HospitalInspections.org

Based on observations as referenced in the Life Safety report of survey completed 02/06/2020, the hospital failed to have an effective governing body ensuring a safe environment for patients.

The findings include:

The hospital failed to develop and maintain the facilities in a manner to ensure the safety of patients.

~ cross refer 482.41 Physical Environment - Tag A0700

Based on review of the hospital policy and procedures, review of medical records, and interviews with patients and staff, the hospital staff failed to provide a language interpreter for a Spanish speaking patient according to hospital policy for 2 of 2 sampled patients requiring an interpreter. (Patient #28 and Patient #27)

The findings include:

Review on 02/06/2020 of the hospital policy titled "Civil Rights - Communication with Persons of Limited English Proficiency" with a revision date 03/2015 revealed "...It is the policy of [Name of Facility] to provide communication aids (at no cost to the person being served) to Limited English Proficient (LEP) persons, including current and prospective patients, clients, family members, interested persons at al., to ensure them a meaningful opportunity to apply for, receive or participate in, or benefit from the services offered. The procedures outlined below will ... ensure that information about services, benefits, consent forms, waivers of rights ... are communicated to LEP persons in a language which they understand ... However, family members, or friends of the LEP persons will not be used as interpreters unless specifically requested by that individual and after the LEP person has understood that an offer of an interpreter at no charge to the person has been made by the facility ..."

Review on 02/06/2020 of the hospital policy titled "Patient Bill of Rights" with a revision date of 10/2013 revealed "... You have the right to have your illness, treatment, pain, alternatives and outcomes be explained in a manner you can understand. You have the right to interpretation services if needed ..."

1. Open medical record for Patient #28 revealed a 51-year-old male admitted to the hospital for hypertensive urgency (very high blood pressure with or without symptoms) on 01/30/2020 at 2347. Patient #28 had a past medical history of End stage renal disease - new to hemodialysis (process of purifying the blood of a person whose kidney are not working normally) and diabetes mellitus (high blood sugar). Review of the "Patient Demographics" revealed "Language: Spanish". Review revealed no documentation of use of a Spanish interpreter for communication with Patient #28.

Interview on 02/06/2020 at 1030 with Patient #28 with the aide of Spanish Interpreter #1 revealed Patient #28 did not understand everything that was said to him. Interview revealed Patient #28 did not know a Spanish Interpreter was available either in person or via the "Marti" system (computer screen that can be used for patient to see and hear interpreter). Interview revealed since admission, the staff had not used an interpreter prior to this surveyor's interview. Interview revealed Patient #28 would like a Spanish Interpreter to be used so he could ask questions and understand his plan of care.

Interview on 02/06/2020 at 1138 with MD (Medical Doctor) #4 revealed she was the primary medical provider for Patient #28. Interview revealed MD #4 used Patient #28's sister during rounds to interpret for Patient #28. Interview revealed MD #4 would normally use the Marti system for a Spanish Interpreter. Interview revealed MD #4 did not verify if Patient #28 was ok using a family member to interpret.

Interview on 02/06/2020 at 1100 with RN (Registered Nurse) #5 revealed she was the primary nurse for Patient #28. Interview revealed Patient #28's primary language was Spanish. Interview revealed RN #5 did not use an interpreter to explain medications or a treatment plan and time for dialysis to Patient #28. Interview revealed Patient #28 could speak some "broken English". Interview revealed because Patient #28 could answer "yes" to questions, RN #5 thought he understood everything.

Interview on 02/06/2020 at 1320 with the Clinical Coordinator revealed the expectation is the aide of either the Marti system, the language line, or get the interpreter for Spanish speaking patients.

