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Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with sealed wall penetrations as required by NFPA 101 (2012 edition), 19.1.6.4, 19.1.6.5, and 8.2.1.3, 8.3.1.1, 8.3.1.2 & 8.3.5. These deficiencies had the potential to affect an undetermined number of patients, staff and visitors.

FINDINGS INCLUDE:

1. On 4/16/2019 at 1:45 PM, observation revealed above the ceiling over cross corridor doors in a 2-hour rated fire barrier wall separating emergency and radiology area, that a 1 inch diameter hole with a bundle of wire penetrations was not properly fire stopped according to an approved method.

2. On 4/16/2019 at 1:55 PM, observation revealed above the ceiling over cross corridor doors in a 2-hour rated fire barrier wall separating the OR suite and radiology area, that a 1 inch diameter hole with a bundle of wire penetrations was not properly fire stopped according to an approved method.

These deficient practices were confirmed by Staff A at the time of discovery.

Based on observation and interview, the facility did not maintain the means of egress door in accordance with the requirements of NFPA 101 - 2012 edition, Sections 19.2.2.2.4 , 7.2.1.5.1, 7.2.1.5.3 , 7.2.1.5.10, 7.2.1.5.10.2 & 7.2.1.6.1.1(4). This deficiency had the potential to affect an undetermined number of staff and visitors.

Finding include:

On 4/17/2019 at 9:45 am, observation revealed in the ground floor dietary room 106A, that the dietary room was locked with a dead bolt and was not readily openable from the egress side.

This deficient practice was confirmed by Staff A at the time of discovery.

Based on observation and interview, the facility did not provide a level walking surface in the path of egress in accordance with the requirements of NFPA 101 (2012 edition), 7.1.6, 7.1.6.2 and 7.1.7. This deficiency had the potential to affect an undetermined number of staff and visitors.

Finding include:

On 4/17/19 at 9:18 am, observation revealed in the exit discharge path from the medical records exit door that there was a 1" grade change in the exit discharge path due to a settled concrete slab.

This deficient practice was confirmed by Staff A at the time of discovery.

Based on observation and staff interview, the facility did not ensure means of egress illumination so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle per NFPA 101- 2012 edition section 7.8.1.4. These deficiencies had the potential to affect an undetermined number of inpatients, staff and visitors.

Findings include:

1. On 4/17/2019 at 9:10 am, observation revealed that the ground floor speciality clinic (East) exit to the parking lot had an exit discharge illumination that was dependent on a single lighting unit.

2. On 4/17/2019 at 9:15 am, observation revealed that the ground floor conference room exit had an exit discharge illumination that was dependent on a single lighting unit.

3. On 4/17/2019 at 9:17 am, observation revealed that the ground floor medical record room exit had an exit discharge illumination that was dependent on a single lighting unit.

These deficient practices were confirmed by Staff A at the time of discovery.

Based on observation and interview, the facility failed to provide protection of the vertical shaft opening in accordance with NFPA 101 (2012 edition); 19.3.1, 8.6., and 8.6.2. This deficiency had the potential to affect an undetermined number of inpatients, staff and visitors.
Finding include:

On 4/16/19 at 2:50 PM, observation revealed in the first floor OR mechanical room that there was a 2'-0" x 1'-0" floor opening connected to chase opened in ground floor boiler room. The floor opening was penetrated by several 1" to 2" diameter pipes and was not sealed with proper fire-stopping.

This deficient practice was confirmed by Staff A at the time of discovery.

Based on observation, interview & record review, the facility did not provide battery powered emergency lights in an anesthetizing location in accordance with the requirements of NFPA 101 (2012 edition), Section 19.3.2.3 , NFPA 99 (2012 edition), Section 6.3.2.2.11.1, 6.3.2.2.11.2, 6.3.2.2.11.3, 6.3.2.2.11.4 & 6.3.2.2.11.5. These deficiencies had the potential to affect an undetermined number of inpatients, staff and visitors.

Findings include:

1. On 4/16/2019 at 11:43 am, during review of the facility emergency light testing records it was discovered that tests were not conducted for the emergency lights located inside first floor operating room for a minimum of 30 seconds each month and 30 minutes annually within the last year.
2. On 4/16/2019 at 2:00 PM, observation revealed in the 1st floor operating room that the operating room was used to administer general anesthesia and deep sedation, and one or more battery powered lighting units were not provided inside this operating room. There was a control for batteries in a control panel inside the operating room and staff A was unable to confirm whether there were one or more battery powered lighting units inside the operating room or not.

