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Based on observation and staff interview, it was determined the facility failed to maintain a safe exit access from the area of refuge from the fifth floor to the first floor. Failure to provide a clear and unimpeded means of egress has potential to cause harm to the patients and staff in a fire emergency.

NFPA 101, Life Safety Code, 2012, Chapter 19, Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7." Chapter 7 Section 7.2.2.5 "Enclosures and Protection of Stairs", Section 7.2.2.5.3 "Usable Space. Enclosed usable spaces within exit enclosures shall be prohibited, including under stairs, unless otherwise permitted by 7.2.2.5.3.2." Section 7.2.2.5.3.2 Enclosed usable space shall be permitted under stairs provided that both of the following are met. (1) The usable space shall be separated from stair enclosure by the same fire resistance as the exit enclosure. (2) Entrance to the enclosed usable space shall not be from within the stair enclosure. (See 7.1.3.2.3)" Section 7.1.3.2.3 "An exit enclosure shall not be used for any purpose that has potential to interfere with its use as an exit and if so designated as an area of refuge."

Findings Include:

Observation on tour of the facility on August 20, 2019, revealed in the south stairwell decorations and combustible materials on the walls of the stairwell. A cart was stored under the stairwell.

The Chief Operating Officer (COO), Facilities Director, and key hospital staff acknowledged during the exit conference on August 20, 2019, that the south stairwell contained decorations and combustible materials on the walls of the stairwell. A cart was stored under the stairwell.

Based on observation and staff interview, it was determined the facility failed to maintain a clear and unobstructed corridor. Blocked exits and unsecured equipment in the corridors has potential to harm the patients and staff in the event of an emergency.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.2.3.4 "Any required aisle, corridor, or ramp shall not be less than 48 in. (1220 mm) in clear width where serving as means of egress from patient sleeping rooms, unless otherwise permitted by one of the following: (5) Where the corridor width is at least 8 ft (2440 mm), projections into the required width shall be permitted for fixed furniture, provided that all of the following conditions are met: (a) The fixed furniture is securely attached to the floor or to the wall. (b) The fixed furniture does not reduce the clear unobstructed corridor width to less than 6 ft (1830mm), except as permitted by 19.2.3.4(2). (c) The fixed furniture is located only on one side of the corridor. (d) The fixed furniture is grouped such that each grouping does not exceed an area of 50 ft* (4.6 m*). (e) The fixed furniture groupings addressed in 19.2.3.4(5)(d) are separated from each other by a distance of at least 10 ft (3050 mm). (f) The fixed furniture is located so as to not obstruct access to building service and fire protection equipment."

Findings include:

Observation on tour of the facility on August 20, 2019, revealed that the corridor was not clear and unobstructed in the following areas:

1. Fourth floor, in the corridor- an Olympic Warm scale by room #405.
2. Fourth floor, in the corridor- a bed by Environmental Services room.
3. Third floor, in the corridor- two floor mounted directional signs by the old Quality Management room.
4. Third floor, in the corridor- a crib by room #3343.
5. Second floor, in the corridor- two wheelchairs by room #202.
6. Second floor, in the corridor- an Olympic Smart scale by room #212.
7. Second floor, in the corridor- dinning carts by the mechanical room.
8. First floor, in the corridor- seven vital carts by the nurses station in Med/Surg 1.
9. ICU, in the corridor- a wheelchair by room #12.
10. ICU, in the corridor- a chair by room #4 .
11. ER, in the corridor- three wheelchairs, a scale, mobile computer by registration.
12. ER, in the corridor- two beds in Hall 1.
13. ER, in the corridor- storage racks by room #13.
14. OR, in the corridor- three storage racks, and one cart with boxes by Surgical Storage room.

The COO, Facilities Director, and key hospital staff acknowledged during the exit conference on August 20, 2019, that the corridors were not clear and unobstructed in the above noted areas.

Based on record review and interview with staff, it was determined the facility failed to complete the annual testing of the emergency battery backup lights. Failing to maintain emergency lighting units in time of an emergency could cause harm to the patients in an emergency power outage.