2. Open medical record for Patient #27 revealed a 75-year-old female admitted to the hospital on 02/03/2020 at 2000 for dialysis. Patient #27 had a past medical history for itching, CKD (Chronic Kidney Disease) and Diabetes Mellitus (high blood sugar). Review of the "Patient Demographics" revealed "Language: Spanish". Review of "Progress Note - Non-Provider" dated 02/04/2020 at 0805 revealed Spanish Interpreter #1 was used to interpret for "Encounter Type: Medical Team Rounds, Assessment, Signed Consent for Dialysis". Review of the "Progress Note - Non-Provider" dated 02/05/2020 at 1414 revealed Spanish Interpreter #1 was used to interpret for "Encounter Type: Dietitian Consult". Review revealed no further documentation of a Spanish Interpreter being used to communicate with Patient #27.

Interview on 02/06/2020 at 1235 with Patient #27 with the aide of a telephone interpreter revealed Patient #27's family was used to interpret for Patient #27. Interview revealed if family was not present, Patient #27 called them on her personal cell phone to have them interpret for her. Interview revealed Patient #27 was not aware the hospital had access to a Spanish Interpreter to communicate with her.

Interview on 02/06/2020 at 1314 with MD #2 revealed he was the primary medical provider for Patient #27. Interview revealed MD #2 used Patient #27's family member to interpret on his first day of caring for Patient #27. Interview revealed MD #2 knew some medical words in Spanish and used that to confirm Patient #27 was not in pain and was comfortable. Interview revealed MD #2 knew "that was not what he was supposed to do nor appropriate to do". Interview revealed MD #2 was aware the Marti system could be used for a Spanish Interpreter.

Interview on 02/06/2020 at 1255 with RN #3 revealed she was the primary nurse for Patient #27. Interview revealed Patient #27 primarily spoke Spanish. Interview revealed RN #3 had not used a Spanish Interpreter with Patient #27 today. Interview revealed Patient #27 could answer yes/no questions.

Interview on 02/06/2020 at 1320 with the Clinical Coordinator revealed the expectation is the aide of either the Marti system, the language line, or get the interpreter for Spanish speaking patients.

Based on observations as referenced in the Life Safety report of survey completed 02/06/2020, the hospital failed to develop and maintain the facilities in a manner to ensure the safety of patients.

Findings included:

The hospital failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association.

~Cross-refer to 482.41(a)(1) Physical Environment Standard Tag A-0702.

~Cross-refer to 482.41(b) Physical Environment Standard Tag A-0709.

Based on observations, staff interview, and/or documentation on 02/042020 at approximately 10 AM onward the hospital staff failed to assure the safety of patients, staff, and visitors by failing to ensure the essential electrical system was maintained to provide emergency power and lighting to critical and appropriate areas of the hospital during outages of normal power.

Findings included:

Building 1:

1. Penthouse from 5th floor did not have emergency lighting. Reference 2012 NFPA 101 section 7.8

2. First floor from door 1-072, near elevator #4, exit egress did not have emergency lighting at the door.
Reference 2012 NFPA 101 section 19.2.8, 7.8 Reference NFPA 101 7.8.1.3 The minimum illumination for floors and walking surfaces shall be to values of at lease 1 ft-candle (10.8 lux), measured at the floor. Reference NFPA 101 7.8.1.4 Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2.2 lux) in any designated area.

This deficiency affected 2 of 26 smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0281

Building 2:

A) 1. The remote generator annunciator located at the emergency department did not provide a signal for loss of battery charger AC failure when checked. Generator #1 and #2. Reference 2012 NFPA 99 section 6.4.1.1.16.2 (Table item O)

2. The remote generator annunciator located at the emergency department did not provide a signal for EPS supplying load when checked. Generator #3 for the women's center. Reference 2012 NFPA 99 section 6.4.1.1.16.2 (Table item J)

This deficiency affected all smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0916

B) 1. The transfer switch to Generator #3 did not transfer from normal to emergency connected load within 10 sec. Transfer took approximately 14 seconds.
Reference 2012 NFPA 101 Sections 19.2.9.1 Emergency lighting shall be provided in accordance with section 7.9
Reference 2012 NFPA 101 Section 7.9.1.3 Where maintenance of illumination depends on changing from one energy source to another, a delay of not more than 10 seconds shall be permitted.