These deficient practices were confirmed by Staff A at the time of discovery.

Based on observation and interview, the facility did not maintain cooking facilities in accordance with the requirements of NFPA 101 - 2012 edition, Sections 19.3.2.6.1 and 9.2.3; NFPA 96 - 2011 edition, 10.2.2 & 11.6.13. These deficiencies had the potential to affect an undetermined number of residents, staff and visitors.

Findings include:

1. On 4/16/2019 at 3:35 PM, observation revealed inside the ground floor kitchen, that the exhaust hood cleaning certificate inside the kitchen did not have the name of the technician who performed the exhaust hood cleaning work.
2. On 4/16/2019 at 3:36 PM, observation revealed inside the ground floor kitchen that a placard containing instruction to use the portable fire extinguisher after the fixed fire protection system's activation was missing.

These deficient practices were confirmed by Staff A at the time of discovery.

Based on observation and interview, the facility did not maintain the fire alarm panel power source as per NFPA 101 (2012 ed.), 9.6.1.3 and NFPA 72 (2010 ed.), 10.5.5.2.1, 10.5.5.2.2, 10.5.5.2.3. These deficiencies had the potential to affect all inpatients, as well as an undetermined number of staff and visitors.

Findings include:

1. On 4/16/2019 at 3:20 PM, observation revealed that the fire alarm panel located in the ground floor boiler room did not have the fire alarm power circuit disconnecting information permanently identified at the main fire alarm panel.
2. On 4/16/2019 at 3:25 PM, observation revealed in the ground floor mechanical room 109, that the fire alarm power circuit disconnecting breaker number 10 inside the electrical panel "LS" was not identified as "FIRE ALARM CIRCUIT".
3. On 4/16/2019 at 3:26 PM, observation revealed in the ground floor mechanical room 109, that the fire alarm power circuit disconnecting breaker number 15 inside the electrical panel "LS" did not have red marking.

These deficient practices were confirmed by Staff A at the time of discovery.

Based on record review and interview, the facility did not perform the semi-annual testing and inspections of the fire alarm system in accordance with the requirements of NFPA 101 - 2012 edition, Sections 19.3.4 and 9.6.1.3 and NFPA 72 - 2010 edition, Sections 14.3.1 and 14.4.5. These deficiencies had the potential to affect 3 inpatients, as well as an undetermined number of staff and visitors.

Findings include:

1. On 4/16/2019 at 10:30 am, review of the documents titled "Johnson Controls - Inspection Summary Results" dated 4/8/2019 revealed that the semi-annual visual inspection of alarm initiating devices for smoke detectors, heat detectors, duct detectors, electromechanical releasing devices (door hold opens) and manual fire alarm boxes (pull stations) were conducted once, on 4/8/2019 by Johnson Controls within the last year.

2. On 4/16/2019 at 10:35 am, review of the documents titled "Johnson Controls - Inspection Summary Results" dated 4/8/2019 revealed that the semi-annual visual inspection of alarm notification devices were conducted once, on 4/8/2019 by Johnson Controls within the last year.

3. On 4/16/2019 at 10:40 am, review of the documents titled "Johnson Controls - Inspection Summary Results" dated 4/8/2019 revealed that the sealed lead acid type batteries for the Fire Alarm System were only tested once, on 4/8/2019 by Johnson Controls within the last year.

4. On 4/16/2019 at 10:40 am, review of the documents titled "Johnson Controls - Inspection Summary Results" dated 4/8/2019 revealed that during Fire Alarm System testing a horn/strobe failed to function properly and the facility had no documentation to prove that failed horn/ strobe was replace or fixed later.

These deficient practices were confirmed by Staff A at the time of discovery.

Based on record review and interview, the facility did not perform the semi-annual testing and inspections of the fire alarm system in accordance with the requirements of NFPA 101 - 2012 edition, Sections 19.3.4 and 9.6.1.3 and NFPA 72 - 2010 edition, Sections 14.3.1 and 14.4.5. These deficiencies had the potential to affect all inpatients, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

