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Based on record review, observation and interview, the facility failed to maintain the limited noncombustible rating in accordance with LSC Table 19.1.6.1. This deficient practice could affect all occupants.

Findings include:

During record review with the Engineering Operations Manager, Quality Improvement Specialist, and Engineering and Maintenance Supervisor on 03/10/2020 between 9:00 a.m. and 10:00 a.m., the Life Safety Plans indicated the basement mechanical/electrical room was constructed to II(222) rating. During a subsequent tour of the basement on the same date, the following were observed:
a) At 2:37 p.m. a horizontal steel support beam had a location measuring approximately two inches by six inches where the protective coating was removed. Based on an interview at the time of observation, the Engineering Operations Manager agreed that protective coating had been removed.
b) At 2:39 p.m. a horizontal steel support beam was located in the 2011 Kitchen Mechanical section of the basement mechanical/electrical room with a three to four foot section missing fire protection. Based on interview at the time of observation, the Engineering Operations Manager and the Engineering and Maintenance Supervisor were unable to determine if the beam required a protective fire coating or not.
c) At 2:41 p.m. a vertical steel support beam in the mechanical/electrical room was found to have an eighteen inch section of fire protection removed. Based on an interview at the time of observation, the Engineering Operations Manager agreed that protective coating had been removed.

Based on observation and interview, the facility failed to ensure 1 of 1 " Bio-Hazard Room" door was only held open by a release device complying with LSC 7.2.1.8.2 that automatically closes such doors upon activation of the fire alarm system. This deficient practice could affect all occupants on the third floor.

Findings include:

During a facility tour with the Engineering Operations Manager, Quality Improvement Specialist, and Engineering and Maintenance Supervisor on 03/10/2020 at 10:07 a.m., the corridor door which lead from the third floor "Bio-Hazard Room" to the corridor did not self-close and positively latch. The door was equipped with a self-closing device and was located in a barrier wall with a 1-hour Fire Resistive Rating. Based on interview at the time of observation, the Engineering Operations Manager, Quality Improvement Specialist, and Engineering and Maintenance Supervisor agreed that the door did not self-close and positively latch into the frame.

Based on observation, the facility failed to meet the clear width requirement for 1 of 5 First Floor corridors or met an exception per 19.2.3.4(5). LSC 19.2.3.4(5) states where the corridor width is at least 8 feet, 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 six feet, 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 square feet.
(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 feet.
(f) the fixed furniture is located so as to not obstruct access to building service and fire protection equipment.
(g) corridors throughout the smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the fixed furniture spaces are arranged and located to allow direct supervision by the facility staff from a nurse's station or similar space.
(h) the smoke compartment is protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.8
This deficient practice could affect occupants, staff and visitors near the MRI Room and Post Acute Care Unit if needing to exit the facility.

Findings include:

During a facility tour with the Engineering Operations Manager, Quality Improvement Specialist, and Engineering and Maintenance Supervisor on 03/10/2020 at 11:41 a.m., the corridor by the MRI room had three unsecured chairs located in the corridor. Based on interview at the time of observation, the Engineering Operations Manager, Quality Improvement Specialist, and Engineering and Maintenance Supervisor agreed that the chairs were not secured, and during an evacuation could obstruct egress. It was noted that this deficient practice was corrected prior to the exit from the facility on 03/11/2020 at 10:00 a.m.

Based on observation and interview, the facility failed to ensure 1 of 5 battery powered emergency lights were maintained in accordance with LSC 7.9. LSC 7.9.2.6 states battery operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition. Batteries used in such lights or units shall be approved for their intended use and shall comply with NFPA 70 National Electric Code. LSC 7.9.2.7 states the emergency lighting system shall be either continuously in operation or shall be capable of repeated automatic operation without manual intervention. This deficient practice could affect all residents, staff and visitors in the facility.

Findings include:

During a facility tour with the Engineering Operations Manager, Director of Rehabilitation, Quality Improvement Specialist, and Engineering and Maintenance Supervisor on 03/11/2020 at 9:21 a.m., the battery operated emergency light near the weight room failed to function when its respective test button was pushed five times. Based on interview at the time of the observations, the Engineering Operations Manager and Director of Rehabilitation stated battery operated lights in the facility are tested, however agreed that the aforementioned battery operated emergency light failed to function when its respective test button was pushed.