2. There was not an emergency light located in the transfer switch room for Generator #3.
Reference 2012 NFPA 101, 2010 NFPA 110 section 7.3.1 The level 1 or level 2 EPS equipment location (s) shall be provided with battery-powered emergency lighting.

3. The generator fuel test for Generator #1, #2, and #3 from 2019 showed fuel test had failed in quality.
Reference 2012 NFPA 101, 2010 NFPA 110 section 8.3.8 A fuel quality test shall be performed at least annually using test approved by ASTM standards.

This deficiency affected all smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0918

Building 3:

1. The remote generator annunciator located at the emergency department did not provide a signal for loss of battery charger AC failure when checked. Generator #2. Reference 2012 NFPA 99 section 6.4.1.1.16.2 (Table item O)

This deficiency affected 12 of 12 smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0916

Building 4:

1. The exit from the hyperbaric suite to the public way did not have emergency lighting installed.
Reference 2012 NFPA 101 section 7.8

This deficiency affected 1 of 1 smoke compartment.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0281

Based on observations, staff interview, and/or documentation on 02/042020 at approximately 10 AM onward the hospital staff failed to the hospital staff failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association ensuring that the life safety from fire requirements are met.

Findings included:

Building 1:

A) 1. The ceiling has penetrations and is not in able to maintain the required rating of the ceiling assembly in the following areas.
a. Ground floor, mechanical room #4, aka old boiler room
b. Ground floor, ceiling tile room, behind the light fixture
c. First floor, imaging #2, 4"x 6" penetration in the wall
Reference 2012 NFPA 101 Sections 19.1.6.1, 8.2.1

This deficiency affected 1 of 26 smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0161

B) 1. Ground floor, medical records exit discharge had a car in the discharge path to the public way.
Reference 2012 NFPA 101 Sections 19.2.1, 7.1.10.1 Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency.

This deficiency affected 1 of 26 smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0211

C) 1. The emergency department door E 4 hardware sticks. The door was equipped with delayed egress locking, once locking had released the door stuck and did not open with 15 lbs of pressure. Reference 2012 NFPA 101 Sections 19.2.2.2, 7.2.1.6.1 (a) The force shall not be required to exceed 15 lbf (67 N).

2. The emergency department doors, two doors, were equipped with delayed egress locking that would not release with fire alarm activation with smoke detectors. The door did release with delayed egress.
Reference 2012 NFPA 101 Sections 19.2.2.2, 7.2.1.6.1
(1) The door leaves shall unlock in the direction of egress upon actuation of one of the following: (a) Approved, supervised automatic sprinkler system in accordance with section 9.7 (b) Not more than one heat detector of an approved, supervised automatic fire detection system in accordance with section 9.6 (c) Not more than two smoke detectors of an approved, supervised automatic fire detection system in accordance with section 9.6
(2) The door leaves shall unlock in the direction of egress upon loss of power controlling the lock or locking mechanism.
(3) An irreversible process shall release the lock in the direction of egress within 15 seconds, or 30 seconds where approved by the authority having jurisdiction, upon application of a force to the release device required in 7.2.1.5.10 under all of the following conditions: (a) The force shall not be required to exceed 15 lbf (67 N). (b) The force shall not be required to be continuously applied for more than 3 seconds. (c) The initiation of the release process shall activate an audible signal in the vicinity of the door opening. (d) Once the lock has been released by the application of force to the releasing device, relocking shall be by manual means only.
(4) A readily visible, durable sign in letters not less than 1 in. (25mm) high and not less than 1/8" (3.2 mm) in stroke width on a contrasting background that reads as follows shall be located on the door leaf adjacent to the release device in the direction of egress: PUSH UNTIL ALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS
(5) The egress side of doors equipped with delayed-egress locks shall be provided with emergency lighting in accordance with section 7.9

This deficiency affected 2 of 26 smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0222

D) 1. Second west stair C exit door did not latch in it's frame.
Reference 2012 NFPA 101 section 19.2.2.3, 19.2.2.4, 7.2

This deficiency affected 1 of 26 smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0225

E) 1. Third floor exit from the roof to the stairwell, near sleep lab & elevators 4 & 5, had a padlock that was removed.
Reference 2012 NFPA 101 section 19.2.7 Discharge from exits, 7.7 Discharge from exits.

