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1) Based on observation and interview with staff, the facility failed to provide smoke barriers that are constructed to provide at least a one half hour fire resistance rating in accordance with NFPA 101 2000 edition chapter 8.3. Findings include:

a) The smoke walls were not maintained , addition of conduit and wiring after initial construction failed to maintain the integrity of the walls. Smoke wall on the west end of the patient wing had penetrations that were not sealed.

1) Based on observation and interview with staff, the facility failed to provide a fire alarm installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. Findings include:

a) The facility failed to have a directory of points, failed to give address and inspection documentation for dampers, smoke evacuation systems and other pieces of equipment connected to the fire alarm system.

b) The is no smoke detector on the garage side of the Two Hour door separating the hospital from the garage.

c) The annual fire alarm report was not signed. The vendor failed to explain and get owners signature.

1) Based on observation and interview with staff, the facility failed to provide a means of egress through an approved space in accordance with NFPA 101 19.2.5.5. Findings include:

a) The exit sign showing the garage as an exit does not meet. The area is considered an hazardous area. NFPA 101 2000 edition chapter 19.2.5.5 Intervening rooms shall not be hazardous areas. NFPA 101 19.3.2. (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.

b) Based on observation and interview with staff, the facility failed to provide a program that included periodic review of manufactures' safety guidelines and usage requirements for electrosurgical units and similar appliances with all personnel concerned with the application and maintenance of electric appliances, including physicians, nurses nurse aids, engineers, technicians, and orderlies, and the shall demonstrate they are cognizant of the risks associated with their use. To achieve this end, the hospital shall provide appropriate programs of continuing education for its personnel in accordance with Qualification and Training of Personnel NFPA 99 chapter 7-6.5. As an example a onetime use battery cautery devices was found in the ER. No documentation was available for review that shows staff was in-serviced or cognizant of the potential for fire in the Emergency Room Department with its use.

1) Based on observation and interview with staff, the facility failed to inspected the Generator weekly and exercised under load for 30 minutes per month in accordance with NFPA 99. 3.4.4.1. Findings include:

a) The generator log did not have the size, there for the required 30% load or greater per month could not be identified or logged .

b) The facility failed to identify or have a policy for when or whom calls for the Generator fuel. In the absence of maintenance staff, the facility did not have means and method of checking Emergency Generator.

1) Based on observation and interview with staff, the facility failed to maintain Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2 Findings include:

a) The facility failed to have a program created by the governing body that is responsibility for assuring that hospital services are provided in compliance with the Medicare Conditions of participation and according to acceptable standards of practice provided by the Bio-medical Equipment contractor. The governing body failed to assess services furnished directly under contract, identify quality and performance problems, implement appropriate corrective or improvement activities, and to ensure the monitoring and sustainability of those corrective or improvement activities. under the QAPI program.

b) The facility failed to check and have a program that provided and maintained Grounding systems in Patient Care Areas. The facility could not provide evidence of Impedance and Receptacle Testing in accordance with NFPA 99 1999 edition chapter 3-3.3.2 through 3-3.4.3.1

1) Based on observation and interview with staff, the facility failed to provide smoke barriers that are constructed to provide at least a one half hour fire resistance rating in accordance with NFPA 101 2000 edition chapter 8.3. Findings include:

a) The smoke walls were not maintained , addition of conduit and wiring after initial construction failed to maintain the integrity of the walls. Smoke wall on the west end of the patient wing had penetrations that were not sealed.

1) Based on observation and interview with staff, the facility failed to provide a fire alarm installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. Findings include:

a) The facility failed to have a directory of points, failed to give address and inspection documentation for dampers, smoke evacuation systems and other pieces of equipment connected to the fire alarm system.

b) The is no smoke detector on the garage side of the Two Hour door separating the hospital from the garage.

c) The annual fire alarm report was not signed. The vendor failed to explain and get owners signature.

1) Based on observation and interview with staff, the facility failed to provide a means of egress through an approved space in accordance with NFPA 101 19.2.5.5. Findings include:

a) The exit sign showing the garage as an exit does not meet. The area is considered an hazardous area. NFPA 101 2000 edition chapter 19.2.5.5 Intervening rooms shall not be hazardous areas. NFPA 101 19.3.2. (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.

b) Based on observation and interview with staff, the facility failed to provide a program that included periodic review of manufactures' safety guidelines and usage requirements for electrosurgical units and similar appliances with all personnel concerned with the application and maintenance of electric appliances, including physicians, nurses nurse aids, engineers, technicians, and orderlies, and the shall demonstrate they are cognizant of the risks associated with their use. To achieve this end, the hospital shall provide appropriate programs of continuing education for its personnel in accordance with Qualification and Training of Personnel NFPA 99 chapter 7-6.5. As an example a onetime use battery cautery devices was found in the ER. No documentation was available for review that shows staff was in-serviced or cognizant of the potential for fire in the Emergency Room Department with its use.

1) Based on observation and interview with staff, the facility failed to inspected the Generator weekly and exercised under load for 30 minutes per month in accordance with NFPA 99. 3.4.4.1. Findings include:

a) The generator log did not have the size, there for the required 30% load or greater per month could not be identified or logged .

b) The facility failed to identify or have a policy for when or whom calls for the Generator fuel. In the absence of maintenance staff, the facility did not have means and method of checking Emergency Generator.

1) Based on observation and interview with staff, the facility failed to maintain Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2 Findings include:

a) The facility failed to have a program created by the governing body that is responsibility for assuring that hospital services are provided in compliance with the Medicare Conditions of participation and according to acceptable standards of practice provided by the Bio-medical Equipment contractor. The governing body failed to assess services furnished directly under contract, identify quality and performance problems, implement appropriate corrective or improvement activities, and to ensure the monitoring and sustainability of those corrective or improvement activities. under the QAPI program.

b) The facility failed to check and have a program that provided and maintained Grounding systems in Patient Care Areas. The facility could not provide evidence of Impedance and Receptacle Testing in accordance with NFPA 99 1999 edition chapter 3-3.3.2 through 3-3.4.3.1