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Based on observations, the facility failed to ensure that all corridor doors latched positively without any impediment preventing the latching mechanism from failure. This deficiency had the potential to affect more than a very limited number of residents, staff and visitors in the building.

Findings include:

In accordance with NFPA 101 and section 19.3.6.3.3, hold-open devices that release when the door is pushed or pulled shall be permitted. Further, Annex A.19.3.6.3.3 states that doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

The forces required to fully open any door manually in a means of egress shall not exceed 15 pounds of force to release the latch, 30 pounds of force to set the door in motion and 15 pounds of force to open the door to the minimum required width per section 7.2.1.4.5 of the Life Safety Code.

The door marked Emergency and the door marked Beauty shop were held open by a heavy coat hanger and a sign stand between 2:00 to 4:00 p.m. on 9/16/13. Both of the doors were equipped with self closure devices.

Based on observations, the facility failed to ensure that hazardous areas were separated from other spaces by smoke resisting partitions and doors. This deficiency had the potential to affect more than very few residents, staff and visitors in the facility.

Findings include:

1. On 9/16/13 at 1:20 p.m., the 20 minute rated metal door between the crawl space of the building and the boiler room (a hazardous area) was observed open. This door must remain closed to ensure that the boiler room was separated from the unsprinklered crawl space and requires an automatic closurer to be fully complaint (spring). Additionally, two large cardboard boxes of storage items were observed on the ground in the unsprinklered crawl space.

2. On 9/16/13 at 2:05 p.m., three unsealed corridor wall penetrations were observed in the housekeeping storage room where one flexible conduit and several data cables extended through these unsealed penetrations.

3. On 9/16/13 at 2:19 p.m., the Central Supply storage was observed. The exit corridor door to room lacked a self closure device installation. The area contained number of card box storage boxes, wheelchairs, an x-ray machine and other storage items and was greater then 50 square feet in size.

4. On 9/16/13 at 2:35 p.m., an unsealed penetration was observed on the kitchen wall where blue communication wires extended from the central supply room into the kitchen.

5. NFPA 99, 10-3.1.1 Health Care laboratories shall be separated from surrounding health care areas and from exit corridors by fire-resistive construction with a minimum rating of 1-hour, and all openings protected by ? hour-rated assemblies. Labs that are sprinkled and are classified as not having severe hazards do not require separation. Any opening in a lab corridor barrier shall be permitted to be held open only by an automatic release device complying with the applicable requirements of NFPA 101.

The lab was observed at 3:55 p.m. on 9/16/13. The exit corridor door self closure was disengaged and was not operational.

Based on observations, the facility failed to provide for complete coverage of the building by an approved automatic sprinkler system. The deficiency could affect all residents, staff, and visitors in the building.

Findings include:

The building is of Type V (111) combustible construction which requires that the facility be protected throughout by an automatic sprinkler system that meets NFPA 13 standards in accordance with NFPA 19.1.6.2.

Except for part of the North hall that housed the boiler room, kitchen and laundry facilities, the entire building was unsprinklered. The unsprinklered areas also included the canopies over certain portions of the facility, for example, the canopy over the main entrance of the ER.

Based on observations and review of sprinkler and fire pump records, the facility failed to document that the weekly and annual inspections and testing of the fire pump had been performed in accordance with the standards of NFPA 25. This deficiency had the potential to affect less than very limited number of resident's, staff and visitors in the partially sprinklered areas of the building.

Findings include:

In accordance with 5-2.2 of NFPA 25 (1998 Edition), pertinent visual observations of the fire pump shall be performed weekly including the conditions of the pump location, fuel or power source, the pump system itself and the electrical system serving the pump. Further, in accordance with 5-3.2.1 of NFPA 25 a weekly test of electric motor-driven pump assemblies shall be conducted without flowing water. This test shall be conducted by starting the pump automatically. The pump shall run a minimum of 10 minutes.

In accordance with 5-3.3.2, 5-3.3.2.1 and 5-3.3.2.2 of NFPA 25 (1998 Edition), the pertinent visual observations, measurements, and adjustments specified in the following checklist shall be conducted annually while the fire pump is running and flowing water under the specified output condition. At No-Flow Condition (Churn) (Conduct this test first.)
(a) Check the circulation relief valve for operation to discharge water.
(b) Check the pressure relief valve (if installed) for proper operation.
(c) Continue the test for 1/2 hour.
At Each Flow Condition.
(a) Record the electric motor voltage and current (all lines).
(b) Record the pump speed in rpm.
(c) Record the simultaneous (approximately) readings of pump suction and discharge pressures and pump discharge flow.
(d) Observe the operation of any alarm indicators or any visible abnormalities.

In accordance with 1-8 and 5-4.2 of NFPA 25 records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, flow, drain, and pump tests. Test results shall be recorded and retained for comparison purposes. All time delay intervals associated with the fire pump's starting, stopping, and energy source transfer shall be recorded.

The facility utilized fire pumps to deliver water and pressure to the existing partial automatic sprinkler system. A review of the records and reports at the facility on 9/16/2013 did not produce any documentation that the fire pumps were inspected and/or tested on an annual schedule in 2012.

