HospitalInspections.org

Based on observation and interview with staff it was determined, the facility failed to provide a safe means of egress out of the emergency exit doors. Failure to provide a clear and unimpeded means of egress could cause harm to the patients and staff in a fire emergency.

NFPA 101, Life Safety Code, 2012, Chapter 19, Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. Section 7.1.10.1 " Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency." Section 7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits or their access thereto egress therefrom, or visibility thereof."

The Director of Maintenance and the surveyor observed on April 16, 2019, the emergency exit door located in the Central Supply Room was impeded by storage, a table, and a storage rack.

The Chief Executive Officer and the Director of Maintenance acknowledged during the exit conference on April 16, 2019, the emergency exit door located in the Central Supply Room was impeded.

Based on record review and interview with staff it was determined, the facility failed to document the monthly thirty second testing of the emergency battery backup lights. Failing to maintain emergency lighting units in time of an emergency could cause harm to the patients in an emergency power outage.

NFPA 101, Life Safety Code, 2012, Chapter 19, Section 19.2.9.1 "Emergency lighting shall be provided in accordance with Section 7.9". Section 7.9.3 " Periodic Testing of Emergency Lighting Equipment" " Section 7.9.3.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows: (1) Functional Testing shall be conducted monthly with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds except as otherwise permitted by 7.9.3.1.1.(2) The Test interval shall be permitted to be extended beyond 30 days with the approval of authority having jurisdiction.(3) Functional testing shall be conducted annually for a minimum of 1/1/2 hours if the emergency lighting system is battery powered. (4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1 (1) and (3). (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction."

Findings include:

The Director of Maintenance and the surveyor reviewed the documentation for the emergency battery backup lights on April 15, 2019, the documentation reviewed was missing the monthly thirty second testing for the following months:

1. February of 2019.
2. May of 2018.

The Chief Executive Officer and the Director of Maintenance acknowledged during the exit conference on April 16, 2019, the emergency battery backup lights was missing the monthly thirty second testing.

Based on observation and interview it was determined, the facility failed to maintain corridor doors to the facility. Failing to maintain corridor doors from being propped open from heat or smoke could cause harm to the patients and staff in time of a fire.

NFPA 101, Life Safety Code, 2012 edition, Chapter 19, Section 19.3.6.3.5. "Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction." Section A.19..3.6.3.10 "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."

Findings Include:

The Director of Maintenance and the surveyor observed on April 16, 2019, the following corridor doors propped open or failed to close due to impediments in the following areas:

1. Dry storage door in the Kitchen propped open by a door wedge.
2. OR Utility room door propped open by oxygen racks.
3. OR Sterile Storage room door was blocked from closing from a table.

The Chief Executive Officer and the Director of Maintenance acknowledged during the exit conference on April 16, 2019, the corridor doors propped open or failed to close due to impediments.

Based on observation and interview it was determined, the facility failed to fill penetrations in the smoke barriers in the facility. Failing to seal the penetrations, holes, and openings in the smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility which could cause harm to the patients in the time of a fire.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire resistance rating of at least ½ hour." Chapter 8, Section 8.5.6.2 Penetrations for cables cable trays, conduits, pipes, tubes, vents wires and similar items to accommodate electrical, plumbing and communications systems that pass through a wall, floor or /ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof /ceiling of a smoke barrier assembly shall be protected by a system or material capable of restricting the transfer of smoke.

Findings include:

The Director of Maintenance and the surveyor observed on April 15, 2019, observed unsealed penetrations in the smoke barriers in the following locations:

1. One penetration above the doors to Surgery.
2. Three penetrations above the Kitchen corridor doors.
3. One penetration above the ICU doors.
4. One penetration above the OB doors.

The Chief Executive Officer and the Director of Maintenance acknowledged during the exit conference on April 16, 2019, that there was unsealed penetrations in the smoke barriers.

Based on observation and interview with staff, it was determined the facility failed to provide a protective guard on light bulbs. Failure to keep light guards on the light bulbs could cause accidental damage or possibly a fire, which could cause harm to the patients.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1." Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70, 2011 Edition, "National Electrical Code." NEC, 2011, Article 110, Section 110-27 (b) "Prevent Physical Damage. 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."

Findings include:

The Director of Maintenance and the surveyor observed on April 16, 2019, that there were exposed light bulbs with no protective guards located in the following areas:

1. Electrical room, old ICU, two exposed bulbs.
2. Decontamination room four exposed bulbs.
3. Electrical room, in Administration, two exposed bulbs.

