HospitalInspections.org

Based on surveyor observations made on 3/31/11 at the Paark Clinic River Drive, it was determined that vertical rated construction
is not being maintained to keep separation intact between the medical clinic and the apartment complex.
Findings include:

At 2:20 p.m.,ceiling tiles were removed to expose the vertical barrier in a office treatment location in the south east corner of the medical clinic. At the barrier above the other ceiling tiles, there was a two inch penetration in the sheet rock barrier which was sealed with a foam product which was not acceptable to maintain the fire rating of the sheet rock vertical barrier. The foam product will need to be removed and the remaining void filled with an acceptable fire stop material.

Based on observations made on 3/29/11, the surveyor determined the facility failed to maintain the fire and smoke resistance rating of the building construction at all building locations.

Findings include:

At 8:55 a.m. in the west mechanical room, the surveyor observed a detached metal access plate at an opening in a wall which opened to an exposed crawl space underneath the building.

During a tour of the main level of the hospital on 3/30/11, it was observed by the surveyor that not all corridor doors could be closed to positive latching.

Findings include:

At 7:55 a.m., the corridor door to the janitor's closet would not close to positive latching.

Based on observations made during a tour of the building on 3/29/11 and 3/30/11, it was determined that the facility failed to ensure that all self closing doors at separations of hazardous and unprotected areas are adequately maintained.

Findings include:

In accordance with Section 19.3.6.3.2 of NFPA 101, 2000 Edition; corridor doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.

Doors which were equipped with self closing devices did not automatically close when these doors were released by the surveyor. Examples are as follows:

1. At 8:35 a.m. on 3/29/11, the self closing metal "spring loaded" hatch door between the kitchen and the west mechanical room was examined by the surveyor. When the hatch door was released, it did not close to positive latching.

2. At 8:41 a.m. on 3/29/11 in the west mechanical room, there were a pair of self closing doors which opened to an outside metal stairway. One of the doors did not close to positive latching.

3. At 2.43 p.m. on 3/29/11, the corridor door to the "CCU Station" could not be closed to positive latching. The oxygen cylinder on the crash cart blocked the door from closing to positive latching.

4. On 3/30/11 at 7:50 a.m. during a tour of 100 Wing, there was a self closing door which opened into the soiled utility room. This door did not close automatically with sufficient force to allow the door hardware to latch.

Based on observations made on 3/29/11, it was determined that the facility failed to ensure all smoke barrier doors closed tightly to resist the passage of smoke.

The findings include:

The smoke barrier doors by room 204 were reviewed at 11:30 a.m. One of the two smoke barrier doors did not close to positive latching. The inability of this set of doors to close and latch resulted in the doors not being resistant to the passage of smoke.

By the end of the survey, the problem with the door had been addressed by facility staff and repaired.

On 3/29/11 based on observations which were made during a tour of the building, it was determined that not all hazardous areas (when required) are separated from other areas by one hour construction and/or walls (includes ceilings) are not maintained to prevent the passage of smoke from any hazardous area.

Findings include:

1. At 9:20 a.m. in the boiler room at the level of the ceiling, there were at least four open penetrations or holes one to three inches in diameter which needed to be repaired with an acceptable fire stop material.

2. At approximately 9:30 a.m., the surveyor made observations in the electrical room which adjoins the maintenance shop. There were three - one inch sections of conduit passing through a wall which needed to be sealed with an acceptable fire stop material.

Based on surveyor observations of 3/29/11, it was determined there was at least one location where an acceptable means of egress was not clearly identified and kept totally free and clear.

Findings include:

At approximately 8:57 a.m., the surveyor made observations in the kitchen. In the kitchen, there ws a locked door with the word "EXIT" on the surface of the door. Two metal food carts were stored in front of this door. When surveyor asked about this door between the kitchen and dining room, he was informed by staff member A that the door is not used for an exit from the kitchen anymore. The door was locked when checked by the surveyor.

Based on discussions with staff on 100 Wing on 3/31/2011, it was determined that not all steps of the fire plan would be followed in the event of a fire emergency.

Findings include:

The Centers for Medicare and Medicaid Services (CMS) has provided guidance in Survey & Certification (S&C) Letter S&C-04-41 which addresses carts in corridors left unattended for more than 30 minutes are considered not in use and therefore need to be removed from the corridor to allow convenient removal of non ambulatory persons during an emergency.

