HospitalInspections.org

Based on observation during tour of Larkin Community Hospital it was determined that the facility failed to ensure that the integrity of smoke barriers was maintained to form two separate and distinct compartments. A smoke barrier wall or door that is not maintained smoke tight would in the event of fire allow fire, smoke and toxic gasses to migrate into adjacent smoke compartments prolonging exposure to the buildings occupants. This poses potential for adverse affects to health and safety.

The findings include:

1. During the tour of the facility on 09/21/11 it was observed in the kitchen area the following doors did not close to a positive latch when tested.

At 2:18 p.m. the cook's office door was hitting the door frame preventing it from shutting completely.

At 2:21 p.m. the storage room door was hitting the door frame preventing it from shutting completely.

2. During the tour of the facility on 09/22/11 it was observed that the following door did not close to a positive latch when tested.

At 3:03 p.m. in the pre op area, second floor the office door did not close completely.

3. During the tour of the facility on 09/23/11 at 10:45 a.m. it was observed that the soiled utility room in the operating area did not have an automatic door closure.

All of the finding were noted by the director of plant operation.

Based on observation and interview with the Director of Plant Operation it was determined that the facility failed to maintain the fire/smoke barrier walls to provide their required fire/smoke resistance rating. A fire/smoke barrier that is not maintained would in the event of fire allow fire, smoke and toxic gasses to migrate into adjacent smoke compartments, prolonging exposure to the buildings occupants. This poses potential for adverse affects to health and safety.

The findings include

1. During the tour of the facility on 09/22/11 at 2:35 p.m. with the director of plant operation it was noted that a small closet near the emergency room to have a power passing thru the ceiling with no fire caulking.

2. During the tour of the facility on 09/23/11 at 10:20 a.m. with the director of plant operation it was noted that a small closet near the nurses station to have a numerous communication cables passing thru the ceiling with no fire caulking.

NFPA 101 (2000 edition)

Based on observations and staff interview the facility failed to provide exit access from the building without the use of a special tool or knowledge from the egress side. This condition could delay or deny access to the exit discharge in the event of a fire, endangering the building occupants.

The findings include:

During the tour of the facility it was noted on 09/21/11 at 2:56 p.m. that the power doors (main entrance) failed to open when tested during a power outage. This condition was note by the director of plant operation and the safety officer.

NFPA 101 (2000) 7.2.1.9.1

Based on a review of the facility records and interview with the staff, it was determined that the facility failed to ensure the staff were trained in emergency fire procedures at the frequency required, consisting of at least one fire drill per shift per quarter, and all Laboratory staff members must participate at least annually. A lack of established routine fire drills for the staff could negate their ability to react without panic, to act swiftly, and orderly without adding to an incident or prolonging exposure to an unsuitable environment.

The findings include:

During the record review and staff interviews during the survey the facility could not provide documentation that the required quarterly fire drills had been conducted for the Laboratory personnel. On 09/22/11 at 1:25 p.m. surveyor spoke to the director of the laboratory and it was stated that the laboratory staff did not have drills for emergencies in the laboratory area.

NFPA 101 2000 edition
NFPA 99 1999 edition: 10-2.1.4.3*

Based upon staff interviews and observations during the tour of Larkin Community Hospital it was determined that several areas of the facilities sprinkler system did not have the proper characteristics for the intended application and were not in compliance of NFPA 13 (1999 edition). This condition could place the lives of the occupants at risk should a fire occur and smoke travels to all upper floors.
The findings include
During the facility tour it was observed by the surveyor and the facility director of plant operation that the following areas did not have sprinkler coverage.

1. In the small conference room, a small storage area was observed on 09/21/11 at 11:35 a.m. this area did not have sprinkler coverage.

2. During the tour of the facility on 09/22/11 at 2:35 p.m. with the director of plant operation it was noted that a small closet near the emergency room did not have sprinkler head in this area.

3. During the tour of the facility on 09/22/11 at 3:05 p.m. with the director of plant operation it was observed that the two elevator shafts did not have a sprinklers head in the pits. These three elevators are operated by hydraulic fluid equipment. In the elevator shaft near the emergency room it was noted a fluid on the floor. Unable to determine what the substance was. The director of plant operations unsure what type of hydraulic fluid was being used.

NFPA 101 (2000 edition)
NFPA 13

Based on observations made during tour of Larkin Community Hospital on 09/23/11 it was determined that the facility failed to ensure that the Ventilation System was installed and maintained in reliable operating condition. This would promote unbalanced air pressure in the facility, promote sustained odors in the facility, and raise potential infection control issues in the facility.