1. On 4/16/2019 at 10:30 am, review of the documents titled "Johnson Controls - Inspection Summary Results" dated 4/8/2019 revealed that the semi-annual visual inspection of alarm initiating devices for smoke detectors, heat detectors, duct detectors, electromechanical releasing devices (door hold opens) and manual fire alarm boxes (pull stations) were conducted once, on 4/8/2019 by Johnson Controls within the last year.
2. On 4/16/2019 at 10:35 am, review of the documents titled "Johnson Controls - Inspection Summary Results" dated 4/8/2019 revealed that the semi-annual visual inspection of alarm notification devices were conducted once, on 4/8/2019 by Johnson Controls within the last year.
3. On 4/16/2019 at 10:40 am, review of the documents titled "Johnson Controls - Inspection Summary Results" dated 4/8/2019 revealed that the sealed lead acid type batteries for the Fire Alarm System were only tested once, on 4/8/2019 by Johnson Controls within the last year.
4. On 4/16/2019 at 10:40 am, review of the documents titled "Johnson Controls - Inspection Summary Results" dated 4/8/2019 revealed that during Fire Alarm System testing a horn/strobe failed to function properly and the facility had no documentation to prove that failed horn/ strobe was replace or fixed later.

These deficient practices were confirmed by Staff A at the time of discovery.

Based on observation and interview, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 101 - 2012 edition, Sections 19.3.5 and 9.7.5, and NFPA 25 - 2011 edition, Sections 5.2.1, and 5.2.1.1.1. These deficiencies had the potential to affect an undetermined number of inpatients, staff and visitors.

Findings include:

1. On 4/16/2019 at 3:03 PM, observation revealed inside the first floor room 318 that a sprinkler head had lint and other foreign materials on it.
2. On 4/16/2019 at 3:30 PM, observation revealed inside the ground floor clean storage room 112 that a sprinkler head had lint and other foreign materials on it.
3. On 4/17/2019 at 9:00 am, observation revealed inside the ground floor speciality clinic (south) exam room 3 that sprinkler head had lint and other foreign materials on it.
4. On 4/17/2019 at 9:30 am, observation revealed inside the ground floor rehab clinic that a sprinkler head had lint and other foreign materials on it.

These deficient practices were confirmed by Staff A at the time of discovery.

Based on observation and interview, the facility failed to provide corridor spaces separated by corridor walls and doors that meet the requirements of NFPA 101 (2012 edition), 19.3.6.1, 19.3.6.2 and 19.3.6.3. This deficiency had the potential to affect an undetermined number of patients, staff and visitors.

Findings include:

On 4/16/19 at 2:37 PM, observation revealed that the first floor radiology reception area 340 was not properly separated from the exit egress corridor by wall or door construction. The room had a 48 inch high by 42 inch wide pass through window. The window had sliding panes of glass with a 48 inch high by 1/2 inch gap between the window panes. Additionally, the window panes were not positive self-latching. The area did not satisfy all of the requirements for an exception for spaces open to the corridor. The space did not have a smoke detector, nor was it arranged and located to allow direct supervision by the facility staff from the nurses' station or similar location.

This deficient practice was confirmed by Staff A at the time of discovery.

Based on observation and staff interview, the facility did not maintain corridor doors in accordance with NFPA 101 (2012 edition), 19.3.6.3.5. Doors shall be provided with a means for keeping the door closed. These deficiencies had the potential to affect an undetermined number of patients, staff and visitors.
Findings include:

1. On 4/16/2019 at 2:20 PM, observation revealed that the inactive leaf on the first floor radiology area room 341 corridor door was not automatically positive latching. The inactive door leaf was equipped with manual latching hardware and if the inactive leaf was not manually latched then the radiology area room 341corridor doors would not positively latch and stay closed.

2. On 4/16/2019 at 2:48 PM, observation revealed that the inactive leaf on the first floor med charge area linen room 322 corridor door was not automatically positive latching. The inactive door leaf was equipped with manual latching hardware and if the inactive leaf was not manually latched then med charge area linen room 322 doors would not positively latch and stay closed.

3. On 4/16/2019 at 3:02 PM, observation revealed in the first floor resident room 315 door that the corridor door was held open with a large computer cart.

These deficient practices were confirmed by Staff A at the time of discovery.

Based on observations and staff interview, the facility did not ensure no louvers were installed in corridor walls per NFPA 101 - 2012 edition section 19.3.6.4.1. & 19.3.6.5.1. This deficiency had the potential to affect an undetermined number of inpatients, staff and visitors.

Finding include:
On 4/16/19 at 2:41 PM, observation revealed a 2'-0" x 2'-0" louvered opening in the corridor door to the first floor mammogram room located above 1 feet from the floor.

This deficient practice was confirmed by Staff A at the time of discovery.

