for the lack of emergency electrical power (LSC 4.6.12.1, NFPA 110, NFPA 99, 3.4.4.1, 6.4.2).
Findings include, but are not limited to:
1. On 3/9/2016, during record review between 8:00 a.m. and 12:45 p.m., monthly maintenance was being performed by staff and there was no documentation showing technician competence in maintaining the generator to the adopted 1999 edition of NFPA 110 standards.
2. On 3/9/2016, during record review between 8:00 a.m. and 12:45 p.m., the facility did not have current documentation for the required 3-yr. 4-hr. load bank test. Last 3-yr. 4-hr. load bank test on the generator was conducted on 2/2015 and was only conducted for a total of 2-hours.
3. On 3/9/2016, during record review between 8:00 a.m. and 12:45 p.m., required monthly load testing was being conducted on a quarterly basis.
4. On 3/9/2016, during record review between 8:00 a.m. and 12:45 p.m., required monthly specific gravity testing was not being conducted.
5. On 3/9/2016, during record review between 8:00 a.m. and 12:45 p.m., required weekly water level/electrolyte checks were being conducted on a monthly basis.
6. On 3/9/2016, at 2:01 p.m., there was not a required emergency generator shutoff device located outside the generator enclosure.
7. On 3/9/2016, at 2:23 p.m., the Emergency Circuit for the Generator failed to transfer properly during a Generator test conducted by Facility Staff and witnessed by the LSC Surveyor.
Surveyor was accompanied by the Facilities Service Manager and Quality Regulatory Staff who acknowledged the existence of these conditions.

Based on record review and interview during the survey, it was determined through on-going dialog with the Facilities Services Manager and Quality Regulatory Staff that the facility failed to provide an alternate source of power in accordance with NFPA 99 3.6, which would provide a minimum of 90 minutes of power in an outage.
This resulted in the potential for panic and confusion for staff and patients in a power outage.
Findings include, but are not limited to:
1. On 3/9/2016, during record review between 8:00 a.m. and 12:45 p.m., the task illumination at the generator was not being tested monthly or annually as mentioned by Maintenance Staff.
Surveyor was accompanied by the Facilities Services Manager and Quality Regulatory Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Service Manager and Quality Regulatory Staff that the facility failed to ensure that that electrical wiring & equipment was used/maintained and in accordance with NFPA 70 for the building.
This resulted in the potential for injury to residents & staff (NFPA 70, 9.1.2, NEC 110-3.8).
Findings include, but are not limited to:
1. On 3/10/2016, at 11:27 a.m., there was a transformer that showed signs of overheating, transformer discolored, within the IDF-B Rm. The transformer appears to be powering the cable TV for the facility.
2. On 3/10/2016, at 11:34 a.m., there was a non-patient relocatable power tap within the Echo Exam Rm. which was a patient treatment area.
3. On 3/10/2016, at 2:00 p.m., there was an open electrical junction box on the exterior of the building adjacent to AH45 that was missing the waterproof seal.
4. On 3/10/2016, at 2:09 p.m., there was an open electrical junction box within the Old Boiler Room.
5. On 3/10/2016, at 2:18 p.m., there were relocatable power taps on the floor within OR #1 and OR #2.
6. On 3/10/2016, at 2:18 p.m., there were relocatable power taps within OR #1 and OR #2 that did not meet UL60601-1 listings for patient treatment/care areas.
Surveyor was accompanied by the Facilities Service Manager and Quality Regulatory Staff who acknowledged the existence of these conditions.