This deficiency affected 1 of 26 smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0271

F) 1. Penthouse from 5th floor did not have exit signage. Reference 2012 NFPA 101 19.2.10.1, 7.10.1.5.1 Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants.

2. Ground floor by door G 018 there was not an exit sign. Reference 2012 NFPA 101 19.2.10.1, 7.10.1.5.1 Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants.

This deficiency affected 2 of 26 smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0293

G) 1. The storage room doors in the following areas did not have a closure, nor confirmed as one hour rated. The room was greater than 50 square feet and is used for storage of combustible materials.
a. Fifth floor storage room door, near room 508
b. Fourth floor, room 404
c. First floor lab storage room across from the switch board
Reference 2012 NFPA 101, 19.3.2.1 Hazardous Areas. 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 8.7.1.
Reference 2012 NFPA 101 19.3.2.1.3 The doors shall be self-closing or automatic-closing.

This deficiency affected 3 of 26 smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0321

H) 1. There was a smoke detector within 3' of the supply or return in the following areas:
a. Fifth floor, near administration/stairwell
b. Fourth floor, near Dept of Social Services office
c. Second floor west, near room 272
d. Ground floor, by med staff lounge (mini space heater near detector)
Reference 2012 NFPA 101 section 19.3.6.1, 2010 NFPA 72 17.7.4.1 In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors. Detectors should not be located in a direct airflow or closer than 36 in. (910 mm) from an air supply diffuser or return air opening.

This deficiency affected 4 of 26 smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0347

I) 1. Penthouse from 5th floor sprinkler head flush against an HVAC supply duct. Reference 2012 NFPA 101 section 19.3.5.1, 9.7, 2011 NFPA 25 section 5.2.1.1.3 sprinkler shall be installed in the correct orientation.

2. Ground floor beside quality insurance office at ladies bathroom had a sprinkler head within 1-3/4" from the wall. Reference 2012 NFPA 101 section 19.3.5.1, 2010 NFPA 13 8.6.3.3 Sprinklers shall be located a minimum of 4 in. (102 mm) from a wall.

This deficiency affected 2 of 26 smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0351

J) 1. The supervisory signal for the electronically supervised tamper alarm on the sprinkler control valve could be silenced permanently at the Fire Alarm Control Panel (FACP) when the valve was in the closed position in the sprinkler riser room. Supervisory signals shall not be silenced permanently except by reopening/restoration of the valve to the normal operating position.

Reference 2012 NFPA 101 Section 19.3.5.1, 9.7.2.1 Where supervised automatic sprinkler systems are required by another section of this code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, AND a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Supervisory signals shall sound and shall be displayed at a location within the protected building that is constantly attended by qualified personnel.

This deficiency affected all smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0352

K) 1. Fourth floor equipment room door swings into the means of egress and in the fully open position projects more than 7 inches into the required width of an aisle without a closure.
Reference 2012 NFPA 101 section 7.2.1.4.3.1 During its swing, any door leaf in a means of egress shall leave not less than one-half of the required width of an aisle, or corridor, a passageway, or a landing unobstructed and shall project not more than 7 in (180 mm) into the required width of an aisle, a corridor, a passageway, or a landing, when fully open.