Based on observation and inteview, the facility failed to protect 1 of 1 Fire Alarm Control Panel as required by LSC 9.6.1.8.1 which requires that in areas not continuously occupied, and unless otherwise permitted, automatic smoke detection shall be installed to provide notification of fire at (1) each fire alarm control unit. This deficient practice could affect all building occupants.

Findings include:

During a facility tour with the Engineering Operations Manager, Director of Rehabilitation, Quality Improvement Specialist, and Engineering and Maintenance Supervisor on 03/11/2020 at 9:40 a.m., , it was found that the Fire Alarm Control Panel did not have automatic smoke protection. Based on interview at the time of observation, the Engineering Operations Manager, Director of Rehabilitation agreed that the office was not continuously occupied, and that the Fire Alarm Control Panel did not have automatic smoke protection.

1) Based on record review, observation and interview; the facility failed to ensure all fire alarm system initiating devices were tested in accordance with the schedules for testing frequency in NFPA 72. LSC Section 9.6.1.3 states a fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electric Code and NFPA 72, National Fire Alarm and Signaling Code. NFPA 72, 2010 Edition, Section 14.4.5 states testing shall be performed in accordance with the schedules in Table 14.4.5. Table 14.4.5 requires alarm notification appliances, batteries, and initiating devices to be tested at least annually. This deficient practice could affect all building occupants.

Findings include:

During a record review with the Engineering Operations Manager, Director of Rehabilitation, Quality Improvement Specialist, and Engineering and Maintenance Supervisor on 03/11/2020 at 9:41 a.m., the facility was unable to provide documentation of an annual fire alarm system test and inspection from the most recent year. Based on interview at the time of record review the Engineering Operations Manager and the Director of Rehabilitation agreed they were unable to provide documentation of a fire alarm test or inspection from the most recent year.

2) Based on record review and interview, the facility failed to maintain 1 of 1 fire alarm systems in accordance with NFPA 72, as required by LSC 101 Sections 19.3.4.5.1 and 9.6. NFPA 72, Section 14.3.1 states that unless otherwise permitted by 14.3.2, visual inspections shall be performed in accordance with the schedules in Table 14.3.1, or more often if required by the authority having jurisdiction. Table 14.3.1 states that the following must be visually inspected semi-annually:
a. Control unit trouble signals
b. Remote annunciators
c. Initiating devices (e.g. duct detectors, manual fire alarm boxes, heat detectors, smoke detectors, etc.)
d. Notification appliances
e. Magnetic hold-open devices
This deficient practice could affect all building occupants.

Findings include:

During a record review with the Engineering Operations Manager, Director of Rehabilitation, Quality Improvement Specialist, and Engineering and Maintenance Supervisor on 03/11/2020 at 9:41 a.m., the facility was unable to provide documentation of an semi-annual fire alarm system visual inspection from the most recent year. Based on interview at the time of record review the Engineering Operations Manager and the Director of Rehabilitation agreed they were unable to provide documentation of a semi-annual fire alarm visual inspection from the most recent year.

Based on observation and interview, the facility failed to maintain the ceiling construction in one area throughout the facility. The ceiling tiles trap hot air and gases around the sprinkler and cause the sprinkler to operate at a specified temperature. NFPA 13, 2010 edition, 8.5.4.11 states the distance between the sprinkler deflector and the ceiling above shall be selected based on the type of sprinkler and the type of construction. This deficient practice could affect occupants in the main lobby area.

Findings include:

During a facility tour with the Engineering Operations Manager, Quality Improvement Specialist, and Engineering and Maintenance Supervisor on 03/10/2020 at 11:01 a.m. 1 of 20 ceiling tiles was missing in the main lobby. Based on interview at the time of observation, the Engineering Operations Manager and Engineering and Maintenance Supervisor were unsure of why the ceiling tile was not in place. It was noted that this was corrected at the time of observation.

