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Based on record review and interview, it was determined the facility failed to provide a current policy for tracking on-duty staff during an emergency, to include the specific name and location of receiving facility or other location in the event they are relocated with patients during an emergency. This information must be readily available, accurate, and shareable among officials within and across the emergency response systems as needed in the interest of the patient. This deficient practice had the potential to affect all patients and staff on the dates of the survey.

Findings include:

On June 11, 2019, from approximately 11:00 AM to 3:00 PM, review of the provided records, policies and procedures failed to demonstrate the facility had in place a system to track the location of on-duty staff during an emergency. Interview of the Emergency Preparedness Liaison on June 12, 2019 at approximately 2:30 PM, revealed the facility was unaware of the requirement to track on-duty staff during an emergency.

Reference:

42 CFR 482.15 (b) (2)

Based on record review and interview, it was determined the facility failed to provide an Emergency Preparedness (EP) training program to include initial and annual training. Failure to implement a training program on the EP plan, has the potential to hinder staff response during a disaster. This deficient practice affected all patients and staff on the dates of the survey.

Findings include:

On June 11, 2019, from approximately 11:00 AM to 3:00 PM, review of the facility EP documentation revealed a written training plan, but there was no documentation that initial/annual training for all new and existing staff, or individuals providing services under arrangement had taken place. Interview of multiple staff members in nursing and support roles during the facility tour on June 12, 2019, from approximately 9:00 AM - 3:30 PM confirmed the facility had not implemented their training program for EP. Staff could not recall training on the Emergency Preparedness plan, nor did they know their role and responsibility during a disaster.

Reference:

42 CFR 482.15 (d) (1)

Based on observation and interview, the facility failed to ensure the fire and smoke resistive properties of the structure were maintained. Failure to maintain rated construction assemblies, has the potential to allow fire, smoke and dangerous gases to pass into unprotected concealed spaces and between compartments. This deficient practice had the potential to affect staff on the dates of the survey.

Findings include:

During the facility tour on June 12, 2019, from approximately 9:00 AM - 3:30 PM, observation of the main server room on the first floor revealed an approximately 12" x 12" penetration in the wall. Interview of the Director of Facilities at the time of discovery revealed the facility was unaware of the hole in the wall.

Actual NFPA standard:

19.1.6 Minimum Construction Requirements.
19.1.6.1 Health care occupancies shall be limited to the building construction types specified in Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7. (See 8.2.1.)
8.2 Construction and Compartmentation.
8.2.1 Construction.
8.2.1.1 Buildings or structures occupied or used in accordance with the individual occupancy chapters, Chapters 11 through 43, shall meet the minimum construction requirements of those chapters.

Based on observation and interview, the facility failed to ensure exits were maintained free of obstructions for full use at all times. Failure to maintain means of egress free of obstruction has the potential to disorientate personnel trying to evacuate during an emergency. This deficient practice affected staff on the dates of the survey.

Findings include:

During the facility tour on June 12, 2019, from approximately 9:00 AM - 3:30 PM, observation of the "Catch All" storage area, revealed one of two exits were obstructed by a full pallet and other storage items. Interview of the Director of Facilities and Interim Director of Facilities at the time of discovery revealed staff had been instructed to keep the exits clear of storage items and the facility was not aware the exit door had been blocked.

Actual NFPA standard:

NFPA 101
19.2 Means of Egress Requirements.
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11.
7.1.10 Means of Egress Reliability.
7.1.10.1% Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on record review and interview the facility failed to provide monthly and annual emergency lighting test documentation. Failure to test the emergency lighting could inhibit egress of patients during an emergency. This deficient practice affected all patients and staff on the dates of the survey.

Findings include:

During review of provided maintenance inspection/testing records on June 11, 2019, from approximately 8:00 AM to 11:00 AM, no documentation could be produced to indicate the battery powered and the generator powered emergency lighting was being tested for 30 seconds monthly or 90 minutes annually. When asked on June 11, 2019 at approximately 11:30 AM, the Chief Engineer stated the facility did have emergency lighting and battery powered emergency lighting but was unaware of the requirement to document a 30 second monthly and 90-minute annual test of the emergency lighting.

Actual NFPA reference:

NFPA 101
19.2.9 Emergency Lighting.
19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.
7.9.3 Periodic Testing of Emergency Lighting Equipment.
7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.
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 1-1/2 hours if the emergency

Based on observation and interview, the facility failed to ensure hazardous areas were protected with self-closing doors. Failure to provide self-closing doors for hazardous areas could allow smoke and dangerous gases to pass freely into corridors and hinder egress of occupants during a fire event. This deficient practice affected two (2) visitors and one (1) staff in the gift shop on the date of the survey.