At 1:40 p.m., the fire alarm system was tested but the steps of the fire drill procedure were not required of staff to be followed. The surveyor noticed two "COWS" (computer on wheels) remained in the corridor after the test of the fire alarm system was being completed. Although a fire drill had not been planned, the surveyor inquired of the staff on the 100 Wing what would happen to the COWS during a drill or in the event of a fire. They did not know that the equipment would need to be removed from the corridor spaces in order to clear the corridor. After an inquiry by phone to staff member A at 3:00 p.m. on 4/07/11, it was learned there is direction in the fire plan for all corridors to be cleared in the event of a drill or fire event.

Based on review of maintenance logs and a discussion with staff member A on 4/1/11, it was determined that the facility failed to document the monthly and annual tests of battery-powered emergency lights.

Findings included:

A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds per section 7.9.3 of the Life Safety Code . An annual test shall be conducted on every required battery-powered emergency lighting system for not less than one and one half hours.

The maintenance logs were reviewed at the facility on 3/29/11. Between 10:30 a.m. and 11:00 a.m. on 4/1/11, the surveyor inquired about what data was put in the maintenance logs for the periodic testing of the emergency battery backup lighting at the hospital. The surveyor understood that the lights were tested every other month to test if they were operational which did not include a 30 second monthly test nor an hour and half annual test. Further, the battery backup lights in the hospital satellite locations had been tested in the same manner as in the hospital.

Based on observations which were made on 3/30/11, it was determined that the facility did not ensure that all exit signs were properly illuminated.

Findings include:

At approximately 12:40 p.m., the exit lights in the church occupancy were examined. At least two exit signs in the building were not illuminated. One exit sign was located in the north/south corridor and the other location was above the main entrance doors to the church.

Based on surveyor observations made on 3/29/11, the facility failed to maintain the sprinkler system and all its components in accordance with the standards of NFPA 25, 1998 Edition and NFPA 13, 1999 Edition.

The findings include:

In accordance with Chapter 2-2.1.2 of NFPA 25 (1998 Edition), storage of materials shall not block the discharge spray pattern of the sprinklers in the event the system is activated. This code requirement is not being followed.

The sprinkler heads were located at the ceiling of the medical record storage room which adjoins the north air handling equipment room. Medical records were blocking the spray pattern of system. Medical record materials and paper were stacked, in some instances, above the horizontal plane of the sprinkler heads.

Based on observations which were made on 3/31/11, it was determined that the facility did not ensure that portable fire extinguishers were always maintained in accordance with all the standards of NFPA 10.

Findings include:

In accordance with 1-6.7 and 1-6.10 of NFPA 10, portable extinguishers other than wheeled types shall be securely installed on the hanger or bracket supplied with them or placed in cabinets or wall recesses. In no case shall the clearance between the bottom of the supported extinguisher and the floor be less than 4 inches. Extinguishers weighing less than or equal to 40 lb shall be installed so that the top of the extinguisher is not more than 5 feet above the floor. Those extinguishers with a weight more than 40 lb shall be installed so that the top of the extinguisher is not more than 3 1/2 feet above the floor.

While making survey observations in the clinic at approximately 11:20 a.m., it was determined that two fire extinguishers were not secured and properly mounted. One fire extinguisher was "free standing" on the floor in the waiting room. The other extinguisher also had not been installed and bracketed and was by the back door wall on the floor and had been left unsecured.

Based on observations made on 3/29/11 and discussions with staff, it was determined that the facility failed to provide for the Type I EES to be divided into branches.

Findings include:

In accordance with 3-4.2.2.1 of NFPA 99 (1999 edition) Type I essential electrical systems are comprised of two separate systems being the emergency system and the equipment system. The emergency system shall be limited to circuits essential to life safety and critical patient care. These are designated the life safety branch and the critical branch. The number of transfer switches to be used shall be based upon reliability, design, and load considerations. Each branch of the emergency system and each equipment system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA (120 kW).

The generator transfer switch was observed at approximately 9:25 a.m. on 3/29/11. The 350 KW generator had only one transfer switch located in the basement of the building. Staff member A & B confirmed that the status of the generator and the building's electrical distrubution system since the time off the last survey remains the same. A waiver request was sought and granted as of 8/01/07. The waiver expired as of 6/26/09. As in the past, surguries being performed at the facility may include the need for life support functions.