Based on observation, and interview; the facility failed to ensure 1 of 1 sprinkler heads in the boiler room covered with lint and debris was replaced or cleaned in accordance with NFPA 25. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.1.1.1 states 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., up-right, pendent, or sidewall). Furthermore, at 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 manufacturer.
In lieu of replacing sprinklers that are loaded with dust, it is permitted to clean sprinklers with compressed air or by a vacuum provided that the equipment does not touch the sprinkler.
This deficient practice could affect staff only in the boiler room.

Findings include:

During a facility tour with the Engineering Operations Manager, Quality Improvement Specialist, and Engineering and Maintenance Supervisor on 03/10/2020 at 11:30 a.m., one sprinkler located in the boiler room was covered with lint and debris. Based on interview at the time of observation, the Engineering Operations Manager and Engineering and Maintenance Supervisor agreed the aforementioned automatic sprinkler was loaded with lint and debris.

Based on observation and interview, the facility failed to maintain 1 of 2 portable fire extinguishers in the corridor near the MRI Room per LSC 4.6.12.3. Section 4.6.12.3 requires existing life safety features obvious to the public if not required by the Code, shall be either maintained or removed. This deficient practice could affect occupants in or near the MRI Room.

Findings include:

During a facility tour with the Engineering Operations Manager, Quality Improvement Specialist, and Engineering and Maintenance Supervisor on 03/10/2020 at 11:45 a.m. a wall cabinet labeled FIRE EXTINGUISHER was discovered to not contain a portable fire extinguisher as indicated by labeling. Next to the cabinet was a properly supported portable fire extinguisher. The extinguisher was too large to be installed in the cabinet. Based on interview at the time of observation, the Engineering Operations Manager, Quality Improvement Specialist, and Engineering and Maintenance Supervisor agreed that the mis-labeled wall cabinet could cause confusion during a fire emergency.

Based on observation and interview, the facility failed to ensure 2 of 20 corridor doors were provided with a means suitable for keeping the door closed, had no impediment to closing, latching and would resist the passage of smoke in accordance with LSC 19.3.6.3. Additionally, 42 CFR 485.623(c)(1)(ii) prohibits roller latches and requires all corridor doors and doors to rooms containing flammable or combustible materials be provided with positive latching hardware. This deficient practice could affect occupants near the Radiology Department.

Findings include:

During a facility tour with the Engineering Operations Manager, Quality Improvement Specialist, and Engineering and Maintenance Supervisor on 03/10/2020 the following were found:
a) At 10:13 a.m. the corridor door to the third floor storage room by Room 305, which was equipped with a self-closing device, did not self-close and latch. Based on interview at the time of observation, the Engineering Operations Manager, Quality Improvement Specialist, and Engineering and Maintenance Supervisor agreed that the door did not latch into the frame when closing.
b) At 11:21 a.m., the door to X-Ray Room 1 was equipped with a roller-latch. Then, at 11:22 a.m. the door to X-Ray Room 2 was found to be equipped with a roller latch. Based on interview at both observations, the Engineering Operations Manager, Quality Improvement Specialist, and Engineering and Maintenance Supervisor agreed that the doors were outfitted with roller latching hardware.

Based on observation and interview, the facility failed to ensure 2 of 2 first floor smoke barrier walls was maintained in accordance with LSC Section 19.3.7.3. Section 19.3.7.3 requires smoke barriers to be constructed in accordance with LSC Section 8.5 and shall have a minimum ½ hour fire resistive rating. Section 8.5.2 states that smoke barriers shall be continuous from outside wall to outside wall and continuous through all concealed spaces. Section 8.5.6.3 states that where a smoke barrier is also consturcted as a fire barrier, penetrations shall be protected in accordance with the requirements of Section 8.3. This deficient practice could affect occupants in smoke compartments 1B and 1C.