2. Fifth floor door, next to the CFO office, opened into the means of egress had the closure disconnected.
Reference 2012 NFPA 101 section 7.2.1.4.3.1 During its swing, any door leaf in a means of egress shall leave not less than one-half of the required width of an aisle, or corridor, a passageway, or a landing unobstructed and shall project not more than 7 in (180 mm) into the required width of an aisle, a corridor, a passageway, or a landing, when fully open.

3. Second floor, door between rooms 205 & 207 storage room did not close and latch in it's frame.
Reference 2012 NFPA 101 section 19.3.6.3.4 Door shall be provided with a means for keeping the door closed.

4. First floor endoscopy workstation by day surgery had a kick down on the corridor door.
Reference 2012 NFPA 101 section 19.3.6.3.10 There is no impediment to the closing of the doors.

This deficiency affected 4 of 26 smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0363

L) 1. Penetrations were not sealed in order to maintain the required fire resistance rating of the smoke barrier wall. UL approved fire stop application had not been supplied to the following areas.
a. Third floor, pharmacy back corridor separation between the old and new building
b. Second floor, IT room, pass the electrical room, 4" conduits
c. Second floor west, case management, above cross corridor doors
d. Second floor west, cardiac recovery, above doors, data cable bundle
e. Ground floor, above doors G 060 & G 057
Reference 2012 NFPA 101 19.3.7.3 Any required smoke barrier shall be constructed in accordance with section 8.5 and shall have a minimum 1/2 hour fire resistance rating.

This deficiency affected 10 of 26 smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0372

M) 1. Fifth floor room 527 receptacle within 6' of a water source and not GFCI protected. Reference 2012 NFPA 101, 2011 NFPA 70 section 210.8 (7) GFCI protected circuits shall be located in areas other than kitchens where receptacles are installed within 1.8 m (6 ft) of the outside edge of the sink.

2. Fourth floor staff kitchen behind refrigerator receptacle within 6' of a water source and not GFCI protected. Reference 2012 NFPA 101, 2011 NFPA 70 section 210.8 (7) GFCI protected circuits shall be located in areas other than kitchens where receptacles are installed within 1.8 m (6 ft) of the outside edge of the sink.

3. Fifth floor copy room across from elevator #2 had a painted receptacle. Reference 2012 NFPA 101, 2011 NFPA 70 110.12 (b) Mechanical execution of work

4. Fourth floor near room 411 had a painted receptacle. Same receptacle had no tension when tested. Reference 2012 NFPA 101, 2011 NFPA 70 110.12 (b) Mechanical execution of work

5. Fifth floor room 527 E had a chipped receptacle. Reference 2012 NFPA 101, 2011 NFPA 70 110.12 (b) Mechanical execution of work

6. Penthouse panel PNLQHPA had four breakers removed without blank covers. Reference 2012 NFPA 101 Sections 19.5.1.1, 9.1.2 2011 NFPA 70 NEC Section 408.7

7. Second floor elevator lobby near utility room had a loose receptacle. Reference 2012 NFPA 101, 2011 NFPA 70 110.12 (b) Mechanical execution of work

8. Second floor west equipment room/data closet by nurses station, had a drop cord going through the ceiling. Reference 2012 NFPA 101, 2011 NFPA 70 110.12 (b) Mechanical execution of work

9. Second floor west cardiac recovery kitchen ice maker, exposed/frayed wiring/cord. Reference 2012 NFPA 101, 2011 NFPA 70 110.12 (b) Mechanical execution of work

10. Second floor west cardiac recovery kitchen receptacle within 6' of a water source and not GFCI protected. Reference 2012 NFPA 101, 2011 NFPA 70 section 210.8 (7) GFCI protected circuits shall be located in areas other than kitchens where receptacles are installed within 1.8 m (6 ft) of the outside edge of the sink.

11. Second floor room 211 receptacle within 6' of a water source and not GFCI protected. Reference 2012 NFPA 101, 2011 NFPA 70 section 210.8 (7) GFCI protected circuits shall be located in areas other than kitchens where receptacles are installed within 1.8 m (6 ft) of the outside edge of the sink.