Based on observations and staff interview, the facility failed to store oxygen in accordance with the standards of NFPA 99 (1999 Edition). This deficiency had potential to affect more than a very limited number of patients, staff, and visitors.

Findings include:

In accordance with NFPA 99, 1999 Edition and Section 8-3.1.11.2, storage for nonflammable gases less than 3000 ft 3 (85 3); subsection (h) requires that cylinder or container restraint shall meet 4-3.5.2.1(b)27. Further, Section 4-3.5.2.1(b)27 states that freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

On 9/16/13 at 3:43 p.m., oxygen storage was observed. The E size cylinders that were stacked on the lower shelf of the storage unit were stacked parallel to the wall, in a matter that one rolled off and partially landed on the ground, leaning on the adjacent cylinders stored next to them. Staff member A, who was accompanying the surveyor, also agreed that oxygen cylinders were not stored in a manner to protect them from falling or rolling onto the ground.

Based on observations and staff interviews, the facility failed to appropriately label a medical gas shut off valve as to its use. This deficiency had the potential to affect more than very limited number of residents, staff and visitors in the building.

Findings include:

In accordance with 12-3.4 of NFPA 99 (1999 Edition) patient gas systems installed in Hospital environments shall conform to Level 1 gas systems of Chapter 4. Section 4-3.4.1.3(2 b & c) of NFPA 99 requires that medical gas systems be subject to system verification. Included in this verification is the requirement that: 1) that valves shall be installed in each medical gas piping system and tested to verify proper operation and rooms or areas of control. Records shall be made listing the rooms or areas controlled by each valve for each gas. The information shall be utilized to assist and verify the proper labeling of the valves; and 2) outlet flow tests shall shall be performed at the station outlet or terminal where the user makes connections and disconnections. Oxygen, nitrous oxide, and air outlets shall deliver 3.5 SCFM with a pressure drop of no more than 5 psi and static pressure of 50 psi. In accordance with 8-2.1.1.5 of NFPA 99, a hazard exists if either oxygen or nitrous oxide leaks into a closed space, creating an oxygen-enriched atmosphere.

1. Record review on 9/16/13 revealed the lack of the annual piped medical gas service review by a certified contractor.

2. On 9/16/13 at 3:05 p.m., staff member stated that valves labeled Hospital and Labor Room were no longer in service; however, the valves were still marked as Hospital and Labor Room instead of being labeled "Not in Service".

Additionally, the valve that was labeled "Labor Room" was also labeled "Room 23". Staff member A stated that the old labor room was now converted to a patient room, room 23.

In view of these observations, all valves must be labeled as not in service or by other means to prevent confusion as to the true condition of the medical gas lines.

Based on observations and staff interview, the facility failed to provide for a remote annunciator for the emergency generator in the hospital building. This deficiency could affect all residents, staff and visitors.

The findings include:

A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station per section 3-4.1.1.15 of NFPA 99, 1999 Edition.
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed

Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually.

During an observation of the building on 9/16/13 and an interview with staff member A at 3:20 p.m. on the same day, validated the lack of a remote annunciator unit to notify alarm conditions for the emergency power systems.

Based on observations, the facility did not ensure a grill/barbecue housing a propane tank was stored as recommended by National Fire Protection Association 58. This deficiency had the potential to affect more than a very limited number of residents, staff and visitors in the building.

Findings included:

Portable liquid petroleum gas (LPG) tanks used for such items as barbecues shall be located at least 3 feet from any building opening and at least 5 feet in any direction from an exterior source of ignition, direct-vent appliances or mechanical ventilation air intakes per section 3-2.2.2 of NFPA 58, 1998 edition.

A portable barbecue cooker with a propane (LPG) tank was observed in the courtyard at 3:20 p.m. on 9/16/13. It was placed between two patient window openings right against the building. Staff member agreed the LPG tank was not 3 feet away from either window opening.

Based on observations, the facility failed to maintain the electrical system and/or its components in accordance with the standards of the National Electrical Code, NFPA 70, 1999 Edition or interpretations from the Centers for Medicare and Medicaid Services (CMS). These deficiencies have the potential to affect more than a limited number of residents, staff and visitors in the basement of the building.

Findings include:

In accordance with 110-27 of NFPA 70 (1999 edition) in locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage.

In accordance with 240-4 of the NFPA 70 (1999 Edition), 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99 (1999 Edition) and interpretations from CMS, extension cords or multiple adaptors used in health care shall be protected against over-current conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS). One means is by providing power taps or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings. The limited use of circuit breaker protected power taps is acceptable, provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to a power strip. These items must be directly connected to an appropriate receptacle.

1. A refrigerator in Central Supply was plugged into a power tap at 2:18 p.m. on 9/16/13.

A portable x-ray machine was observed being stored in the Central Supply. The unit was plugged into the outlet with its cord stretching at maximum tension from its location to the wall outlet across the room.

2. The North Hall storage room was observed at 2:55 p.m. on 9/16/13. A radio receiver was plugged into a multiple adaptor with a built-in circuit breaker; however, the circuit breaker was not in operational condition. Staff member A, who was accompanying the surveyor agreed and stated the adaptor was a very old unit, and would be replaced with a newer one.