Findings include:

During a facility tour with the Engineering Operations Manager, Quality Improvement Specialist, and Engineering and Maintenance Supervisor on 03/10/2020 the following conditions were found:
a) At 2:54 p.m., the smoke barrier near cross-corridor Door 5 was found to have penetrations above the lay-in ceiling tile sealed with a yellow spray foam. Based on interview at the time of observation, the Engineering Operations Manager and Engineering and Maintenance Supervisor were unable to state the foam met the requirements of ASTM E 814, Standard Test Method for Fire Tests of Through Penetration Fire Stops. No further documentation could be provided regarding the material at the time of the facility exit at 10:00 a.m. on 03/11/2020.
b) At 2:57 p.m. the smoke barrier near cross-corridor Door 4 was found to have two 1.5 inch unsealed penetrations around piping above the lay-in ceiling tile. Based on interview at the time of observation, the Engineering Operations Manager agreed there were two unsealed penetrations in the smoke barrier.

Based on observation and interview, the facility failed to ensure 1 of 1 smoke barrier door in the third floor IT room would restrict the movement of smoke for at least 20 minutes. LSC 19.3.7.8 requires doors in smoke barriers shall comply with LSC Section 8.5.4. LSC 8.5.4.1 requires doors in smoke barrier shall close the opening leaving only the minimum clearance necessary for proper operation. This deficient practice could affect all occupants on the third floor.

Findings include:

During a facility tour with the Engineering Operations Manager, Quality Improvement Specialist, and Engineering and Maintenance Supervisor on 03/10/2020 at 10:24 a.m., the scuttle door into the floor/ceiling assembly above the third floor was left open. Based on interview at the time of observation, the Engineering Operations Manager agreed that the scuttle was open.

1) Based on observation and interview, the facility failed to ensure 1 of 1 electrical wirings in the Radiology storage room was protected. NFPA 70, 2011 Edition. Article 406.5 (F) Exposed Terminals, Receptacles shall be enclosed so that live wiring terminals are not exposed to contact. This deficient practice could affect occupants near the Radiology storage room.

Findings include:

During a facility tour with the Engineering Operations Manager, Quality Improvement Specialist, and Engineering and Maintenance Supervisor on 03/10/2020, at 11:16 a.m., an electrical receptacle was located in the radiology storage room which was missing the cover plate. Based on interview at the time of observation, the Engineering Operations Manager agreed that the coverplate was missing.

2) Based on observation and interview, the facility failed to ensure 1 of 1 Maintenance Room and 1 of 1 Nurse Informatics room flexible cords were not used as a substitute for fixed wiring. LSC 9.1.2 requires electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code. NFPA 70, 2011 Edition, Article 400.8 requires that, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice affects staff only.

Findings include:

During a facility tour with the Engineering Operations Manager, Quality Improvement Specialist, and Engineering and Maintenance Supervisor on 03/10/2020, the following were found:
a) At 1:48 p.m. a multi-plug adapter was found powering battery charger and a telephone in the Maintenance Office.
b) At 2:15 p.m. a surge protector was found powering a refrigerator.
Based on interview at the time of observation, the Engineering Operations Manager and Quality Improvement Specialist agreed that the flexible cords were being used improperly.

Based on observation and interview, the facility failed to ensure 1 of 1 Front Office room and 1 of 1 Therapy Room flexible cords were not used as a substitute for fixed wiring. LSC 9.1.2 requires electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code. NFPA 70, 2011 Edition, Article 400.8 requires that, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice affects staff and up to 1 resident in the Therapy Room.

Findings include:

During a facility tour with the Engineering Operations Manager, Director of Rehabilitation, Quality Improvement Specialist, and Engineering and Maintenance Supervisor on 03/11/2020 at 9:16 a.m., a Relocatable Power Tap was powering a coffee maker; then, at 9:34 a.m. a Relocatable Power Tap was found powering a refrigerator in the Therapy Room. Based on interview at the time of each observation, the Engineering Operations Manager and Engineering and Maintenance Supervisor agreed that the power taps were being use improperly in place of fixed wiring. It was noted that both conditions were corrected at the time of observation.

1) Based on record review and interview, the facility failed to ensure 1 of 12 fire drills included the verification of transmission of the fire alarm signal to the monitoring station in fire drills conducted between 6:00 a.m. and 9:00 p.m. for the last 4 quarters. LSC 19.7.1.4 requires fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. This deficient practice affects all residents in the facility as well as staff and visitors.