The findings include:

During the tour of the operation suite on 09/23/11 at 10:55 a.m. it was observed that there was no exhaust fan in the janitors closet.



NFPA 101-2000
NFPA 90A, 19.5.2.2

Based on observations made during tour of Larkin Community Hospital it was determined the facility failed to ensure that non-medical flammable medical gas is handled and stored in accordance with NFPA 99. Unsecured oxygen cylinders have the potential, if knocked over, to rupture at the neck of the cylinder causing a super oxygen-enriched atmosphere, increasing the flammability of all surrounding building contents, and the cylinder itself becoming projectile endangering all building occupants.

The findings include:

1. During the tour of the facility on 09/21/11 it was observed oxygen cylinders were not secure properly.

At 2:33 p.m. in the emergency room it was observed a free standing oxygen cylinder.

At 2:37 p.m. in the emergency triage room it was observed a free standing oxygen cylinder.

2. During the tour of the facility on 09/22/11 it was observed oxygen cylinder were not secure properly.

At 2:32 p.m. it was observed a free standing oxygen cylinder in the critical care unit

3. During the tour of the facility on 09/23/11 it was observed oxygen cylinder were not secure properly.

At 10:07 a.m. it was observed a free standing oxygen cylinder in the third floor nurses station.

Based on observations and staff interviews conducted at Larkin Community Hospital during the survey it was determined that this facility did not comply with specific requirements of NFPA 70, the National Electrical Code and the NFPA 99.

The findings include:

1. There was documentation available at the time of the survey to show that the main and feeder circuit breakers are inspected and exercised annually as required. The documentation that was presented on 09/21/11 at 4:20 p.m. indicated that main breaker labeled number one was not tested. The documentation that review showed that this testing was not performed because it needs to be repaired.

2. During the tour of the pre-operation suite on 09/23/11 at 10:25 a.m. it was observed a brown extension cord attached to the automatic medication storage unit.

3. During the tour of the fifth floor in the activity room it was observed on 09/22/11 at 2:10 p.m. it was observed an extension cord attached to a power strip and office equipment plugged into the power strip.

4. During the tour of the facility on 09/21/11 at 9:45 a.m. it was observed an extension cord in use for floor scrubber. The floor scrubber was located outside near the MRI trailer. The was observed by the director of plant operation.

NFPA 101-2000
NFPA 99 3-4.4.1.2.(a).
FAC 59A-3.077

Based on observation during tour of Larkin Community Hospital it was determined that the facility failed to ensure that the integrity of smoke barriers was maintained to form two separate and distinct compartments. A smoke barrier wall or door that is not maintained smoke tight would in the event of fire allow fire, smoke and toxic gasses to migrate into adjacent smoke compartments prolonging exposure to the buildings occupants. This poses potential for adverse affects to health and safety.

The findings include:

1. During the tour of the facility on 09/21/11 it was observed in the kitchen area the following doors did not close to a positive latch when tested.

At 2:18 p.m. the cook's office door was hitting the door frame preventing it from shutting completely.

At 2:21 p.m. the storage room door was hitting the door frame preventing it from shutting completely.

2. During the tour of the facility on 09/22/11 it was observed that the following door did not close to a positive latch when tested.

At 3:03 p.m. in the pre op area, second floor the office door did not close completely.

3. During the tour of the facility on 09/23/11 at 10:45 a.m. it was observed that the soiled utility room in the operating area did not have an automatic door closure.

All of the finding were noted by the director of plant operation.

Based on observation and interview with the Director of Plant Operation it was determined that the facility failed to maintain the fire/smoke barrier walls to provide their required fire/smoke resistance rating. A fire/smoke barrier that is not maintained would in the event of fire allow fire, smoke and toxic gasses to migrate into adjacent smoke compartments, prolonging exposure to the buildings occupants. This poses potential for adverse affects to health and safety.

The findings include

1. During the tour of the facility on 09/22/11 at 2:35 p.m. with the director of plant operation it was noted that a small closet near the emergency room to have a power passing thru the ceiling with no fire caulking.

2. During the tour of the facility on 09/23/11 at 10:20 a.m. with the director of plant operation it was noted that a small closet near the nurses station to have a numerous communication cables passing thru the ceiling with no fire caulking.

NFPA 101 (2000 edition)

Based on observations and staff interview the facility failed to provide exit access from the building without the use of a special tool or knowledge from the egress side. This condition could delay or deny access to the exit discharge in the event of a fire, endangering the building occupants.

The findings include:

During the tour of the facility it was noted on 09/21/11 at 2:56 p.m. that the power doors (main entrance) failed to open when tested during a power outage. This condition was note by the director of plant operation and the safety officer.

