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Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients on the upper and lower levels of the facility, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the building's exit access corridors.

Findings include:
A. The sprinklered Soiled Utility room for the ICU/CCU did not have self-closing doors (two doors) to comply with 19.3.2.1(5), 8.4.1.2 and 8.2.4.3.5.
Update 09/07/12: The facility was not able to meet the complatetion date of 01/27/12 noted on the PoC.

B. Corrected 09/07/12.
C. Corrected 09/07/12.
D. Corrected 09/07/12.
E. Corrected 09/07/12.

Based on random observation during the survey walk-through, not all exit doors are arranged so that exits are readily accessible at all times in accordance with 19.2.1 and Chapter 7. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:
A. Doors were observed to be provided with dead bolt locks in addition to lock/latchsets. The dead bolt lock constitutes a second releasing operation to operate the the door in noncompliance with 7.2.1.5.4. Locations observed include but are not necessarily limited to the following:

1. Corrected 09/07/12.
2. Corrected 09/07/12.
3. Corrected 09/07/12.
4. Corrected 09/07/12.
5. Corrected 09/07/12.
6. Corrected 09/07/12.
7. Corrected 09/07/12.
8. At both sets of the cross corridor doors exiting surgery.
9. Corrected 09/07/12.

Based on random observation during the survey walk-through not all portions of the facility's Type 1 emergency system are installed in accordance with NFPA 99-1999 and NFPA 110-1999.

Findings include:
A. Corrected 09/07/12.

B. At the generator location it was discovered the generator was not provided with a duplex outlet connected to the load side of the transfer switch in accordance with NFPA 99, 3-4.2.2.2 (b).
Update 09/07/12: The was not able to meet the completion dated of 02/17/12 noted on the PoC.

C. Corrected 09/07/12.
D. Corrected 09/07/12.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

Based on random observation during the survey walk-through of the laboratory area, not all portions of laboratory safety devices are installed in accordance with NFPA 99 1999 10-6.

Findings include:

A. The eye wash appeared to be mounted on a sink gooseneck faucet without pressure and temperature adjusting devices.

B. The emergency shower did not appear to have a floor receptor installed and/or was mounted over the top of equipment.

These deficiencies could result in staff injury due to injurious water pressure/temperature and inaccessibility for use of the safety devices.

Update 09/07/12: According to the facility's maintenance staff the eyewash that appeared to be mounted on a sink gooseneck faucet without pressure was removed and was no longer needed per the Facility's Infection Control Risk Assesment Committee. The surveyor was not able to request for documentations from the facility to demonstrate why the eyewash was not required.

Based on random observation, staff interview and document review, not all portions of the facility's emergency electrical system are identified and maintained in accordance with NFPA 70-1999 and NFPA 99-1999.

Findings include:
A. During the penthouse walk-through, an interview was held with the Director of Maintenance on how the facility identified electric panels on the emergency electrical system and the reply was not descriptive of how they were identified. During the survey walk-through the emergency electric system was not identified consistently in accordance with NFPA 99, 3-4.2.2.2 and NFPA 70, 517-30(c) for the 3 branches of Life Safety, Critical and Equipment branch.

B. During the survey walk-through of critical care areas as defined in NFPA 99, outlets connected to the emergency electrical system were not labeled consistently in accordance with NFPA 70, 517-19 as to the panel and circuit number serving the outlet.

C. During the document review records for testing Line Isolation Monitors (LIM), monthly in accordance with NFPA 99, 3-3.3.3.4.2(b).

D. LIM 3ME 2101 observed in the operating room area, test switch did not work when depressed showing it in need of repair in accordance with NFPA 99, 3-3.3.4.2(c).

E. The 3 transfer switches connected to the 450 KW generator did not have a green light illuminated to show connection to the normal electric system and therefore in need of repair in accordance with NFPA 110, 4-2.4.11.

F. Patient rooms on the upper level was observed without an emergency circuit serving an outlet in the room in accordance with NFPA 70, 517-18.

G. During the survey walk-through of the Emergency Room bed location 2 was observed with only emergency power outlets and no normal power outlets in accordance with NFPA 70, 517-19(a).

H. During the survey walk-through of the Emergency Room bed location 2 was observed with four receptacles and not six in accordance with NFPA 70, 517-19(b).

The deficiencies listed above could cause injury to patients and staff due to equipment failure.