Based on surveyor observations made on 3/31/11 at the Paark Clinic River Drive, it was determined that vertical rated construction
is not being maintained to keep separation intact between the medical clinic and the apartment complex.
Findings include:

At 2:20 p.m.,ceiling tiles were removed to expose the vertical barrier in a office treatment location in the south east corner of the medical clinic. At the barrier above the other ceiling tiles, there was a two inch penetration in the sheet rock barrier which was sealed with a foam product which was not acceptable to maintain the fire rating of the sheet rock vertical barrier. The foam product will need to be removed and the remaining void filled with an acceptable fire stop material.

Based on observations made on 3/29/11, the surveyor determined the facility failed to maintain the fire and smoke resistance rating of the building construction at all building locations.

Findings include:

At 8:55 a.m. in the west mechanical room, the surveyor observed a detached metal access plate at an opening in a wall which opened to an exposed crawl space underneath the building.

During a tour of the main level of the hospital on 3/30/11, it was observed by the surveyor that not all corridor doors could be closed to positive latching.

Findings include:

At 7:55 a.m., the corridor door to the janitor's closet would not close to positive latching.

Based on observations made during a tour of the building on 3/29/11 and 3/30/11, it was determined that the facility failed to ensure that all self closing doors at separations of hazardous and unprotected areas are adequately maintained.

Findings include:

In accordance with Section 19.3.6.3.2 of NFPA 101, 2000 Edition; corridor doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.

Doors which were equipped with self closing devices did not automatically close when these doors were released by the surveyor. Examples are as follows:

1. At 8:35 a.m. on 3/29/11, the self closing metal "spring loaded" hatch door between the kitchen and the west mechanical room was examined by the surveyor. When the hatch door was released, it did not close to positive latching.

2. At 8:41 a.m. on 3/29/11 in the west mechanical room, there were a pair of self closing doors which opened to an outside metal stairway. One of the doors did not close to positive latching.

3. At 2.43 p.m. on 3/29/11, the corridor door to the "CCU Station" could not be closed to positive latching. The oxygen cylinder on the crash cart blocked the door from closing to positive latching.

4. On 3/30/11 at 7:50 a.m. during a tour of 100 Wing, there was a self closing door which opened into the soiled utility room. This door did not close automatically with sufficient force to allow the door hardware to latch.

Based on observations made on 3/29/11, it was determined that the facility failed to ensure all smoke barrier doors closed tightly to resist the passage of smoke.

The findings include:

The smoke barrier doors by room 204 were reviewed at 11:30 a.m. One of the two smoke barrier doors did not close to positive latching. The inability of this set of doors to close and latch resulted in the doors not being resistant to the passage of smoke.

By the end of the survey, the problem with the door had been addressed by facility staff and repaired.

On 3/29/11 based on observations which were made during a tour of the building, it was determined that not all hazardous areas (when required) are separated from other areas by one hour construction and/or walls (includes ceilings) are not maintained to prevent the passage of smoke from any hazardous area.

Findings include:

1. At 9:20 a.m. in the boiler room at the level of the ceiling, there were at least four open penetrations or holes one to three inches in diameter which needed to be repaired with an acceptable fire stop material.

2. At approximately 9:30 a.m., the surveyor made observations in the electrical room which adjoins the maintenance shop. There were three - one inch sections of conduit passing through a wall which needed to be sealed with an acceptable fire stop material.

Based on surveyor observations of 3/29/11, it was determined there was at least one location where an acceptable means of egress was not clearly identified and kept totally free and clear.

Findings include:

At approximately 8:57 a.m., the surveyor made observations in the kitchen. In the kitchen, there ws a locked door with the word "EXIT" on the surface of the door. Two metal food carts were stored in front of this door. When surveyor asked about this door between the kitchen and dining room, he was informed by staff member A that the door is not used for an exit from the kitchen anymore. The door was locked when checked by the surveyor.

Based on discussions with staff on 100 Wing on 3/31/2011, it was determined that not all steps of the fire plan would be followed in the event of a fire emergency.

Findings include:

The Centers for Medicare and Medicaid Services (CMS) has provided guidance in Survey & Certification (S&C) Letter S&C-04-41 which addresses carts in corridors left unattended for more than 30 minutes are considered not in use and therefore need to be removed from the corridor to allow convenient removal of non ambulatory persons during an emergency.

