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Based on observation and staff interview, the facility does not ensure that the fire rating for 1 of 2 stairwells is maintained. Failure to maintain the fire rating may cause harm to the staff, patients and visitors in the event of an actual emergency.

Findings include:

During the facility tour on 11/16/18 at approximately 11:00 AM, it was observed that penetrations were present in the southwest stairwell. It was observed that fiber optic cable, phone lines and conduit penetrated the rated walls.

Interview with Staff (C), Maintenance on 11/16/18 at approximately 11:00 AM verified this finding.

Based on observation and interview, the facility does not ensure that the manual pull station for the Ansul hood is provided in the egress pathway for the fire extinguishing equipment in the kitchen. Failure to provide this pull station in the egress pathway has the potential to result in harm to the staff in the event of an actual emergency.

Findings include:

Observation on 11/16/18 at 12:15 PM revealed that the pull station for the Ansul hood that is located in the kitchen was not located in the pathway of egress. This device was located on the wall, adjacent to the stainless-steel cart, on the far side of the tray preparation area. This device must be located in the pathway of egress to ensure proper activation in the event of a fire emergency.

Interview on 11/16/18 at 12:20 PM with Staff (C), Maintenance verified this finding.

Based on document review and staff interview, the facility does not ensure that 10 of 10 combination smoke/fire dampers are tested or that access is provided for 2 of 36 fire dampers. Failure to test these devices may result in harm to the patients, staff and visitors.

Findings include:

Review of the Fire Damper Schedule for 2017 on 11/15/18 at 12:30 PM revealed that 10 of 10 combination smoke/fire dampers were not tested. These dampers must be tested every six years to ensure their proper operation in the event of an actual emergency.

Review of this Schedule also revealed that access panel to the fire damper above the door into the emergency room and above the door into x-ray were obstructed by piping and could not be fully opened to observe the damper.

Interview with Staff (C), Maintenance on 11/15/18 at 1:15 PM verified this finding.

Based on staff interview and observation, the facility does not ensure that the rated fire doors are tested annually. Failure to test these doors may result in the malfunctioning of the doors in the event of an actual emergency.

Findings include:

During the facility tour on 11/16/18 at 10:45 AM, it was observed that the fire door between the 1960/1969 buildings and at fire door M did not latch when closed. It was also observed that the fire door assembly between the 1960/1969 buildings lacked a rating on the frame. It was also observed that the fire rating label on fire door M had been painted over.

Interview with Staff (C), Maintenance on 11/14/18 at 1:15 PM indicated that the facility has not performed annual testing on any of the fire doors throughout the facility.

Based on staff interview, the facility does not have a policy/procedure that specifies when maintenance will be performed on the medical gas system. Failure to develop a policy/procedure for this system may result in malfunctioning of the medical gas system.

Findings include:

Interview with Staff (C), Maintenance on 11/14/18 at 1:00 PM revealed that the facility does not have a policy/procedure for when maintenance is required on the medical gas system. This policy/procedure must be established through a risk assessment and developed with manufacturer recommendations.

K908

Based on document review and staff interview, the facility does not ensure that the medical gas system is maintained. Failure to maintain the medical gas system may cause harm to the patients.

Findings include:

Review of the Annual Testing of the Medical Gas Distribution System report dated May 2018 on 11/16/18 at 1:15 PM, it was noted that several of the zone valves required updated labeling, area alarms were not labeled, area alarms were broken, the master alarms were not labeled to the area they serve, gauges were lacking on the zone valves, zone valves were blocked, multiple oxygen outlets were leaking, oxygen outlets had low flow, oxygen and vacuum outlets were not color coded or not accessible. The following findings were noted on the report:
-4 of 5 zone valves on the first floor require updated labels to the area that is served;
-2 of 6 zone valves on the second floor require updated labels to the area that is served;
-1 of 5 zone valves is located within a closet (ambulance storage closet) and 1 of 6 zone valves on the second floor is located within the room it serves (procedure room #3);
-Pressure gauges were not present on 1 of 5 zone valves on the first floor and 2 of 6 zone valves on the second floor;
-23 of 50 oxygen outlets leaked and 1 of 50 vacuum outlets leaked on the first floor;
-25 of 56 oxygen outlets leaked and 1 of 56 vacuum outlets leaked on the second floor;
-The oxygen flow meter was broken in x-ray room #1 and the oxygen and vacuum outlets were not accessible in the office area of X-ray;
-The oxygen/ vacumn gas alarm panel located in the operating room work station has a broken display and the alarm located at the endoscopy work station does not function.