NFPA 101 (2000) 7.2.1.9.1

Based on a review of the facility records and interview with the staff, it was determined that the facility failed to ensure the staff were trained in emergency fire procedures at the frequency required, consisting of at least one fire drill per shift per quarter, and all Laboratory staff members must participate at least annually. A lack of established routine fire drills for the staff could negate their ability to react without panic, to act swiftly, and orderly without adding to an incident or prolonging exposure to an unsuitable environment.

The findings include:

During the record review and staff interviews during the survey the facility could not provide documentation that the required quarterly fire drills had been conducted for the Laboratory personnel. On 09/22/11 at 1:25 p.m. surveyor spoke to the director of the laboratory and it was stated that the laboratory staff did not have drills for emergencies in the laboratory area.

NFPA 101 2000 edition
NFPA 99 1999 edition: 10-2.1.4.3*

Based upon staff interviews and observations during the tour of Larkin Community Hospital it was determined that several areas of the facilities sprinkler system did not have the proper characteristics for the intended application and were not in compliance of NFPA 13 (1999 edition). This condition could place the lives of the occupants at risk should a fire occur and smoke travels to all upper floors.
The findings include
During the facility tour it was observed by the surveyor and the facility director of plant operation that the following areas did not have sprinkler coverage.

1. In the small conference room, a small storage area was observed on 09/21/11 at 11:35 a.m. this area did not have sprinkler coverage.

2. During the tour of the facility on 09/22/11 at 2:35 p.m. with the director of plant operation it was noted that a small closet near the emergency room did not have sprinkler head in this area.

3. During the tour of the facility on 09/22/11 at 3:05 p.m. with the director of plant operation it was observed that the two elevator shafts did not have a sprinklers head in the pits. These three elevators are operated by hydraulic fluid equipment. In the elevator shaft near the emergency room it was noted a fluid on the floor. Unable to determine what the substance was. The director of plant operations unsure what type of hydraulic fluid was being used.

NFPA 101 (2000 edition)
NFPA 13

Based on observations made during tour of Larkin Community Hospital on 09/23/11 it was determined that the facility failed to ensure that the Ventilation System was installed and maintained in reliable operating condition. This would promote unbalanced air pressure in the facility, promote sustained odors in the facility, and raise potential infection control issues in the facility.

The findings include:

During the tour of the operation suite on 09/23/11 at 10:55 a.m. it was observed that there was no exhaust fan in the janitors closet.



NFPA 101-2000
NFPA 90A, 19.5.2.2

Based on observations made during tour of Larkin Community Hospital it was determined the facility failed to ensure that non-medical flammable medical gas is handled and stored in accordance with NFPA 99. Unsecured oxygen cylinders have the potential, if knocked over, to rupture at the neck of the cylinder causing a super oxygen-enriched atmosphere, increasing the flammability of all surrounding building contents, and the cylinder itself becoming projectile endangering all building occupants.

The findings include:

1. During the tour of the facility on 09/21/11 it was observed oxygen cylinders were not secure properly.

At 2:33 p.m. in the emergency room it was observed a free standing oxygen cylinder.

At 2:37 p.m. in the emergency triage room it was observed a free standing oxygen cylinder.

2. During the tour of the facility on 09/22/11 it was observed oxygen cylinder were not secure properly.

At 2:32 p.m. it was observed a free standing oxygen cylinder in the critical care unit

3. During the tour of the facility on 09/23/11 it was observed oxygen cylinder were not secure properly.

At 10:07 a.m. it was observed a free standing oxygen cylinder in the third floor nurses station.

Based on observations and staff interviews conducted at Larkin Community Hospital during the survey it was determined that this facility did not comply with specific requirements of NFPA 70, the National Electrical Code and the NFPA 99.

The findings include:

1. There was documentation available at the time of the survey to show that the main and feeder circuit breakers are inspected and exercised annually as required. The documentation that was presented on 09/21/11 at 4:20 p.m. indicated that main breaker labeled number one was not tested. The documentation that review showed that this testing was not performed because it needs to be repaired.

2. During the tour of the pre-operation suite on 09/23/11 at 10:25 a.m. it was observed a brown extension cord attached to the automatic medication storage unit.

3. During the tour of the fifth floor in the activity room it was observed on 09/22/11 at 2:10 p.m. it was observed an extension cord attached to a power strip and office equipment plugged into the power strip.

4. During the tour of the facility on 09/21/11 at 9:45 a.m. it was observed an extension cord in use for floor scrubber. The floor scrubber was located outside near the MRI trailer. The was observed by the director of plant operation.

NFPA 101-2000
NFPA 99 3-4.4.1.2.(a).
FAC 59A-3.077