The Chief Executive Officer and the Director of Maintenance acknowledged during the exit conference on April 16, 2019, that there were exposed light bulbs with no protective guards.

Based on record review and interview with staff, it was determined the facility failed to have written documentation of the Annual Inspection and Testing of Door openings in accordance with NFPA 80, 2010 Edition, "Standard for Fire doors and Other Opening Protective's." Failing to inspect and test fire rated door assemblies in accordance with NFPA 80 annually could cause harm to the patients.

NFPA 101 2012 Life Safety Code Section 8.3.3. Fire door and Windows Section 8.3.3.1 "Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed labeled fire door assemblies and fire window assemblies and their accompanying hardware,including all frames, closing devices, anchorage and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening protective, except as otherwise specified in this code."

NFPA 80 Section 5.2* Inspections Section 5.2.1*"Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for the AHJ. Section 5.2.3 Functional Testing. Section 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing."

NFPA 80 Section 13.4 Automatic closing Section 5.2.5 Horizontal sliding,Vertically Sliding, and Rolling Doors.
Section 5.2.14.3 "All horizontal or vertical sliding or rolling fire doors shall be inspected and tested annually to check for proper operation at frequent intervals to ensure operation."

Findings include:

The Director of Maintenance and the surveyor reviewed the annual fire rated door assembly records on April 15, 2019. The facility did not have written records for 2018 of the Annual Inspection and Testing of Door Openings in accordance with NFPA 80 Standard for Fire Doors and Other Opening Protective's.

The Chief Executive Officer and the Director of Maintenance acknowledged during the exit conference on April 16, 2019, that there was no documentation to review of the annual fire rated door assemblies for 2018.

Based on record review and interview with staff it was determined, the facility failed to document the monthly testing of the line isolation monitoring. Failing to test the isolated electrical panel units in time of an emergency could cause harm to the patients in an emergency power outage.

NFPA 101 Life Safety Code, 2012, NFPA 99 Health Care Facilities Chapter 6 Section 6.3.3.3 "Isolated Power systems." Section 6.3.4.1 Maintenance and Testing of electrical Systems. Section 6.3.4.1.4" The LIM circuit shall be tested at intervals of not more than one month by actuating the LIM test switch see (6.3.2.6.3.6,) which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4"

Findings include:

The Director of Maintenance and the surveyor reviewed the documentation for the line isolation monitors on April 15, 2019, the facility failed to document the following monthly checks:

1. February of 2019.
2. May of 2018.

The Chief Executive Officer and the Director of Maintenance acknowledged during the exit conference on April 16, 2019, the facility failed to document the following monthly checks of the line isolation monitors.

Based on record review and interview with staff it was determined, the facility failed to document the required elements of the weekly visual inspection of the emergency generators. Failure to do weekly visual inspections of the emergency generators could result in harm to patients during emergency system failures.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.7.6 "Maintenance and Testing (See 4.6.12) Section 4.6.12.2 "Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 99 "HEALTH CARE FACILITIES". Chapter 3, Section 3-5.4.1.1 (a) and Section 3-4.4.1.1 (b) "Generator sets shall be tested twelve (12) times a year...Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Chapter 6, Section 8.4.1 "Level 1 and Level 2 EPSSs, including all appurtenant components shall be inspected weekly and shall be exercised under load at least monthly." NFPA 110, Chapter 8, Section 8.4.2 "Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes..."

Findings Include:

The Director of Maintenance and the surveyor reviewed the documentation for the emergency generators on April 15, 2019, the documentation onsite only showed some of the required elements for the weekly visual checks. There was also fifteen weeks of missing documentation for 2017, 2018, and 2019.

The Chief Executive Officer and the Director of Maintenance acknowledged during the exit conference on April 16, 2019, the documentation onsite only showed some of the required elements for the weekly visual checks. There was also fifteen weeks of missing documentation for 2017, 2018, and 2019.

Based on observation, it was determined the facility failed to ensure that staff did not use daisy chain power strips. The use of daisy chained power strips could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.

NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2 , "All Patient Care Areas," Sections 6.3.2.2..6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings include:

The Director of Maintenance and the surveyor observed on April 15, 2019, the following daisy chained power strips in the facility and not directly plugged in to the receptacle wall outlets:

1. Medical Records office power strip daisy chained to a power strip.

The Chief Executive Officer and the Director of Maintenance acknowledged during the exit conference on April 16, 2019, that the power strips were daisy chained and not plugged directly into a receptacle wall outlet.