Findings include:

During the facility tour on June 12, 2019, from approximately 9:00 AM - 3:30 PM, observation of the gift shop storage room revealed the self-closing door was being chocked open. The room was larger than 50 ft2. When asked, the person working in the gift shop stated the door is always chocked open and has been for years.

Actual NFPA standard:

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.
19.3.2.1.3 The doors shall be self-closing or automatic-closing.
19.3.2.1.5 Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Rooms with soiled linen in volume exceeding 64 gal (242 L)
(6) Rooms with collected trash in volume exceeding 64 gal (242 L)
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.

Based on record review, observation and interview, the facility failed to ensure alcohol-based hand rub (ABHR) dispensers were maintained properly. Failure to ensure ABHR dispensers are clear of ignition sources and tested during refilling procedures, has the potential of increasing the risk of fires from flammable liquids. This deficient practice affected all patients and staff on the dates of the survey.

Findings include:

1.) During review of provided maintenance inspection/testing records on June 11, 2019, from approximately 8:00 AM to 11:00 AM, no documentation could be produced for the testing of ABHR dispensers each time they are refilled. At approximately 9:00 AM, on June 11, 2019, interview of the Safety Coordinator and Environment of Care Coordinator revealed the facility was unaware of this requirement. The Safety Coordinator stated housekeeping staff check to ensure proper operation of the dispenser but was unaware of any documentation to support this claim.

2.) During the facility tour on June 11, 2019, from approximately 3:00 PM - 5:10 PM, and on June 12, 2019, from approximately 9:00 AM - 3:30 PM, both automatic and manual ABHR dispensers were identified throughout the facility. Further observation revealed the following areas had ABHR dispensers installed over an electrical outlet:
a.) First Floor corridor outside of the Emergency Room Par Room.
b.) Kitchen Dietary Office
c.) Nuclear Medicine Suite Dressing Room
Interview of the Director of Facilities, the Safety Coordinator, and Chief Engineer on June 12, 2019, at approximately 11:00 AM, revealed the facility was unaware ABHR dispensers had been installed above electrical outlets.

Actual NFPA standard:

NFPA 101
19.3.2.6% Alcohol-Based Hand-Rub Dispensers. Alcoho

Based on record review, observation and interview, the facility failed to ensure fire suppression systems were maintained properly. Failure to inspect system components and ensure fire suppression system pendants were maintained free of obstructions such as paint or corrosion could hinder system performance during a fire event. This deficient practice affected all patients and staff on the dates of the survey.

Findings include:

1.) During the facility tour on June 11, 2019, from approximately 3:00 PM - 5:10 PM, and June 12, 2019, from approximately 9:00 AM - 3:30 PM, observation of the bath in room #14 at the Behavioral Health Center (BHC) revealed a corroded sprinkler head, and the SANE room bath in Radiology had a painted sprinkler head. The Behavioral Health Clinic (BHC) Gym was missing eight (8) escutcheon rings, the Gift Shop storage room was missing one (1) escutcheon ring and the Labor & Delivery dressing room was missing one (1) escutcheon ring.
2.) During record review on June 11, 2019, from approximately 8:00 AM to 11:00 AM, no documentation for weekly dry system gauge inspections could be produced.

Actual NFPA standard:

NFPA 25

1.) 5.2.1 Sprinklers.
5.2.1.1% Sprinklers shall be inspected from the floor level
annually.
5.2.1.1.1% Sprinklers shall not show signs of leakage; shall be
free of corrosion, foreign materials, paint, and physical damage;
and shall be installed in the correct orientation (e.g., upright,
pendent, or sidewall).
5.2.1.1.2 Any sprinkler that shows signs of any of the following
shall be replaced:
(1) Leakage
(2) Corrosion
(3) Physical damage
(4) Loss of fluid in the glass bulb heat responsive element
(5)%Loading
(6) Painting unless painted by the sprinkler manufact

Based on observation and operational testing, the facility failed to maintain doors that protect corridor openings. Failure to maintain corridor doors could allow smoke and dangerous gases to pass freely and hinder protection in place.

During the facility tour on June 12, 2019 at approximately 11:00 AM, observation and operational testing of the corridor door leading to the Burn Trauma waiting room was chalked open. After removing the chalk, it was determined the door was self-closing. Observation of the size of the waiting room revealed it was greater than 600 ft2.

Actual NFPA Standard
19.3.6.3.1% 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

Based on observation, the facility failed to ensure the fire and smoke resistive properties of the structure were maintained. Failure to maintain rated barriers could allow fire, smoke and dangerous gases to pass between compartments during a fire. This deficient practice affected patients and staff on the second floor, in 1 of 7 smoke compartments on the dates of the survey.

Findings include:

During the facility tour on June 12, 2019, at 9:45 AM, inspection of the rated barrier above the drop ceiling located in the central supply surgery center near the entrance door, revealed approximately one-fourth of the wall had been cut away.

