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Based on document review and staff interview, the facility fails to test and maintain their emergency light systems in accordance with NFPA 101. This deficient practice would affect no patients and all visitors, and staff in 1 of 5 smoke zones. The facility has a capacity of 25 with a census of 3 at the time of the survey.

Findings include:

During the survey conducted on 7/23/18 and 7/24/2018 the following deficiency is noted:

1. At approximately 10:43 AM on 7/24/2018, it is observed that in the Major ER the emergency light failed to illuminate when tested.

Staff A was present and acknowledged the finding.

NFPA Standard: NFPA 101 2012 7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows: (1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2). (2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction. (3) Functional testing shall be conducted annually for a minimum of 11?2 hours if the emergency lighting system is battery powered. (4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3). (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Based on observation and staff interview the facility fails to ensure proper separation of hazardous areas from other spaces. This deficient practice would affect all patients, visitors, and staff in 5 of 5 smoke zones. The facility has a capacity of 25 with a census of 3 at the time of the survey.

Findings include:

During the survey conducted on 7/23/18 and 7/24/2018 the following deficiencies are noted:

1. At approximately 9:22 AM on 7/24/2018, it is observed that the door to biohazard room 329 does not properly close or latch.

2. At approximately 9:26 AM on 7/24/2018, it is observed that the boiler room has multiple unsealed penetrations along the
corridor wall that would not resist the passage of smoke.

3. At approximately 10:34 AM on 7/24/2018, it is observed that the door to Storage room 111 has no closing device.

4. At approximately 10:35 AM on 7/24/2018, it is observed that the door to Storage room 112 has no closing device.

5. At approximately 10:40 AM on 7/24/2018, it is observed that the door to Laboratory room 514 has no closing device.

Staff A was present and acknowledged the findings.

NFPA Standard: 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. 2012 NFPA 101, 19.3.2.1

NFPA Standard: Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. 19.3.2.1

Based upon observation and staff interview, the facility fails to assure that cooking equipment is protected and maintained in a in accordance with the requirements of NFPA 10. This deficient practice would affect no patients and all visitors, and staff in 1 of 5 smoke zones. The facility has a capacity of 25 with a census of 3 at the time of the survey.

Findings include:

During the survey conducted on 7/23/18 and 7/24/2018 the following deficiency is noted:

1.At approximately 9:10 AM on 7/24/2018, It is observed that there is no placard placed in the kitchen for the class K fire extinguisher to be activated before the hood system.

Staff A was present and acknowledged the finding.

NFPA Standard: NFPA 10 5.5.5.3 A placard shall be conspicuously placed near the extinguisher that states that the fire protection system shall be actuated prior to using the fire extinguisher.

Based on staff interview and observation, the facility fails to install and maintain their Alcohol Based Hand Rub dispensers in accordance with NFPA 101.This deficient practice would affect all patients, visitors, and staff in 1 of 5 smoke zones. The facility has a capacity of 25 with a census of 3 at the time of the survey.

Findings include:

During the survey conducted on 7/23/18 and 7/24/2018 the following deficiency is noted:

1. At approximately 9:42 AM on 7/24/2018, It is observed that in room 333 the alcohol-based hand sanitizer dispenser is directly above the light switch.

Staff A was present and acknowledged the finding.

NFPA Standard: Life Safety Code 101 2012 19.3.2.6* Alcohol-Based Hand-Rub Dispensers. Alcohol-based hand-rub dispensers shall be protected in accordance with 8.7.3.1, unless all of the following conditions are met: (8) Dispensers shall not be installed in the following locations: (a) Above an ignition source within a 1 in. (25 mm) horizontal distance from each side of the ignition source (b) To the side of an ignition source within a 1 in. (25mm) horizontal distance from the ignition source (c) Beneath an ignition source within a 1 in. (25 mm) vertical distance from the ignition source.

Based on record review, observation and staff interview, this facility is not maintaining the sprinkler system in accordance with the 2011 edition of NFPA 25 by not providing complete documentation of monthly visual inspections of the automatic, wet-pipe sprinkler system. This deficient practice would affect all patients, visitors, and staff in 5 of 5 smoke zones. The facility has a capacity of 25 with a census of 3 at the time of the survey.

Findings include:

During the survey conducted on 7/23/18 and 7/24/2018 the following deficiencies are noted:

1. At approximately 2:42 PM on 7/23/2018 during the review of records, it is discovered that there is no documentation of monthly visual inspections of the fire sprinkler system.