At 1:40 p.m., the fire alarm system was tested but the steps of the fire drill procedure were not required of staff to be followed. The surveyor noticed two "COWS" (computer on wheels) remained in the corridor after the test of the fire alarm system was being completed. Although a fire drill had not been planned, the surveyor inquired of the staff on the 100 Wing what would happen to the COWS during a drill or in the event of a fire. They did not know that the equipment would need to be removed from the corridor spaces in order to clear the corridor. After an inquiry by phone to staff member A at 3:00 p.m. on 4/07/11, it was learned there is direction in the fire plan for all corridors to be cleared in the event of a drill or fire event.

Based on review of maintenance logs and a discussion with staff member A on 4/1/11, it was determined that the facility failed to document the monthly and annual tests of battery-powered emergency lights.

Findings included:

A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds per section 7.9.3 of the Life Safety Code . An annual test shall be conducted on every required battery-powered emergency lighting system for not less than one and one half hours.

The maintenance logs were reviewed at the facility on 3/29/11. Between 10:30 a.m. and 11:00 a.m. on 4/1/11, the surveyor inquired about what data was put in the maintenance logs for the periodic testing of the emergency battery backup lighting at the hospital. The surveyor understood that the lights were tested every other month to test if they were operational which did not include a 30 second monthly test nor an hour and half annual test. Further, the battery backup lights in the hospital satellite locations had been tested in the same manner as in the hospital.

Based on observations which were made on 3/30/11, it was determined that the facility did not ensure that all exit signs were properly illuminated.

Findings include:

At approximately 12:40 p.m., the exit lights in the church occupancy were examined. At least two exit signs in the building were not illuminated. One exit sign was located in the north/south corridor and the other location was above the main entrance doors to the church.

Based on surveyor observations made on 3/29/11, the facility failed to maintain the sprinkler system and all its components in accordance with the standards of NFPA 25, 1998 Edition and NFPA 13, 1999 Edition.

The findings include:

In accordance with Chapter 2-2.1.2 of NFPA 25 (1998 Edition), storage of materials shall not block the discharge spray pattern of the sprinklers in the event the system is activated. This code requirement is not being followed.

The sprinkler heads were located at the ceiling of the medical record storage room which adjoins the north air handling equipment room. Medical records were blocking the spray pattern of system. Medical record materials and paper were stacked, in some instances, above the horizontal plane of the sprinkler heads.

Based on observations which were made on 3/31/11, it was determined that the facility did not ensure that portable fire extinguishers were always maintained in accordance with all the standards of NFPA 10.

Findings include:

In accordance with 1-6.7 and 1-6.10 of NFPA 10, portable extinguishers other than wheeled types shall be securely installed on the hanger or bracket supplied with them or placed in cabinets or wall recesses. In no case shall the clearance between the bottom of the supported extinguisher and the floor be less than 4 inches. Extinguishers weighing less than or equal to 40 lb shall be installed so that the top of the extinguisher is not more than 5 feet above the floor. Those extinguishers with a weight more than 40 lb shall be installed so that the top of the extinguisher is not more than 3 1/2 feet above the floor.

While making survey observations in the clinic at approximately 11:20 a.m., it was determined that two fire extinguishers were not secured and properly mounted. One fire extinguisher was "free standing" on the floor in the waiting room. The other extinguisher also had not been installed and bracketed and was by the back door wall on the floor and had been left unsecured.

Based on observations made on 3/29/11 and discussions with staff, it was determined that the facility failed to provide for the Type I EES to be divided into branches.

Findings include:

In accordance with 3-4.2.2.1 of NFPA 99 (1999 edition) Type I essential electrical systems are comprised of two separate systems being the emergency system and the equipment system. The emergency system shall be limited to circuits essential to life safety and critical patient care. These are designated the life safety branch and the critical branch. The number of transfer switches to be used shall be based upon reliability, design, and load considerations. Each branch of the emergency system and each equipment system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA (120 kW).

The generator transfer switch was observed at approximately 9:25 a.m. on 3/29/11. The 350 KW generator had only one transfer switch located in the basement of the building. Staff member A & B confirmed that the status of the generator and the building's electrical distrubution system since the time off the last survey remains the same. A waiver request was sought and granted as of 8/01/07. The waiver expired as of 6/26/09. As in the past, surguries being performed at the facility may include the need for life support functions.