12. First floor radiology staff locker room north wall had a chipped receptacle. Reference 2012 NFPA 101, 2011 NFPA 70 110.12 (b) Mechanical execution of work

13. First floor radiology north bay had 3 chipped receptacles. Reference 2012 NFPA 101, 2011 NFPA 70 110.12 (b) Mechanical execution of work

14. First floor speech pathology workstation near sink had a chipped receptacle. Reference 2012 NFPA 101, 2011 NFPA 70 110.12 (b) Mechanical execution of work

15. First floor Women's Pavilion physicians lounge on call bedroom #2 light switch loose and not functioning properly. Reference 2012 NFPA 101, NFPA 70, 2011 NEC 110.12 (b) Mechanical execution of work.

16. First floor Women's Pavilion server room had a wire mold to equipment hanging. Reference 2012 NFPA 101, 2011 NFPA 70 110.12 (b) Mechanical execution of work

This deficiency affected 15 of 26 smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0511

N) 1. Fifth floor rooms 526 E and 527 E bathroom exhausts was not functioning. Reference 2012 NFPA 101 19.7.7, 4.6.12 , 2011 NFPA 70 National Electric Code

2. First floor above the bronchscopy room near the switchboard the smoke damper did not function. Reference 2012 NFPA 101, 19.5.2.1, 9.2, 2012 NFPA 90A section 5.4.8.1

3. Ground floor, old ceiling tile room, emergency air handler shut down switch to AHU#3 did not shut down the unit. Reference 2012 NFPA 101, 19.5.2.1, 9.2, 2012 NFPA 90A section 6.4.3

This deficiency affected 4 of 26 smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0521

O) 1. Receptacle annual testing was not available at the time of the survey.
Reference 2012 NFPA 99 section 6.3.4.1 Receptacles shall be test at intervals not exceeding 12 months.

2. First floor Women's Pavilion near door #6 had a GFCI receptacle when tripped the electrical panel NL1A-70 was not properly labeled so to reset the GFCI receptacle. Label panel as to circuits served. NFPA 101: 19.5.1
NFPA 99: 6.3.3.2

3. First floor Women's Pavilion electrical panel NCR1A-1 circuit #1 and #9 were not functioning properly. When #1 was tripped #9 went out as well and vise versa, when #9 was tripped #1 went out as well.

This deficiency affected all smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0914

P) 1. Fifth floor, near room 525 E, zone valves were not labeled. The label was located on the removable box cover but not on the valve itself. Reference 2012 NFPA 99 Section 5.1.4.8.8 Zone valves shall be labeled in accordance with 5.1.11.2

2. Second floor, near room 225, zone valves were not labeled. The label was located on the removable box cover but not on the valve itself. Reference 2012 NFPA 99 Section 5.1.4.8.8 Zone valves shall be labeled in accordance with 5.1.11.2

3. First floor med gas storage room had H size oxygen tanks gang chained together. Reference 2012 NFPA 19.3.2.4, 99 11.6.2.3 (11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

This deficiency affected 3 of 26 smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0923

Building 2:

A) 1. Ground floor, sterile processing small closet next to environmental closet. The ceiling is not in good condition to maintain the required rating of the ceiling assembly. Reference 2012 NFPA 101 Sections 19.1.6.1, 8.2.1

This deficiency affected 1 of 16 smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0161

B) 1. Ground floor, central supply storage, confirm all doors have closures. The room was greater than 50 square feet and is used for storage of combustible materials.

Reference 2012 NFPA 101, 19.3.2.1 Hazardous Areas. 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 8.7.1. Reference 2012 NFPA 101 19.3.2.1.3 The doors shall be self-closing or automatic-closing.