2. At approximately 8:59 AM on 7/24/2018 it is discovered that throughout the kitchen IT data wire is hanging or attached to the fire sprinkler pipes by zip ties.

3. At approximately 10:23 AM it is discovered that in storage room 305, on the west wall, there are pillows stacked closer than 18 inches to the sprinkler head.

Staff A was present and acknowledged the findings.

NFPA Standard: Automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25 per 2012 NFPA 101, 9.7.5.

NFPA Standard: Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. 2012 NFPA 101 4.6.12.1

NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 2012 NFPA 101, 4.6.12.1

Based on interview and record review, this facility is not assuring that a complete policy is in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than ten hours in any twenty-four-hour period. Lack of complete written policies and procedures could result in staff failing to implement interim safety measures in the event of an emergency. This deficient practice would affect all patients, visitors, and staff in 5 of 5 smoke zones. The facility has a capacity of 25 with a census of 3 at the time of the survey.

Findings include:

During the survey conducted on 7/23/18 and 7/24/2018 the following deficiency is noted:

1. At approximately 3:22 PM during record review on 7/23/2018, It is discovered that the Fire Watch policy does not include contact information for the insurance company or building owner.

Staff A was present and acknowledged the finding.

NFPA Standard: Where the inspection, testing, and maintenance of standpipe and hose systems results or involves a system that is out of service, the impairment procedures outlined in Chapter 15 shall be followed. 2011 NFPA 25 6.1.6

NFPA Standard: The following procedures shall implemented: the extent and expected duration of the impairment shall be determined; the areas or buildings involved have been inspected and the increased risks determined; recommendations submitted to management or the property owner or designated representative. Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following: evacuation of the building or portion of the building affected by the system out of service; an approved fire watch; establishment of a temporary water supply; establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire; the fire department has been notified; the insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified; the supervisors in the areas to be affected have been notified; tag impairment system has been implemented. (See Section 15.3.); all necessary tools and materials have been assembled on the impairment site. A fire watch should consist of trained personnel who continuously patrol the affected area, with ready access to fire extinguishers and the ability to promptly notify the fire department. During the patrol of the area, the person should be looking for fire, and other fire protection features of the building such as egress routes and alarm systems are available and functioning properly. 2011 NFPA 25, 15.5.2

Based on observation and staff interview the facility is not ensuring that room doors latch properly. This deficient practice of not ensuring that room doors latch properly prevents the ability of the facility to properly confine fire and smoke products. This deficient practice would affect all patients, visitors, and staff in 1 of 5 smoke zones. The facility has a capacity of 25 with a census of 3 at the time of the survey.

Findings include:

During the survey conducted on 7/23/18 and 7/24/2018 the following deficiency is noted:

1. At approximately 3:22 PM on 7/24/2018, it is discovered that the corridor door to room 321 is held open with a door wedge.

Staff A was present and acknowledged the finding.

Review of the following NFPA Standard revealed: Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following:
(1) 13?4 in. (44 mm) thick, solid-bonded core wood
(2) Material that resists fire for a minimum of 20 minutes
2012 NFPA 101, 19.3.6.3.1

Review of the following NFPA Standard revealed: Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply:
(1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.
(2) Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7.
2012 NFPA 101, 19.3.6.3.5

Review of the following NFPA Standard revealed: Doors shall not be held open by devices other
than those that release when the door is pushed or pulled. 2012 NFPA 101, 19.3.6.3.10

Based on observation and staff interview the facility fails to properly maintain their electrical systems in accordance with NFPA 70. This deficient practice would affect all patients, visitors, and staff in 5 of 5 smoke zones. The facility has a capacity of 25 with a census of 3 at the time of the survey.

Findings include:

During the survey conducted on 7/23/18 and 7/24/2018 the following deficiencies are noted:

1. At approximately 9:24 AM on 7/24/2018, it is observed that in the boiler room 344 Panel A has an open slot where a breaker or blank would normally be located.

2. At approximately 9:28 AM on 7/24/2018, it is observed that in boiler room 344 on the east wall wires are exposed out of conduit.

3. At approximately 10:49 AM on 7/24/2018, it is observed that in environmental services room 343 the electrical panel has an open section approximately 3x12 inches in diameter near the top of the panel.

4. At approximately 11:02 AM on 7/24/2018, it is observed that in room 333 the electrical panel is obstructed by a soiled linen cart.

5. At approximately 11:08 AM on 7/24/2018, it is observed that in room 335, below the electrical panel, there is an open junction box.

