HospitalInspections.org

A. Kindred Hospital Phoenix.
Survey on July 23, 2013

Based on observation the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On July 23, 2013 the surveyor, accompanied by the CEO, and Clinical Operations, observed the following corridor doors would not tightly close when tested.

Fourth Floor
1. Room 401, door tested three of three times would not positively latch
Third Floor
2. ICU Main Door, tested three of three times would not positively latch

B. Kindred Hospital Northwest Phoenix
Findings include on Survey July 24, 2013

1. Room 118, door tested three of three times would not positively latch

During the exit conference on July 23 rd. and 24th, the above findings were again acknowledged by Two CEOs, Vice President, Operations Manager, Director of Clinical Operations and the Director of Quality Risk.

In time of a fire failing to protect patients from heat and smoke could cause harm to the patients.

A. Kindred Hospital Phoenix.
Survey on July 23, 2013

Based on observation the facility did not maintain the integrity, smoke resistance, of doors in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.2.1 requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls and doors must be able to resist the passage of smoke. NFPA 80 "Fire Doors and Fire Windows" Chapter 2, Section 2-3.1.7 "The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. +/- 1/16 in for steel doors and shall not exceed 1/8 in. for wood doors.

On July 23, 2013 the surveyor, accompanied by the CEO, and Clinical Operations, observed the following hazardous area doors:

1. Kitchen, dry food storage door with a closing device held open with an impediment
2. Kitchen janitors closet, flammables and combustibles, no door closing device
3. Third floor, soiled utilities closet, door tested three of three times will not positively latch

B. Kindred Hospital Northwest Phoenix
Findings include on Survey July 24, 2013

1. Dialysis storage room, approximately 170 square feet, door closing device removed

During the exit conference on July 23 rd. and 24th, the above findings were again acknowledged by Two CEOs, Vice President, Operations Manager, Director of Clinical Operations and the Director of Quality Risk.


Failing to prevent heat and smoke from spreading into the exit corridor will cause harm to patients.

A. Kindred Hospital Phoenix.
Survey on July 23, 2013

Based on record review the facility failed to conduct the required fire drills.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.7.1.2 Fire exit drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions."

Findings include:

On July 23, 2013 the surveyor, accompanied by the CEO, and Clinical Operations reviewed the facility's fire drill records. The surveyor noted the Fire Drill reports for second shift, first and second quarter of 2013 were marked second shift, however the time written in for Fire Drill was 7AM- 7PM (first shift) time.

During the exit conference on July 23 rd. and 24th, the above findings were again acknowledged by Two CEOs, Vice President, Operations Manager, Director of Clinical Operations and the Director of Quality Risk.

Failure to train and drill the staff on fire procedures could result in harm to the patients.

A. Kindred Hospital Phoenix.
Survey on July 23, 2013

Based on observation the facility failed to maintain the sprinkler heads and assure that all parts of the sprinkler system were in accordance with the UL Listing.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.5.1 "Buildings containing health care facilities shall be protected throughout by and approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection,
Testing, and Maintenance of Water-Based Fire Protection systems. NFPA 25, Section 2-2.1.1 "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign material , paint, and physical damage and shall be installed in the proper orientation..." NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, Chapter 3, Section 3-2.7.2, "Escutcheon Plates used with a recessed or flushed sprinkler shall be part of a listed sprinkler assembly."

Findings Include:

On July 23, 2013 the surveyor, accompanied by the CEO, and Clinical Operations, observations include the following findings:

1. Kitchen, two of three sprinklers in the dish wash area, grease and lint
2. Kitchen, four of eight sprinklers in main cook area, grease and lint
3. Fourth floor, room 422, bathroom sprinkler paint
4. Forth floor, room 422, two of two sprinklers paint
5. Third floor, rooms 300, 307, 309, and 310, two of two sprinklers in each room paint

During the exit conference on July 23 rd. and 24th, the above findings were again acknowledged by Two CEOs, Vice President, Operations Manager, Director of Clinical Operations and the Director of Quality Risk.

Failing to maintain sprinkler heads and keep the fusible link clean could allow a fire to burn longer before the sprinkler head will activate. Failing to maintain sprinkler heads, missing escutcheon plates, which are part of the UL Listing of the sprinkler assembly, could allow heat and smoke to effect other areas of the building. This could cause harm to the patients.

B. Kindred Hospital Northwest Phoenix
Survey on July 24, 2013

Based on Observation the facility failed to store the oxygen bottles 5 ft from combustible materials.

NFPA 101 Life Safety Code 2000, or Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99 Standard for Health Care Facilities"NFPA 99, Chapter 8, Section 8-3.1.11 "Storage Requirements" Section 8-3.1.11.2 "Storage of nonflammable gases less than 3000 cubic. feet.." (a) "Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. (c) "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by: (c) (2) A minimum distance of 5 ft. if the entire storage location is protected by an automatic sprinkler system..."

Findings Include:

On July 23, 2013 the surveyor, accompanied by the CEO, and Clinical Operations, observations include the following findings:

1. Shower room south, twelve E-O2 bottles stored next to combustibles

During the exit conference on July 23 rd. and 24th, the above findings were again acknowledged by Two CEOs, Vice President, Operations Manager, Director of Clinical Operations and the Director of Quality Risk

Leaking oxygen could penetrate combustible materials and create an extreme fire hazard, which could cause harm to the patients. In an emergency, patients could be harmed if an empty medical gas cylinder was mistakenly taken from the storage area.

A. Kindred Hospital Phoenix.
Survey on July 23, 2013

Based on Observation the facility allowed the use of a multiple outlet adapter, power strips and did not use the wall outlet receptacles for appliances, the facility failed to provide a guard on the light bulbs, and failed to provide receptacle face plates.

NFPA 101, Life Safety Code, 2000, Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 1999 Edition. NFPA 99, Chapter 3, Section 3-3.2.1.2, "All Patient Care Areas," Section 3-3.2.1.2 (d) Receptacles (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, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1, Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70 National Electrical Code." NEC, 1999, Article 110, Section 110-27 (b) Prevent Physical Damage. " In locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage. Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1. Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70 "National Electrical Code." NEC, 1999, Article 410, Section 410-56 (e) Position of Receptacle Faces. "3. After installation, receptacle faces shall be flush with or project from faceplate of insulating material and shall project a minimum of 0.015 in. From metal faceplate. Faceplate shall be installed so as to completely cover the opening and seat against the mounting surface."

Findings include:

On July 23, 2013 the surveyor, accompanied by the CEO, and Clinical Operations, observed the following deficiencies:

1. Second floor, mechanical room, J-box no cover, exposed energized electrical
2. Second floor, Housekeeping supply, 110 outlet cover missing, exposed energized electrical

B. Kindred Hospital Northwest Phoenix
Findings include on Survey July 24, 2013

1. Plant Operations, Refrigerator plugged into power strip
2. FACP, three of three light units no covers
3. RRT, refrigerator plugged into power strip
4. RT Department refrigerator plugged into power strip

During the exit conference on July 23 rd. and 24th, the above findings were again acknowledged by Two CEOs, Vice President, Operations Manager, Director of Clinical Operations and the Director of Quality Risk.

The use of multiple outlet adapters could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.
Failure to keep light guards on the light could cause accidental damage or possibly a fire, which could cause harm to the patients.
Failing to repair broken receptacles and face plates may contribute to starting a fire by allowing the electrical wiring to short when an electrical appliance is plugged in or removed from the receptacle. A fire in the facility may cause harm to the patients.