2. First floor, the operating room sterile core confirm all doors have closures. The room was greater than 50 square feet and is used for storage of combustible materials.
Reference 2012 NFPA 101, 19.3.2.1 Hazardous Areas. 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 8.7.1. Reference 2012 NFPA 101 19.3.2.1.3 The doors shall be self-closing or automatic-closing.

This deficiency affected 2 of 16 smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0321

C) 1. Ground floor, sterile processing small closet next to environmental closet. Sprinkler head within two inches of the wall.
Reference 2012 NFPA 101 section 19.3.5.1, 2010 NFPA 13 8.6.3.3 Sprinklers shall be located a minimum of 4 in. (102 mm) from a wall.

This deficiency affected 1 of 16 smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0351

D) 1. Second floor, Progressive Care Unit (PCU), above the doors, there were penetrations in the smoke barrier that are not sealed in order to maintain the required fire resistance rating of the wall.
Reference 2012 NFPA 101 19.3.7.3 Any required smoke barrier shall be constructed in accordance with section 8.5 and shall have a minimum 1/2 hour fire resistance rating.

This deficiency affected 1 of 16 smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0372

E) 1. Second floor across from ICU #11, Empty E-sized oxygen storage was within five foot of combustibles.
Reference 2012 NFPA 99 Section 11.3.2.3 Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following:
(1) Minimum distance of 6.1 m (20 ft)
(2) Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13.3
(3) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1/2 hour.

This deficiency affected 1 of 16 smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0923

Building 3:

A) 1. First floor, sterile corridor/storage, could not confirm all doors have closures. The room was greater than 50 square feet and is used for storage of combustible materials.
Reference 2012 NFPA 101, 19.3.2.1 Hazardous Areas. 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 8.7.1.
Reference 2012 NFPA 101 19.3.2.1.3 The doors shall be self-closing or automatic-closing.

This deficiency affected 1 of 12 smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0321

B) 1. There were two of four sprinkler systems that were not tied to the main fire alarm panel. The MRI and IT room sprinkler systems had annunciator panels in the mechanical room only and not in an area likely to heard 24/7. Confirm dry system for the canopy is on the main fire alarm system. Reference 2012 NFPA 101 section 19.3.5.1, 9.7, 9.7.2

2. First floor accelerated claims office had a sprinkler head drop that was several inches lower than the ceiling.
Reference 2012 NFPA 101 section 19.3.5.1, 9.7, 2011 NFPA 25 section 5.2.1.1.3 sprinkler shall be installed in the correct orientation.

This deficiency affected 12 of 12 smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0351

C) 1. The supervisory signal for the electronically supervised tamper alarm on the sprinkler control valve could be silenced permanently at the Fire Alarm Control Panel (FACP) when the valve was in the closed position in the sprinkler riser room. Supervisory signals shall not be silenced permanently except by reopening/restoration of the valve to the normal operating position.
Reference 2012 NFPA 101 Section 19.3.5.1, 9.7.2.1 Where supervised automatic sprinkler systems are required by another section of this code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, AND a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Supervisory signals shall sound and shall be displayed at a location within the protected building that is constantly attended by qualified personnel.

This deficiency affected 12 of 12 smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0352

D) 1. First floor, short stay, 14 rooms had a normal and critial branch circuits within six foot of a water source that was not GFCI protected.
Reference 2012 NFPA 19.5.1.1, 9.1.1, 9.1.2, NFPA 70, National Electric Code

2. First floor, EVS floor care room had a receptacle within six foot of a water source that was not GFCI protected.
Reference 2012 NFPA 19.5.1.1, 9.1.1, 9.1.2, NFPA 70, National Electric Code

3. Third floor, storage room receptacle did not have power when tested.
Reference 2012 NFPA 19.5.1.1, 9.1.1, 9.1.2, NFPA 70, National Electric Code

4. Second floor, receptacle between rooms 214 and 215 identified as CRL-2A-16 show open neutral when tested.
Reference 2012 NFPA 19.5.1.1, 9.1.1, 9.1.2, NFPA 70, National Electric Code

This deficiency affected 4 of 12 smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0511

E) 1. The smoke dampers located at the employee entrance and at the birth center elevator did not close with fire alarm activation nor smoke detector activation. Reference 2012 NFPA 101, 2010 NFPA 90A: 6.4.3.1

This deficiency affected 2 of 12 smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0521

E) 1. Receptacle annual testing was not available at the time of the survey.
Reference 2012 NFPA 99 section 6.3.4.1 Receptacles shall be test at intervals not exceeding 12 months.