Staff A was present and acknowledged the findings.

NFPA Standard: Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2

Based upon a review of records and staff interview the facility is not inspecting and maintaining fire-rated door assemblies in compliance with NFPA 80. This deficient practice could prevent the ability of the facility to properly confine smoke and prevent fire from spreading to other areas of the building. This deficient practice would affect all patients, visitors, and staff in 5 of 5 smoke zones. The facility has a capacity of 25 with a census of 3 at the time of the survey.

Findings include:

During the survey conducted on 7/23/18 and 7/24/2018 the following deficiency is noted:

1. At approximately 3:31 PM during record review on 7/23/2018, It is discovered that there is no documentation for any inspection or testing of rated door assemblies or qualifications of staff.

Staff A was present and acknowledged the finding.

NFPA Standard: NFPA 80 2010 5.2.1 Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ. 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing. 5.2.4.2 As a minimum, the following items shall be verified: (1) No open holes or breaks exist in the surfaces of either the door or frame. (2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped. (3) The door, frame, hinges, hardware, and non combustible threshold are secured, aligned, and in working order with no visible signs of damage. (4) No parts are missing or broken. (5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7 (6) The self-closing device is operational; that is, the active door completely closes when operated from the open position. (7) If a coordinator is installed, the inactive leaf closes before the active leaf. (8) Latching hardware operates and secures the door when it is in the closed position. (9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame. (10) No field modifications to the door assembly have been performed that void the label. (11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity. 3.3.95 Qualified Person. A person who, by possession of a recognized degree, certificate, professional standing, or skill, and who by knowledge, training, and experience, has demonstrated the ability to deal with the subject matter, the work, or the project.

Based on observation and interview, the facility failed to maintain proper space heating appliances within the facility that have heating elements limited to 212 degrees Fahrenheit. This deficient practice would affect no patients and all visitors, and staff in 1 of 5 smoke zones. The facility has a capacity of 25 with a census of 3 at the time of the survey.

Findings include:

During the survey conducted on 7/23/18 and 7/24/2018 the following deficiency is noted:

1. At approximately 11:13 AM on 7/24/2018, It is discovered that there is a space heater in room 515.
Staff A was present and acknowledged the finding.

NFPA Standard: Prohibits the use of portable space heating devices in healthcare occupancies except for nonresident and staff sleeping areas with heating elements that exceed 212 degrees. 2012 NFPA 101, 18/19.7.8

Based on staff interview and document review, the facility failed to maintain and test their electrical receptacles and systems in accordance with NFPA 99. This deficient practice would affect all patients, visitors, and staff in 5 of 5 smoke zones. The facility has a capacity of 25 with a census of 3 at the time of the survey.

Findings include:

During the survey conducted on 7/23/18 and 7/24/2018 the following deficiency is noted:

1. At approximately 2:36 PM during record review on 7/23/2018, It is observed that there is no documentation for any electrical receptacle systems testing.

Staff A was present and acknowledged the finding.



NFPA Standard: NFPA 99 2012 6.3.3.2 Receptacle Testing in Patient Care Rooms 6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection. 6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified. 6.3.3.2.3 correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. 6.3.4.1 Maintenance and testing of Electrical System 6.3.4.1. 1 Where hospital-grade receptacles are required at patient bed location and in location where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device. 6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data. 6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months. 6.3.4.1.4 The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch (see 6.3.2.6.3.6). For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators. 6.3.4.1.5 After any repair or renovation to an electrical distribution system, the LIM circuit shall be tested in accordance with 6.3.3.3.2 6.4.4.1.2.1* Circuit Breakers. Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer's recommendations. 6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modification. 6.3.4.2.1.2 At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter. 6.3.4.2.2 Isolated Power System (Where Installed). A permanent record shall be kept of the results of each of the tests.

Based on record review and staff interview the facility failed to assure the generator is inspected and tested in accordance with NFPA 110 and fails to provide a remote shut-off for the generator. These deficient practices fail to ensure that the generator will not fail when needed in the event of an emergency and could result the inability to remotely discontinue electrical services of the generator to avoid electrocution. This deficient practice would affect all patients, visitors, and staff in 5 of 5 smoke zones. The facility has a capacity of 25 with a census of 3 at the time of the survey.

Findings include:

During the survey conducted on 7/23/18 and 7/24/2018 the following deficiencies are noted:

1. At approximately 8:36 AM during record review on 7/24/2018, it is discovered that there is no documentation of fuel quality testing for the generator.