NFPA 101, Life Safety Code, 2012, Chapter 19, Section 19.2.9.1 "Emergency lighting shall be provided in accordance with Section 7.9". Section 7.9.3 " Periodic Testing of Emergency Lighting Equipment" " Section 7.9.3.1 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) The Test interval shall be permitted to be extended beyond 30 days with the approval of authority having jurisdiction.(3) Functional testing shall be conducted annually for a minimum of 1/1/2 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."

Findings include:

The emergency battery backup lights testing documentation was requested on August 19, 2019. The documentation reviewed indicated the last annual testing of the emergency battery backup lights was last tested on 01/18/2018. There was no documentation to review that the emergency battery backup lights have been tested in 2019.

The COO, Facilities Director, and key hospital staff acknowledged during the exit conference on August 20, 2019, that the documentation reviewed indicated the last annual testing of the emergency battery backup lights was last tested on 01/18/2018. There was no documentation to review that the emergency battery backup lights have been tested in 2019.

Based on observation and staff interview, it was determined the facility failed to ensure proper placement of emergency exit signage in all parts of the hospital. Failing to have proper emergency exit signage during an emergency has potential to delay egress, a delay has potential to harm staff and patients.

NFPA 101 2012 Edition Section 19.2.10 "Marking of Means of Egress." Section 19.2.10.1 "Means of egress shall have signs in accordance with Section 7.10, unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4." Section 19.2.10.2 "Where the path of egress travel is obvious, signs shall not be required in one-story buildings with an occupant load of fewer than 30 persons." Section 7.10.1.2.1 "Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access."

Findings include:

Observation on tour of the facility on August 20, 2019, revealed in PACU that there was no emergency exit signage to lead to an exit access clearly visible.

The COO, Facilities Director, and key hospital staff acknowledged during the exit conference on August 20, 2019, that in PACU, there was no emergency exit signage to lead to an exit access clearly visible.

Based on observation and staff interview, it was determined the facility failed to ensure the hazardous areas have the doors be self-closing or automatic closing. Failing to maintain the the self-closing hardware on the door and frame to a hazardous room has potential to cause harm to patients in time of a fire if the door does not latch and close.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.1, "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. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing."

Findings Include:

Observation on tour of the facility on August 20, 2019, revealed hazardous areas did not have doors that were self-closing or automatic-closing in the following areas:

1. Second floor, #2238 Utility room, both doors had tape over the latches preventing them to positively latch.
2. Lab store room, #1333A, door was not self-closing or automatic-closing.
3. Lab storage room, #1332A, door was not self-closing or automatic-closing.
4. SPD room, door was held open by a cart.

The COO, Facilities Director, and key hospital staff acknowledged during the exit conference on August 20, 2019, that the hazardous areas did not have doors that were self-closing or automatic-closing.

Based on observation and staff interview, it was determined the facilty failed to ensure ABHR dispensers were not located above an ignition source. Having ABHR dispensers mounted or placed in the wrong locations has potential to cause harm to patients or staff in the event of a fire.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.6. " Alcohol-based hand-rub dispensers shall be protected in accordance with 8.7.3.1, unless all of the following conditions are met: (4) Dispensers shall be separated from each other by horizontal spacing of not less than 48 in.(1220 mm). (8) Dispensers shall not be installed in the following locations: (a) Above an ignition source within 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. (25 mm) horizontal distance from the ignition source. (c) Beneath an ignition source within a 1 in. (25 mm) vertical distance from the ignition source."

Findings include:

Observation on tour of the facility on August 20, 2019, revealed ABHR dispensers located directly above an ignition source in the following areas:

1. Third floor, Newborn Nursery room, two ABHR dispensers were directly above two wall outlets.
2. Third floor, Med room, one ABHR dispenser wa directly above a light switch.

The COO, Facilities Director, and key hospital staff acknowledged during the exit conference on August 20, 2019, that three ABHR dispensers were located directly above an igition source.