Actual NFPA standard:

8.5.6 Penetrations.
8.5.6.3 Where a smoke barrier is also constructed as a fire barrier, the penetrations shall be protected in accordance with the requirements of 8.3.5 to limit the spread of fire for a time period equal to the fire resistance rating of the assembly and 8.5.6 to restrict the transfer of smoke, unless the requirements of 8.5.6.4 are met.

Based on observation and operational testing, the facility failed to ensure cross corridor doors were maintained to limit the transfer of smoke, fire and dangerous gases between compartments. Failure to ensure rated doors limit the transfer of smoke, has the potential to hinder egress and the ability to shelter in place. This deficient practice affected patients and staff in the burn trauma and medical imaging areas of the facility on the dates of the survey.

Findings include:

During the facility tour on June 12, 2019, from approximately 9:00 AM - 3:30 PM, observation and operational testing of the cross-corridor smoke barrier doors located on the second floor near the CT-1 room and at the front hall of Medical Imaging, revealed both sets of cross-corridor doors would not self-close and latch when released from the magnetic hold open device.

Actual NFPA standard:

19.3.7.8% Doors in smoke barriers shall comply with 8.5.4 and all of the following:
(1) The doors shall be self-closing or automatic-closing in accordance with 19.2.2.2.7.
(2) Latching hardware shall not be required
(3) The doors shall not be required to swing in the direction of egress travel.
8.5.4.1% Doors in smoke barriers shall close the opening, leaving only the minimum clearance necessary for proper operation, and shall be without louvers or grilles. The clearance under the bottom of a new door shall be a maximum of 3.4 in. (19 mm).
8.5.4.4% Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1.

Based on record review and interview, the facility failed to ensure positive pressure gas central piping, medical-surgical vacuum, and WAGD systems have a documented maintenance program. Failure to inventory all components, create a schedule for inspections/maintenance by a qualified person, and develop a written maintenance program based on a facility risk assessment and manufacturers recommendations, could result in fire, explosion, or a lack of system performance as designed. This deficient practice affected all patients and staff on the dates of the survey.

Findings include:

During record review on June 11, 2019, from approximately 8:00 AM to 11:00 AM, no documentation of a written maintenance program for the positive pressure gas central piping, medical-surgical vacuum, and WAGD systems could be produced. Interview of the Safety Coordinator and Environment of Care Coordinator at the time of record review, and the Director of Facilities and Chief Engineer on June 12, 2019 at approximately 8:15 AM, confirmed the facility did not have a written maintenance program. All staff interviewed were unaware of the requirement for a written maintenance program based on a facility risk assessment and manufacturers recommendations.

Actual NFPA standard:

NFPA 99
5.1.14.2.1% General. Health care facilities with installed medical gas, vacuum, WAGD, or medical support gas systems, or combinations thereof, shall develop and document periodic maintenance programs for these systems and their subcomponents as appropriate to the equipment installed.
5.1.14.2.2 Maintenance Programs.
5.1.14.2.2.1 Inventories. Inventories of medical gas, vacuum, WAGD, and medical support gas systems shall include at least all source subsystems, control valves, alarms, manufactured assemblies containing patient gases, and outlets

Based on observation and interview, the facility failed to ensure medical gas cylinders and oxygen storage areas were maintained in accordance with NFPA 99. Failure to properly sign oxygen storage areas and segregate full cylinders from empty, could lead to ignition of an oxygen rich environment, and/or the potential to inadvertently use the incorrect cylinder during an emergency requiring supplemental oxygen. This deficient practice affected patients and staff utilizing the sixth floor Physical Therapy Gym, and patients utilizing secondary oxygen on the second floor on the dates of the survey.

Findings include:

1.) During the facility tour on June 11, 2019 at 8:50 AM, observation of the oxygen storage room on the sixth floor, in the Physical Therapy Gym, revealed the oxygen storage room was not identified as an oxygen storage area with the required signage.

2.) On June 12, 2019, during the facility tour of the second floor at approximately 9:00 AM - 11:30 AM, observation of both the Surgical Holding area and the Cath Lab storage, revealed full and empty oxygen cylinders were being stored together. There was no segregation or signage to indicate where full and empty oxygen cylinders should be stored. On the facility tour, at the time of discovery, interview of the Director of Facilities and Safety Coordinator revealed, staff were aware of the requirement to segregate full and empty oxygen cylinders but had not stored them properly.

Actual NFPA standard:

NFPA 99
1.) 11.3.4 Signs.
1.3.4.1 A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure.

2.) 11.6.5 Special Precautions - Storage of Cylinders and Containers.
11.6.5.1 Storage shall be planned so that cylinders can be used in the order in