This deficiency affected 12 of 12 smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0914

Building 4:

A) 1. The exit from the hyperbaric suite to the public way did not have emergency lighting installed.
Reference 2012 NFPA 101 section 7.8

This deficiency affected 1 of 1 smoke compartment.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0281

B) 1. There were two illuminated exit signs that were not functioning properly in the exit from the hyperbaric suite to the public way.
Reference 2012 NFPA 101 section 7.10

This deficiency affected 1 of 1 smoke compartment.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0293

C) 1. There was a smoke detector within 3' of the supply or return in the following areas:
a. Patient changing room
b. Electrical room in the hyperbaric lab area
Reference 2012 NFPA 101 section 19.3.6.1, 2010 NFPA 72 Sect 17.7.4.1 In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors. Detectors should not be located in a direct airflow or closer than 36 in. (910 mm)from an air supply diffuser or return air opening.

This deficiency affected 1 of 1 smoke compartment.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0347

D) 1. The clean utility light switch was loose and not functioning properly. Reference 2012 NFPA 101, NFPA 70, 2011 NEC 110.12 (b) Mechanical execution of work

2. The ground fault circuit interrupter circuit (GFCI) was chipped and the box housing loose from the wall in the following rooms: 1,3,6 and 7. Reference 2012 NFPA 101, NFPA 70

This deficiency affected 1 of 1 smoke compartment.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0511

E) 1. Zone valves located in the intervening hallway were not labeled. The label was located on the removable box cover but not on the valve itself. Reference 2012 NFPA 99 Section 5.1.4.8.8 Zone valves shall be labeled in accordance with 5.1.11.2

2. Zone valve, to medical air, located in the intervening hallway was open but there was no pressure on the analog gauge.
Reference 2012 NFPA 99 Section 14.3.4.1.1 The hyperbaric safety director shall ensure that all valves, regulators, meters, and similar equipment used in the hyperbaric chamber are compensated for use under hyperbaric conditions and tested as part of the routine maintenance program of the facility.

This deficiency affected 1 of 1 smoke compartment.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0923

F) 1. The hyperbaric chamber blow off on the roof was not properly labeled.
Reference 2012 NFPA 99 14.2.9.2.5 The point of exhaust shall be identified as an oxygen exhaust by a sign prohibiting smoking or open flame.

2. The hyperbaric chamber blow off on the roof did not have a screen/cover.
Reference 2012 NFPA 99 14.2.9.2.4 The point of exhaust shall be protected by the provision of a minimum of 0.3 cm (0.12 in.) mesh screen and situated to prevent the intrusion of rain, snow, or airborne debris.

This deficiency affected 1 of 1 smoke compartment.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0924

Based on observations during tour and staff interview, the hospital failed to ensure equipment used for physical therapy was maintained and safe for patient use for 2 of 3 physical therapy mats.

The findings include:

Observation during tour on 02/06/2020 at 1120, revealed two of the three flat mats on which patients lie to perform physical therapy had torn upholstery on the cushion side of the table which was unable to be cleaned or disinfected.

Observation during tour on 02/06/2020 at 1200 revealed a patient lying supine on a patient therapy mat which contained torn upholstery.

Interview during the observation on 02/06/2020 at 1120 with the Director of Rehab Services revealed she was unsure who or if anyone checked the mats for tears in the upholstery. Interview revealed the director wasn't aware that mats with torn upholstery were not safe for patient use.