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Based on observation, interview, and review of National Fire Protection Association (NFPA) 101 2012 Edition and NFPA 80 2010 Edition, it was determined the facility failed to maintain ten of ten fire-rated door assemblies (Respiratory Sterilization, Respiratory Storage, Labor-Delivery-Recovery-Postpartum (LDRP) Soil, Emergency Department (ED) Soil, Sterile Processing 1, Dietary Housekeeping, Critical Care Unit (CCU) Soil, Generations Soil, Day Surgery Soil, Kitchen Storage) in accordance with NFPA standards in that one fire-rated door assembly (Sterile Procedure 1) did not have a self-closing device installed, seven fire-rated door assemblies (Sterile Processing 1, LDRP Soil, ED Soil, Dietary Housekeeping, CCU Soil, Generations Soil, Day Surgery Soil) did not fully close and latch when released, and three fire-rated door assemblies (Respiratory Sterilization, Respiratory Storage, Kitchen Storage) were wedged in the open position. Findings follow:

A. Review of NFPA 101 2012 Edition: 7.2.1.8.2 showed any door leaf required to be kept closed shall only be held open by a device which automatically releases the door leaf upon operation of a smoke detector and upon loss of power to the device. Review of NFPA 101 2012 Edition: 8.3.3.1 showed all openings required to have a fire protection rating shall be protected by fire door assemblies and accompanying hardware in accordance with NFPA 80.
B. Review of NFPA 80 2010 Edition: 5.1.3.2 showed fire-rated doors shall be kept closed and latched or arranged for automatic closing. Review of NFPA 80 2010 Edition: 6.1.4.2.1 showed self-closing doors shall be equipped with a closing device to cause the door to close and latch each time the door is opened. Review of NFPA 80 2010 edition: 5.2.13.3 showed blocking or wedging of doors in the open position shall be prohibited.
C. Observation on 10/19/22 at 2:40 PM of the LDRP Soil room showed the doorway was comprised of a fire-rated door assembly which had a kick-down doorstop installed near the bottom of the door leaf and did not close and latch when released.
D. Observation on 10/19/22 at 2:50 PM of the ED Soil room showed the doorway was comprised of a fire-rated door assembly which did not close and latch when released.
E. Observation on 10/19/22 at 10:00 AM of the Dietary Housekeeping room showed the doorway was comprised of a fire-rated door assembly which did not close and latch when released.
F. Observation on 10/19/22 at 10:20 AM of the Kitchen Storage showed the doorway was comprised of a fire-rated door assembly which was held open by a kick-down doorstop installed near the bottom of the door leaf.
G. Observation on 10/19/22 at 9:15 AM of the CCU Soil room showed the doorway was comprised of a fire-rated door assembly which did not close and latch when released.
H. Observation on 10/19/22 at 9:30 AM of the Generations Soil room showed the doorway was comprised of a fire-rated door assembly which did not close and latch when released.
I. Observation on 10/19/22 at 12:30 PM of Sterile Processing 1 showed the doorway was comprised of a fire-rated door assembly which did not have a closing device installed and did not close and latch when released.
J. Observation on 10/19/22 at 1:15 PM of the Day Surgery Soil room showed the doorway was comprised of a fire-rated door assembly which did not close and latch when released.
K. Observation on 10/19/22 at 3:30 PM of the Respiratory Department showed Respiratory Storage and Respiratory Sterilization were each comprised of fire-rated door assemblies which were held open by wooden doorstops wedged under each door leaf.
L. The above findings in C - K were verified with the Director of Maintenance at the times of observation.

Based on observation, interview, and review of National Fire Protection Association (NFPA) 101 Life Safety Code 2012 Edition, it was determined the facility failed to install five of five alcohol-based hand-rub (ABHR) dispensers at a safe distance from hazardous locations as required by NFPA 101. The failed practice created a fire hazard in the Medical-Surgical Unit, Emergency Department, and Day Surgery Unit. Findings follow:

A. Review of NFPA 101 2012 Edition: 19.3.2.6 (8) showed ABHR dispensers shall not be installed above an ignition source within a 1-inch horizontal distance from each side of the ignition source or to the side of an ignition source within a 1-inch horizontal distance of the ignition source.
B. Observation on 10/18/22 at 2:20 PM of the Medical-Surgical Unit showed an ABHR dispenser was installed in Room 210 within 1 inch of a light switch and in Room 211 within 1 inch of a light switch. Further observation of the Medical-Surgical Unit showed an ABHR dispenser was installed directly above a duplex electrical receptacle in Room 201.
C. Observation on 10/18/22 at 3:10 PM of the Emergency Department showed an ABHR dispenser was installed within 1 inch of a light switch in Room C128.
D. Observation on 10/19/22 at 1:35 PM of the Day Surgery Unit showed an ABHR dispenser was installed directly above a duplex electrical receptacle near the entrance to the unit.
E. The above findings in B, C, and D were verified with the Director of Maintenance at the times of observation.