Based on observation and staff interview, it was determined the facility failed to prevent the fire alarm pull station to be accessible and unobstructed. Obscuring the fire alarm pull stations from view may prevent or delay the initiating of the fire alarm system in an emergency and this has potential harm to the patients during a fire.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.4.2.1 "Initiation of the required fire alarm systems shall be by manual means in accordance with 9.6.2 and by means of any required sprinkler system waterflow alarms, detection devices, or detection systmes, unless otherwise permitted by 19.3.3.2.2 through 19.3.4.2.4." Chapter 9, Section 9.6.2.7, "Each manual fire alarm box on a system shall be accessible, unobstructed, and visible."

Findings include:

Observation on tour of the facility on August 20, 2019, revealed a wheelchair in ICU, by room #12, obstructing access to the manual fire alarm pull station.

The COO, Facilities Director, and key hospital staff acknowledged during the exit conference on August 20, that a wheelchair in ICU, by room #12, obstructed access to the manual fire alarm pull station.

Based on observation and staff interview, it was determined the facility failed to assure that all parts of the facility were provided sprinkler system coverage. Failing to provide sprinkler coverage in storage areas by blocking the sprinkler heads has potential to result in harm to the patients in time of a fire.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.1, "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." ." Chapter 9, Section 9.7.1.1, "Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems."NFPA 13, Chapter 8, Section 8.5.6 Clearance to Storage. Section 8.5.6.1 Unless the requirements of 8.5.6.2, 8.5.6.3, 8.5.6.4. or 8.5.6.5 are met a clearance between the deflector and the storage shall be 18 inches. (457mm) or greater."

Findings include:

Observation on tour of the facility on August 20, 2019, revealed in the Lab Store room multiple boxes on the top shelf within 18 inches of the sprinkler head deflector.

The COO, Facilities Director, and key hospital staff acknowledged during the exit conference on August 20, 2019, that in the Lab Store room, there were multiple boxes on the top shelf which were within 18 inches of the sprinkler head deflector.

Based on observation and staff interview, it was determined the facility failed to ensure that fire extinguishers were protected and properly installed. Failing to protect and have proper installation of fire extinguishers has potential to cause harm to staff and patients.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.12 "Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1" Section 9.7.4.1 "Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for portable Fire Extinguishers." NFPA 10, Section 6.1.3.7 "Fire extinguishers installed under conditions where they are subject to physical damage (e.g., from impact, vibration, the environment) shall be protected against damage." Section 6.1.3.8.1 "Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Section 6.1.3.8.2 "Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be installed so that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor."

Findings Include:

Observation on tour of the facility on August 20, 2019, revealed three fire extinguishers unprotected and not installed per NFPA 10. The three fire extinguishers were placed on the ground of the helipad.

The COO, Facilities Director, and key hospital staff acknowledged during the exit conference on August 20, 2019, that the three fire extinguishers were unprotected and not installed per NFPA 10. The three fire extinguishers were placed on the ground of the helipad.

Based on observation and interview with staff, it was determined the facility failed to provide a protective guard on light bulbs. Failure to keep light guards on the light bulbs could cause accidental damage or possibly a fire, which could cause potential harm to the patients.

NFPA 101 Life Safety Code, 2012, 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, 2011 Edition, "National Electrical Code." NEC, 2011, 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."

Findings include:

Observation on tour of the facility on August 20, 2019, revealed that there were exposed light bulbs with no protective guards located in the following areas:

1. Four exposed bulbs in the Telementry Equipment room, #1040.
2. Two exposed bulbs in the Data room, #1039.

The COO, Facilities Director, and key hospital staff acknowledged during the exit conference on August 20, 2019, that there were exposed light bulbs with no protective guards.

Based on record review and interview with staff, it was determined the facility failed to have written documentation of the Annual Inspection and Testing of Door openings in accordance with NFPA 80, 2010 Edition, "Standard for Fire doors and Other Opening Protective's." Failing to inspect and test fire rated door assemblies in accordance with NFPA 80 annually could potentially cause risk of harm to the patients.

NFPA 101 2012 Life Safety Code Section 8.3.3. Fire door and Windows Section 8.3.3.1 "Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed labeled fire door assemblies and fire window assemblies and their accompanying hardware,including all frames, closing devices, anchorage and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening protective, except as otherwise specified in this code."