Based on record review and interview, the facility failed to maintain its fire and smoke dampers in accordance with NFPA 101 (2012 edition), 19.5.2.1, 9.2.1; NFPA 90A (2012 edition), 5.4.8.1, 5.4.8.2; NFPA 80 (2010 edition) 19.4.1, 19.4.1.1 and NFPA 105 (2010 edition), 6.5.2 This deficient practice could affect all inpatiens, as well as an undetermined number of staff and visitors.

Finding include:

On 4/16/19 at 11:10 am, during interview, staff A confirmed that facility's HVAC duct system had fire or smoke dampers. Record review revealed that the facility had no documentation verifying required 6-year function damper inspection and testing was performed.

The deficient practice was confirmed by Staff A at the time of discovery.

Based on record review and interview, the facility failed to maintain its fire and smoke dampers in accordance with NFPA 101 (2012 edition), 19.5.2.1, 9.2.1; NFPA 90A (2012 edition), 5.4.8.1, 5.4.8.2; NFPA 80 (2010 edition) 19.4.1, 19.4.1.1 and NFPA 105 (2010 edition), 6.5.2 This deficient practice could affect all inpatients, as well as an undetermined number of staff and visitors.

Finding include:

On 4/16/19 at 11:10 am, during interview, staff A confirmed that facility's HVAC duct system had fire or smoke dampers. Record review revealed, that facility had no documentation verifying required 6-year function damper inspection and testing was performed.

The deficient practice was confirmed by Staff A at the time of discovery.

Based on record review and interview, the facility did not conduct fire drills in accordance with the requirements of NFPA 101 (2012 edition), section 21.7.1.6. This deficiency had the potential to affect an undeterminable number of outpatients, staff and visitors.

Findings included:

On 4/16/2019 at 11:47 am, review of the facility fire drill documents for the last 12 months revealed that there was no fire drill conducted on the first shift during 1st quarter of 2019 and 2nd, 3rd and 4th quarters of 2018 in the Argyle out patient clinic.

This deficient practice was confirmed by Staff A & Staff F at the time of discovery.

Based on record review and interview, the facility failed to conduct fire drills in accordance with, the requirements of NFPA 101 - 2012 edition, Sections 4.7.1, 4.7.2, 4.7.6, 19.7.1, 19.7.1.4, 19.7.1.5, 19.7.1.6 and 19.7.1.7. This deficiency had the potential to affect all inpatients, as well as an undetermined number of staffs and visitors.

Finding include:

On 4/16/2019 at 11:45 am, review of the facility fire drill documents for the last 12 months revealed that fire drills on the 1st shift and 2nd shift were not conducted at varied times. Three of four 1st shift fire drills were conducted between 1:00 PM and 1:55 PM and three of four 2nd shift fire drills were conducted between 3:55 PM and 4:15 PM.

This deficient practice was confirmed by Staff A & Staff F at the time of discovery.

Based on interview and observation, the facility failed to provide an emergency electrical generator with a remote stop in accordance with the requirements of NFPA 101 - 2012 edition, Sections 9.1.2, 9.1.3.1; NFPA 110 - 2010 edition, Sections 5.6.5.6 and 5.6.5.6.1; NFPA 70 - 2011 edition sections 314.28(C). These deficiencies had the potential to affect all inpatients, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

1. On 4/16/2019 at 1:30 PM, observation revealed that the prime mover of the emergency generator II was located outside the building and a remote manual stop station was not provided elsewhere on the premises. Staff A mentioned that emergency generator II was installed in 2015.

2. On 4/16/2019 at 3:37 PM, observation revealed in the washing area drop ceiling side wall inside the ground floor kitchen 1st Floor that an electrical fixture was taken out of wall and all the energized wires were left hanging from the wall without any cover.

These deficient practices were confirmed by Staff A at the time of discovery.

Based on observation and interview the facility did not use electrical ownerships in accordance with the requirements of NFPA 101 - 2012 edition, Sections 19.5.1.1 and 9.1.2; NFPA 99 - 2012 edition, Section 10.2.3.6, 10.2.4; NFPA 70 (2011 edition) section 400.8. This deficient practice could affect an undetermined number of staff and visitors.

Finding include:

On 4/16/18 at 3:16 PM, observation in the ground floor boiler room revealed one flexible cord four-outlet strip device was plugged in a wall outlet and two more flexible cord four-outlet strip devices were plugged into the first flexible cord device in a series connection. Rest of the 10 more outlets in those three flexible cord four-outlet strip devices were plugged in to power 10 electrical appliances.

This deficient practice was confirmed by Staff A at the time of discovery.