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Based on observations, testing and interviews with facility staff, the facility failed to maintain fire protection and occupancy features necessary to minimize danger to residents from smoke, fumes or panic should a fire occur. The facility did not maintain four (4) of 30 plus sampled corridor doors to prevent impediments to closing them to limit the transfer of smoke / heated gases should a fire occur. NFPA 101-2000, 4.6.12.1 requires that "every...item of equipment / system required by this Code shall be continuously maintained in proper operating condition." Also, per NFPA 101-2000, 19.3.6.3 "must provide a means suitable for keeping the door closed (tightly closed in the frame)." This condition could allow smoke and fire gases to quickly spread, in the event of a fire, endangering building occupants.

Findings are:

During the general life safety tour of the Select Hospital South on April 7, 2010 with the Plant Operations Director, observed that the following doors had an impediment to closing them so they would limit the transfer of smoke should a fire occur:

At 11:14 a.m., the automatic opening / self closing cross corridor doors to the Intensive Care Unit (ICU) on the west side of the building were tested and found that they did not close tightly in their frames. There was a 1/4 inch gap between the two closed doors after they were closed. Closer examination revealed that this gap became wider between the bottom halves of these closed smoke doors. Interview of the plant operations director revealed that these doors served as a smoke barrier / partition and separated the ICU suites from the medical wings. "This condition will be corrected." A service provider was contacted and was scheduled to repair this condition on April 8, 2010.

Interviews of the administrator and the plant operations director during the closing conference at 10:30 a.m. on April 8, 2010, re-confirmed these findings.

NFPA 101-2000, 19.2.2.2.6, 19.3.6.3, 4.6.12.1; NFPA 90A & NFPA 80
Correction Date: 04/22/2010

Based on observations, interviews and testing, the facility failed to maintain the ventilation system equipment in accordance with NFPA 90A and with NFPA 101-2000, 4.6.12.4, ' every...item of equipment required by this Code shall be continuously maintained in proper operating condition. ' One soiled holding room had little or no ceiling exhaust ventilation (exchange of air) when tested. One (1) in 3 sampled smoke zones was so affected.

The findings are:

During the life safety tour of the Select Specialty Hospital North on April 7, 2010 with the Plant Operations Director and several Florida Hospital plant operations professionals, observed / tested (with a tissue) the ceiling exhaust ventilation system in various sampled housekeeping closets and soiled utility rooms. At 2:35 p.m., little or no air movement/exchange was noted at the ceiling exhaust vent located inside / within the soiled utility room (K-ILR-01-C-65-O) on the middle hallway near the nursing station. Not having the exhaust working continuously could lead to increased odors within patient areas due to less than the required air exchanges per hour. Interview of the electronic department's manager at 3 p.m., revealed that "the exhaust motor on the roof has seized up".

Interview of the Administrator and the Maintenance Director at the closing conference at 10:30 p.m. on 04/08/2010, re-confirmed these findings.

NFPA 101-2000, 4.6.12.1; 19.5.2.1, 9-2 & NFPA 90A
Correction Date: 05/08/2010

Based on observations and interviews while touring the facility with the plant operations director, it was determined that not all uses and storage of oxygen / medical air were in accordance with NFPA 99, 8-3.1.11 and 8-2.1.2.4. Unsecured oxygen cylinders have the potential, if knocked over, to rupture at the neck of the cylinder causing a super oxygen enriched atmosphere and the cylinder itself becoming a projectile. Three (3) of 12 cylinders were unsecured.

The findings include:

The following issue related to oxygen use / storage was observed on April 7, 2010 inside the external medical air system area which included a large liquefied oxygen tank and backup fixed bank of medical oxygen cylinders:

During the life safety tour of the oxygen storage area on the west side of the Select Specialty Hospital North at 2:25 p.m., observed that three (3) oxygen cylinders (H-tanks) inside this secured area were standing upright without being secured from falling over, thus presenting a hazard. Interview of the plant operations associate revealed that the outside delivery vendor did not ensure that such tanks were secured from falling over.

The observations were re-confirmed with the administrator and the plant operations director during the closing conference at 10:30 a.m. on April 8, 2010.

NFPA 99 (99), 7-6.2.4.1, 8-2.1.2.4(d), 8-3.1.11, 8-6.2.5.2, 4-5.1.1.2; NFPA 101-2000, 19.7.4
Correction Date: 05/08/2010

Based on observations, testing and interviews with facility staff, the facility did not maintain the following per the National Electric Code (NEC) and NFPA 99. The facility failed to maintain fire protection and occupancy features necessary to minimize danger to life. This includes not ensuring that areas were free of hazardous conditions. Use of an extension cord (power strip) did not demonstrate compliance with the code / standard. One (1) out of 20 plus electrical devices sampled did not operate as required.

Findings include:

Observations and interview of the plant operations director and safety officer during the life safety tour on April 8, 2010 at Select Specialty Hospital North, revealed that the following electrical application was not in accordance with NFPA 70, the National Electrical Code. Temporary wiring (unapproved extension cord) / non hospital grade / power strip was found in the hallway near the southwest exit door;

Observed at 2:10 p.m. that the electrical plug for the ADC Solo X-ray Imaging System was plugged into a non-circuit breaker extension cord (non-hospital grade unit)) and not directly into the outlet. This device was not rated for use in wet areas or for high amperage devices. Observation of the rating plate revealed that this unit (Imager) was rated at 12 amps. Such a condition could place an increased electrical load (amperage) on this unapproved device.

The facility was able to evidence that receptacle testing was accomplished per NFPA 99, 3-3.3.3 since it was documented. Such testing shall include: physical integrity of each receptacle; continuity of the grounding circuit; confirm correct polarity of the hot and neutral connections; and ensure the proper retention force of grounding blade, (4 oz.). Note: Receptacles not listed as hospital grade shall be tested at intervals not exceeding 12 months per 3-3.4.2.3. Per 3-3.4.3......'A record shall be maintained of tests and associated repairs / modifications noting date; rooms/ areas tested; met or failed test', etc.

Also note: per guidelines set forth from the Dept. of Food and Drug Administration (consumer Product Safety Commission), 'electrical cords for high amperage devices should be placed (plugged) directly into an outlet'.

These findings were reconfirmed with the administrator and the plant operations director during the closing conference at 10:30 a.m. on April 8, 2010.

NFPA 70 , National Electric Code (NEC), 384-13 & NFPA 101-2000, 4.6.12.1-.4 NFPA 70, Article 517; NFPA 99 ,7-5.1.2.4, 9-2.1.2.1/.2 ,3-3.4.2.3,3-3.4.3
Correction Date: 05/08/2010