NFPA 80 Section 5.2* Inspections Section 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 the AHJ. Section 5.2.3 Functional Testing. Section 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."

NFPA 80 Section 13.4 Automatic closing Section 5.2.5 "Horizontal sliding , Vertically Sliding, and Rolling Doors."
Section 5.2.14.3 "All horizontal or vertical sliding or rolling fire doors shall be inspected and tested annually to check for proper operation at frequent intervals to ensure operation."

Findings include:

The annual fire rated door assembly records were requested on August 19, 2019. The facility did not have written records of the Annual Inspection and Testing of Door Openings in accordance with NFPA 80 Standard for Fire Doors and Other Opening Protective's for 2018.

The COO, Facilities Director, and key hospital staff acknowledged during the exit conference on August 20, 2019, that there was no documentation to review of the annual fire rated door assemblies for 2018.

Based on record review and interview with staff, it was determined that the facility failed to conduct, maintain and document electrical receptacle testing in all patient care areas annually throughout the facility. Failing to test and document annually the receptacle testing of all patient care areas of the facility could lead to an ignition hazard in a patient care area, and potentially cause a fire and or injury to the patients.

NFPA 101 Life Safety Code, 2012, Chapter 4, Section 4.6.12.4 "Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected or operated as specified elsewhere in the Code or as directed by the authority having jurisdiction." NFPA 99, Health Care Facilities Code, 2012, Chapter 6, Section 6.3.4.1.1 "Where hospital-grade receptacles are required at patient bed locations and in locations 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."

Findings include:

The receptacle testing documentation was requested on August 19, 2019. There was no documentation available for review provided for receptacle testing in patient care areas for 2018.

The COO, Facilities Director, and key hospital staff acknowledged during the exit conference on August 20, 2019, that there was no documentation to review for receptacle testing in patient care areas for 2018.

Based on record review and interview with staff, it was determined the facility failed to have an annual fuel quality test completed for the facility diesel generators. Failure to conduct an annual fuel quality fuel test for the emergency generator has potential to result in harm to patients during emergency system failures.

NFPA 101 Life Safety Code, 2012, Chapter 21, Section 21.7.6 "Maintenance and Testing (See 4.6.12) Section 4.6.12.2 "Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 99 "HEALTH CARE FACILITIES" 2012, Chapter 6, Section 6.4.4.1.1.4 (A) Test Criteria. "Generator sets shall be tested 12 times a year with testing intervals of not less than 20 days nor more than 40 days. Generator sets serving essential electrical systems shall be tested in accordance with NFPA 110, Standards for Emergency and Standby Power Systems, Chapter 8." Operational Inspection and Testing. Section 8.4.1 "EPPS, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. NFPA 110 2010 Edition Standard for Emergency and Standby Power Systems; Section 8.3 Maintenance and Operational Testing Section: 8.3.8 "A fuel quality test shall be performed at least annually using tests approved by ASTM standards."

Findings Include:

The annual emergency generator testing and maintenance documentation was requested on August 19, 2019. There was no documentation to review of the annual fuel quality tests for the emergency generators for 2018.

The COO, Facilities Director, and key hospital staff acknowledged during the exit conference on August 20, 2019, that there was no documentation to review of the annual fuel quality tests for the emergency generators for 2018.

Based on observation and staff interview, it was determined the facility failed to ensure that appliances were directly plugged into wall outlet receptacles and not power strips. 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 has potential harm to the patients.

NFPA 101, Life Safety Code, 2012. 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, " 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2 , "All Patient Care Areas," Sections 6.3.2.2..6.2 (A) through 6.3.2.2.6.2 (E) 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."

Findings include:

Observation on tour conducted on August 20, 2019, revealed the following items plugged into a power strip, and not directly plugged into the receptacle wall outlets:

1. First floor, Med/Surg 1, physicians dictation desk, a power strip was plugged into a power strip.
2. PACU, nurses station, a power strip was plugged into a power strip.


The COO, Facilities Director, and key hospital staff acknowledged during the exit conference on August 20, 2019, that the above items were plugged into a power strip, and not directly plugged in to the receptacle wall outlets.