Based on observation, interview, and review of NFPA 101 2012 Edition, it was determined the facility failed to maintain three of three (Health Information Management, Mail Room, Electrical Room) smoke barriers in accordance with the requirements of NFPA 101 2012 Edition in that all three barriers had penetrations which were not sealed with a firestop system or device to restrict the transfer of smoke. The risk of fire or smoke spreading had the likelihood to affect all patients, visitors, and staff in the facility in the event of a fire. Findings follow:

A. Review of NFPA 101 2012 edition, 8.4.4.1, showed where penetrations for conduits that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier shall be protected by a system or material capable of restricting the transfer of smoke.
B. Observation on 10/19/22 at 1:25 PM of the smoke barrier surrounding the Electrical Room adjacent to the Day Surgery Unit showed 5 electrical conduits penetrating the barrier were not sealed to restrict the transfer of smoke.
C. Observation on 10/20/22 at 9:00 AM of the smoke barrier separating the Patient Corridor from the Health Information Management Unit showed 1 electrical conduit penetrating the barrier and 2 tubes filled with wires penetrating the barrier were not sealed to restrict the transfer of smoke.
D. Observation on 10/20/22 at 9:30 AM of the smoke barrier separating the Mail Room from the Patient Corridor showed a bundle of 3 wires penetrating the barrier and a bundle of 8 wires penetrating the barrier were not sealed to restrict the transfer of smoke.
E. The above findings in B, C, and D were verified with the Director of Maintenance at the times of observation.

Based on interview and review of National Fire Protection Association (NFPA) 101 2012 Edition, it was determined the facility failed to meet the provisions of the life safety from fire requirements in that a fire drill was not conducted on the 1st Shift during the first or third quarter of 2022, and a fire drill was not conducted on the 2nd shift during the first, second, or third quarter of 2022. The failed practice had the likelihood to affect all staff and patients in that in the event of a fire the staff would not be trained to respond to the emergency, which could result in injury or death if the proper actions were not taken to preserve the lives of patients and staff. Findings follow:

A. Review of NFPA 101:19.7.1.6 showed fire drills are to be conducted by the facility once per shift per quarter.
B. Review of the facility's Fire Drill Log showed in the 12 months prior to the survey (November 2021 - October 2022) there were no fire drills conducted on the 1st Shift during the first or third quarter of 2022, and a fire drill was not conducted on the 2nd shift during the first, second, or third quarter of 2022. This was verified with the Director of Maintenance on 10/19/22 at 2:30 PM.

Based on observation, interview, and review of National Fire Protection Association (NFPA) 101 and NFPA 80, it was determined the facility failed to maintain the fire-rated door assemblies in the building in accordance with NFPA standards in that no annual inspection was being conducted of the fire-rated door assemblies in the facility. Findings follow:

A. Review of NFPA 101 2012 Edition: 8.3.3.1 showed all openings required to have a fire protection rating shall be protected by fire door assemblies and accompanying hardware in accordance with NFPA 80. Review of NFPA 80 2010 Edition: 5.2.1 showed fire door assemblies shall be inspected and tested not less than annually.
B. In an interview on 10/19/22 at 2:30 PM with the Director of Maintenance it was verified the facility did not conduct any annual inspection or testing of the fire-rated door assemblies in the building.

Based on interview and review of the facility's generator logs and National Fire Protection Association (NFPA) 101 and NFPA 110, it was determined the facility failed to maintain one of one emergency power generator as required by NFPA 101 Life Safety Code 2012 Edition in that the emergency generators were not being inspected weekly or tested in accordance with NFPA 110 to ensure functionality in the event of an emergency. The failed practice had the likelihood to affect all patients, staff, and visitors in that in the event of a power outage emergency the generators may not function properly and could fail to support all equipment and emergency lighting relying on the essential electrical system for emergency power. Findings follow:

A. Review of NFPA 101 2012 Edition: 9.1.3 showed emergency generators must be installed and maintained in accordance with NFPA 110 Standard for Emergency and Standby Power Systems.
B. Review of NFPA 110 2010 Edition: 8.4.1 showed EPS (emergency power supply) systems shall be inspected weekly and exercised under load at least monthly. Further review of NFPA 110 2010 Edition: 8.4.2 showed diesel generator sets shall be exercised monthly under load for 30 minutes using either loading that maintains the minimum exhaust temperatures recommended by the manufacturer or loading which exceeds 30 percent of the EPS nameplate kW (kilowatt) rating. Further review of NFPA 110 2010 Edition: 8.4.2.3 showed diesel-powered EPS systems that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours.
C. Review on 10/19/22 at 2:00 PM of the facility's Generator Log showed the generators were not being visually inspected weekly in the 12 months prior to the survey (November 2021 - October 2022). This finding was verified with the Director of Maintenance at the time of review.
D. In an interview on 10/19/22 at 2:15 PM with the Director of Maintenance it was verified there was no documentation of the diesel-fueled emergency generator being exercised monthly under load for 30 minutes using either loading that maintains the minimum exhaust temperatures recommended by the manufacturer or loading which exceeds 30 percent of the EPS nameplate kW (kilowatt) rating, and there was no documentation that the emergency generator was being exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours.

Based on observation, interview, and review of National Fire Protection Association (NFPA) 99 Health Care Facilities Code 2012 Edition, it was determined the facility failed to use multiple-receptacle power cords in accordance with NFPA 99 standards in two of two patient care areas (Operating Room (OR) 1, Operating Room 2) in that there was no measure in place to prevent additional devices from being plugged in to the power cords, there was no measure in place to ensure the devices powered by the cords did not exceed 75% of each cord's rated ampacity, the electrical and mechanical integrity of the cords were not regularly verified and documented, and the power cords were not permanently attached to the equipment they were powering. The failed practices had the likelihood to affect all patients receiving care in the vicinity of the power cords in that there were no processes in place to ensure the cords would not exceed their ampacity and cause a fire or electrical shock. Findings follow:

A. Review of NFPA 99 2012 Edition: 10.2.3.6 showed flexible power cords with two or more receptacles shall be permitted to be used provided they are permanently attached to the assembly they are powering, the sum of all appliances connected to the outlets does not exceed 75% of the power cord's ampacity, the electrical and mechanical integrity of the cord are regularly verified and documented, and means are employed to ensure additional devices or nonmedical equipment cannot be connected to the power cords after leakage currents have been verified as safe.
B. Observation on 10/19/22 at 12:50 PM of OR 2 showed two patient care-related electrical devices were being powered by a multiple-receptacle power cord with 6 receptacles which was plugged into a ceiling receptacle and was hanging from the ceiling. There was no measure in place to prevent additional devices from being plugged in to the power cord. This finding was verified with the Director of Maintenance at the time of observation.
C. Observation on 10/19/22 at 1:00 PM of OR 1 showed two patient care-related electrical devices were being powered by a multiple-receptacle power cord with 6 receptacles which was plugged into a ceiling receptacle and was hanging from the ceiling, and one patient care-related electrical device was being powered by a multiple-receptacle power cord with 6 receptacles which was plugged into a ceiling receptacle and was hanging from the ceiling. There was no measure in place to prevent additional devices from being plugged in to the power cord. This finding was verified with the Director of Maintenance at the time of observation.
D. In an interview on 10/19/22 at 2:30 PM with the Director of Maintenance it was verified that the facility did not have a process in place to ensure the sum of the appliances connected to a multiple-receptacle power cord would not exceed 75% of the power cord's ampacity, and the facility did not have a process in place to regularly verify the electrical and mechanical integrity of the multiple-receptacle power cords in the facility.

Based on observation, interview, and review of National Fire Protection Association (NFPA) 101 Life Safety Code 2012 Edition and NFPA 99 Health Care Facilities Code 2012 Edition, it was determined the facility failed to store portable oxygen cylinders in accordance with NFPA standards in that full and empty cylinders were being stored together and the empty cylinders were not marked. The failed practice had the likelihood to affect all patients relying on oxygen in that in the event of an emergency an empty portable oxygen tank could be mistaken as full and result in delayed care for the patient in need of oxygen. Findings follow:

A. Review of NFPA 101: 19.3.2.4 showed medical gas storage and administration shall be in accordance with section 8.7 and NFPA 99.
B. Review of NFPA 99: 11.6.5.2 showed if empty and full portable oxygen cylinders are stored together, full cylinders shall be segregated from empty cylinders. Further review of NFPA 99: 11.6.5.3 showed empty portable oxygen cylinders shall be marked to avoid confusion.
C. Observation on 10/19/22 at 12:40 of the Surgical Recovery Unit showed 7 full portable oxygen tanks and 3 empty portable oxygen tanks were stored together in a rack. The empty tanks were not marked to indicate they were empty. This finding was verified with the Director of Maintenance at the time of observation
D. Observation on 10/19/22 at 3:30 PM of the Respiratory Department area showed 9 full portable oxygen cylinders and 1 empty portable oxygen cylinder were stored in a rack together. The empty tank was not marked to indicate it was empty. This finding was verified with the Director of Maintenance at the time of observation.