2. At approximately 8:38 AM during the survey on 7/24/2018, it is discovered that there is no emergency remote shut off for the generator.

Staff A was present and acknowledged the findings.

Review of the following NFPA Standard revealed: EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. 2010 NFPA 110, 8.4.1

Review of the following NFPA Standard revealed: A permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available.
The permanent record shall include the following:
(1) The date of the maintenance report
(2) Identification of the servicing personnel
(3) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(4) Testing of any repair for the time as recommended by the manufacturer. 2010 NFPA 110, 8.3.4, 8.3.4.1
Review of the following NFPA Standard revealed: Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:

(1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
(2) Under operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating. 2010 NFPA 110, 8.4.2

Review of the following NFPA Standard revealed: 8.4.2.3 Diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours.. 2010 NFPA 110, 8.4.2.3

Review of the following NFPA Standard revealed: For a diesel-powered EPS, loading shall be not less than 30 percent of the nameplate kW rating of the EPS. A supplemental load bank shall be permitted to be used to meet or exceed the 30 percent requirement. 8.4.9.5.2 For a diesel-powered EPS, loading shall be that which maintains the minimum exhaust gas temperatures as recommended by the manufacturer. 2010 NFPA 110, 8.4.9.5.1

NFPA Standard: All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.

NFPA Standard: For Level 1 and Level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.

Based on observation and staff interview, the facility failed to properly protect and store compressed gasses as required by NFPA 99. This deficient practice would affect all patients, visitors, and staff in 1 of 5 smoke zones. The facility has a capacity of 25 with a census of 3 at the time of the survey.

Findings include:

During the survey conducted on 7/23/18 and 7/24/2018 the following deficiency is noted:

1. At approximately 10:02 AM on 7/24/2018, it is discovered that in room the oxygen storage room 341, one of the oxygen storage racks is constructed of a non-fire-retardant wood material.

Staff A was present and acknowledged the finding.

NFPA Standard: NFPA 99 5.1.3.3.2* Design and Construction. Locations for central supply systems and the storage of positive-pressure gases shall meet the following requirements: (1) They shall be constructed with access to move cylinders,
equipment, and so forth, in and out of the location on hand trucks complying with 11.4.3.1.1. (2) They shall be secured with lockable doors or gates or otherwise secured. (3) If outdoors, they shall be provided with an enclosure (wall or fencing) constructed of noncombustible materials with a minimum of two entry/exits. (4) If indoors, they shall be constructed and use interior finishes
of noncombustible or limited-combustible materials such that all walls, floors, ceilings, and doors are of a minimum 1-hour fire resistance rating. (5)*They shall be compliant with NFPA 70, National Electrical Code, for ordinary locations. (6) They shall be heated by indirect means (e.g., steam, hot water) if heat is required. (7) They shall be provided with racks, chains, or other fastenings
to secure all cylinders from falling, whether connected, unconnected, full, or empty. (8)*They shall be supplied with electrical power compliant with the requirements for essential electrical systems as described in Chapter 6. (9) They shall have racks, shelves, and supports, where provided, constructed of noncombustible materials or limited-combustible materials. (10) They shall protect electrical devices from physical damage.

Based on staff interview and document review the facility fails to properly train and document their staff on the proper handling of compressed gas equipment in accordance with NFPA 99. This deficient practice would affect all patients, visitors, and staff in 5 of 5 smoke zones. The facility has a capacity of 25 with a census of 3 at the time of the survey.

Findings include:

During the survey conducted on 7/23/18 and 7/24/2018 the following deficiency is noted:

1. At approximately 8:42 AM during record review on 7/23/2018, it is discovered that there is no documentation for any medical gas training for staff members.

Staff A was present and acknowledged the finding.

NFPA Standard: NFPA 99 11.5.2 Gases in Cylinders and Liquefied Gases in Containers.
11.5.2.1 Qualification and Training of Personnel. 11.5.2.1.1* Personnel concerned with the application and maintenance of medical gases and others who handle medical gases and the cylinders that contain the medical gases shall be trained on the risks associated with their handling and use. 11.5.2.1.2 Health care facilities shall provide programs of continuing education for their personnel. 11.5.2.1.3 Continuing education programs shall include periodic review of safety guidelines and usage requirements for
medical gases and their cylinders. 11.5.2.1.4 Equipment shall be serviced only by personnel trained in the maintenance and operation of the equipment. 11.5.2.1.5 If a bulk cryogenic system is present, the supplier shall provide annual training on its operation.