Findings include:

During record review of titled "Franciscan Health Rensselaer Fire Drill Report" dated 08/28/19 with the Maintenance Engineering Supervisor on 03/10/2020 at 12:05 p.m., the 08/28/19 fire drill included the transmission of signal but did not include the time when the signal was received by the fire alarm monitoring company. Based on interview at the time of record review, the Maintenance Engineering Supervisor indicated the drill documentation did not include the time the fire alarm signal was transmitted and received by the fire alarm monitoring company.

2) Based on record review and interview, the facility failed to conduct quarterly fire drills at unexpected times under varying conditions on the second shift for 3 of 4 quarters. This deficient practice could affect all residents, staff and visitors in the facility.

Findings include:

Based on review of "Franciscan Health Rensselaer Fire Drill Report" documentation with the Maintenance Engineering Supervisor during record review on 03/10/2020 at 12:05 p.m., first shift (7:00 a.m. to 3:00 p.m.) fire drills conducted on 07/29/2019, 10/29/2019, and 01/24/2020 were conducted at, respectively, 1:35 p.m., 1:30 p.m. and 1:35 p.m. Based on interview at the time of record review, the Maintenance Engineering Supervisor acknowledged the aforementioned first shift fire drills were not conducted at unexpected times under varying conditions.

Based on observation and interview, the facility failed to maintain 1 of 1 master alarm system for the medical gas delivery system in accordance with NFPA 99, Health Care Facilities Code. This deficient practice could affect all persons in the facility.

Findings include:

During a facility tour with the Engineering Operations Manager, Quality Improvement Specialist, and Engineering and Maintenance Supervisor on 03/10/2020 at 11:04 a.m., the main alarm panel for the Beacon medical gas delivery system in the Front Desk area did not provide a visual or audible warning when tested. Based on interview at the time of observation, the Engineering Operations Manager, Quality Improvement Specialist, and Engineering and Maintenance Supervisor agreed that the alarm panel did not produce a visual or audible warning when the test button was pushed.

Based on observation and interview, the facility failed to ensure 1 of 1 generator was in accordance with NFPA 99, 2012 Edition, Health Care Facilities Code Section 6.4.1.1.6.1. Section 6.4.1.1.6.1 states that Type 1 and Type 2 essential electrical system power sources shall be classified as Type 10, Class X, Level 1 generator sets per NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110 Section 7.3.1 states the Level 1 or Level 2 EPS equipment location(s) shall be provided with battery-powered emergency lighting. This requirement shall not apply to units located outdoors in enclosures that do not include walk-in access. NFPA 110 7.3.2 states the emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch. This deficient practice could affect staff and all patients.

Findings include:

During a facility tour with the Engineering Operations Manager, Quality Improvement Specialist, and Engineering and Maintenance Supervisor on 03/10/2020 at 11:24 a.m., it was determined that the East Automatic Transfer Switch location was not protected by a battery operated emergency light. Based on interview at the time of observation, the Engineering Operations Manager, Quality Improvement Specialist, and Engineering and Maintenance Supervisor agreed that the transfer switch was not protected by battery operated emergency lighting.

Based on observation and interview, it could not be assured 1 of 1 Relocatable Power Tap (surge protector) in the CT Scan patient care vicinity met UL 1363A or UL60601-1. NFPA 99, Standard for Health Care Facilities, 2012 edition, defines patient care areas as any portion of a health care facility wherein patients are intended to be examined or treated. Patient care vicinity is defined as a space, within a location intended for the examination and treatment of patients, extending 6 feet beyond the normal location of the bed, chair, table, treadmill, or other device that supports the patient during examination and treatment. A patient care vicinity extends vertically to 7 feet 6 inches above the floor. This deficient practice could affect staff and one patient in the CT scan room.

Findings include:

During a facility tour with the Engineering Operations Manager, Quality Improvement Specialist, and Engineering and Maintenance Supervisor on 03/10/2020 at 11:16 a.m., the Relocatable Power Tap powering the 4-Lead Cardiac Monitor was determined to be UL 1363 listed. Based on interview at the time of observation, the Maintenance Engineering Supervisor acknowledged the aforementioned power strip was not a UL 1363A or UL60601-1 listed Special Purpose -- Relocatable Power Tap.