Review of this report also indicated that failures were noted for the vacuum system that is in the mechanical room. Some of the failures noted on the report are:
-The receiver cannot be isolated via a by-pass valve without shutting down the system;
-A common exhaust is not provided to prevent back pressure;
-The pump does not have separate overload protection;
-Backup pumps do not turn on automatically if the primary pump fails.

-Interview with Staff (B), Nursing Administration on 11/16/18 at 2:15 PM included a review of the report and the above noted findings were verified.

Based on staff interview, the facility does not ensure that documentation is maintained to indicate the milliamperes (mA) at which the Ground Fault Circuit Interrupters (GFCI) were inactivated. Failure to ensure that the GFCI are fully operational may result in patient, staff and visitor harm.

Findings include:

Interview with Staff (OO), Environmental Services on 11/16/18 at 2:30 PM, revealed that the GFCI's throughout the facility had not been tested to ensure that these outlets were inactivated if they exceed 10 mA when utilized. These outlets must be tested every six months in patient care areas and annually elsewhere within the facility. These outlets must also have a visual inspection monthly to ensure that the outlet is inactivated if the test button is pressed.

Based on staff interview, the facility does not ensure that documentation is maintained to indicate non-hospital grade outlets are tested annually. Failure to ensure that these outlets are fully operational may result in patient, staff and visitor harm.

Findings include:

An interview with Staff OO on 11/16/18 at 2:30 PM, revealed that the facility does not have documentation that the non-hospital grade outlets are tested annually. These outlets must be tested annually for tension, polarity and grounding.

Based on document review and staff interview, the facility does not ensure that 2 of 2 emergency generators (Onan and CAT) are tested every 20-40 days. Failure to test these emergency generators may result in patient harm in the event of an actual emergency.

Findings include:

Review of the Generator Check Sheet on 11/15/18 at 3:30 PM revealed that the emergency generators are not tested every 20-40 days. Review of these reports indicated the following:
-The emergency generators were tested on 02/21/18 and 03/06/18 with only a 13-day lapse;
-The emergency generators were tested on 08/07/18 and 09/18/18 with a 42-day lapse;
- The emergency generators were tested on 09/18/18 and 10/02/18 with only a 13-day lapse.

Interview with Staff (C), Maintenance on 11/15/18 at 3:45 PM verified this finding.

Based on document review and staff interview, the facility does not ensure that the generator is tested every three years for four continuous hours or that electrical panel and the circuits are marked. Failure to operate the generator for an extended period and to adequately identify the panel and circuits may result in a delay or failure of the generator in an emergency situation.

Findings include:
Review of the of the generator log on 11/15/18 at 3:00 PM did not provide evidence that the emergency generator is tested every three years for four continuous hours. The emergency generator must be tested every three years for a minimum of four hours to ensure that the generator is capable of operating under the required load rating.

Interview with Staff (C), Maintenance on 11/15/18 at 11:45 AM revealed that the electrical panel and the circuits specific to the generator are not labeled to allow quick notification in the event of an emergency. This equipment must have an attached label, symbol or other identifying mark to allow for quick identification.

Interview with Staff (C), Maintenance on 11/15/18 at 3:30 PM confirmed there was no documentation to indicate that a full load generator test had been performed in the last three years.