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The Condition of Participation for Patient Rights has not been met.

Based upon a tour of the hospital, review of hospital documentation, and staff interviews, the hospital failed to ensure care in a safe setting when it was identified that that the Bliss Wing 11 Intensive Care Unit (ICU) and the Hartford Hospital High & Bliss Wings were not maintained in such a manner as to promote the safety and well-being of patients, and failed to ensure that only approved power sources were used during a power failure.

Please see A 144

Based upon a tour of the hospital, review of hospital documentation, and staff interviews, the hospital failed to ensure care in a safe setting when it was identified that that the Bliss Wing 11 Intensive Care Unit (ICU) and the Hartford Hospital High & Bliss Wings were not maintained in such a manner as to promote the safety and well-being of patients, and failed to ensure that only approved power sources were used during a power failure. The findings include:

a. On 09/16/20 at approximately 9:15 AM upon arrival at the facility, interview with the Director of Facilities identified that on 09/14/2020 at approximately 9:45 AM a facility electrician was sent to Bliss 11 I room 5 to investigate a loss of power to the electrical/medical gas patient utility tower that provides power, nurse call and medical gases to the room. Upon the electrician's arrival, no power to the tower was identified, however the electrician was asked to leave temporarily as the patient in the room was in the process of receiving an ultrasound. The electrician stated he went to the Bliss silo electrical room that feeds the intensive care unit, found no tripped breakers and called for the electrical shop foreman. The electrician and the foreman returned to room 5 after the patient's treatment was completed and found that electrical breakers 7, 10, and the main breaker to the tower in the room were all tripped. However all equipment in the room was plugged into a power strip and then to the wall quad outlet. The electricians trouble shot the tower by trying to reset breakers and all re-tripped except for the main breaker. The plugs were all examined from the exterior with no evident damage and as the electricians could go no further with a patient in the room, the tower was locked out and tagged out. The electrical shop foreman explained to the unit Nurse Manager that the electrical outlets on the tower were not useable, and unless the patient was moved, they could go no further, and the electrical shop staff would return when the room was vacant. The electrical shop foreman and electrician returned to the Bliss 11 I room 5 on 09/15/2020 at approximately 10:37 AM to investigate why the electrical breakers kept tripping and found outlets 7, 8 and 10 charred and melted, the wiring within the tower to the outlets had been melted off and the interior of the tower had evident heat and smoke damage. The electrical department with assistance from Biomedical engineering removed all the covers and then notified fire safety and all appropriate personnel of this incident.

Subsequent to these observations, the Director of Facilities and the Electrical Shop Foreman were asked for documentation of electrical receptacle testing and the surveyor was informed that none was available for Bliss 11 I.

In addition, a review of the hospital and facilities policies lacked intervals for testing as defined by documented performance data as required by NFPA 99, "Health Care Facility's Code" 6.3.4.1.2 and as part of the facility's preventive maintenance program and documentation of any history of electrical issues and or work orders returned with no issues or work orders prior to this incident.


b. On 09/16/20 at approximately 10:30 AM and times throughout the investigation, the surveyor, while accompanied by the Director of Facilities, the System Fire and Life Safety Manager and Hospital Administration observed that on Bliss Wing 11 th floor intensive care unit Room 5 had an electrical/medical gas patient utility tower that had an apparent fire. The plugs and wiring within the utility tower were melted and the breakers were tripped. A relocatable power tap (plug strip/power strip/extension cord) was identified on the window sill. Upon examination of the relocatable power tab, it was marked with Bliss 11 I. The hospital's policy on extension cord use identified that all power strips shall be UL listed for the intended purpose (hospital environment). This relocatable power tap was not hospital grade and/or listed for use in the patient care vicinity and/or for use on patient care medical devices in accordance with section #'s 10.2.3.6 & 10.2.4 of NFPA 99, "Health Care Facility's" and NFPA 70, "National Electrical Code" and UL Listed for the purpose of its use and when observed to be in use by facility staff not replaced with a proper relocatable power (power strip).

Interview with RN #3 on 9/17/20 at 9:30 AM identified that in the early morning hours on 9/14/20, there was an electrical failure in Bliss 11 I room #5, and Patient #1's ventilator alarm sounded. RN #3 identified that he was able to plug all patient care equipment into the wall outlet with the exception of the "heart monitor" which he placed on a travel pack. RN #3 requested that maintenance be contacted regarding the power failure, then got a power cord from the unit secretary and used it to plug in the "heart monitor". RN #3 was not aware that the power strip was not approved for patient care equipment. In addition, RN #3 identified that he did not smell any smoke associated with the electrical failure.

Interview with RN #1 on 9/16/20 at 11:18 AM identified that on 9/14/20, she noticed a power strip in use in Patient #1's room and there were 3 things plugged into it. In addition, RN #1 did not smell any smoke associated with the power failure.

Interview with RN #2 on 9/16/20 at 11:25 PM identified that on 9/16/20, she noticed a power strip in use in Patient #1's room and there were 3 things plugged into it. In addition, RN #1 did not smell any smoke associated with the power failure.

Interview with the Medical Director (ICU) on 9/17/20 at 10:00 AM identified that there was no disruption in care or services for Patient #1 during the time of the power failure.

The Condition of Participation for Physical Environment has not been met.

Based upon a tour of the hospital, review of hospital documentation, and staff interviews, the hospital failed to ensure that the Bliss Wing 11 Intensive Care Unit (ICU) and the Hartford Hospital High & Bliss Wings were designed and maintained in such a manner as to promote the safety and well-being of patients, and failed to ensure that only approved power sources were used during a power failure. And,
the facility failed to ensure that Hartford Hospital was in compliance with the requirements of the 2012 Life Safety Code to ensures Life Safety from Fire.



Please see A 701 and 710

Based upon a tour of the hospital, review of hospital documentation, and staff interviews, the hospital failed to ensure that the Bliss Wing 11 Intensive Care Unit (ICU) and the Hartford Hospital High & Bliss Wings were designed and maintained in such a manner as to promote the safety and well-being of patients, and failed to ensure that only approved power sources were used during a power failure. The findings include:

a. On 09/16/20 at approximately 9:15 AM upon arrival at the facility, interview with the Director of Facilities identified that on 09/14/2020 at approximately 9:45 AM a facility electrician was sent to Bliss 11 I room 5 to investigate a loss of power to the electrical/medical gas patient utility tower that provides power, nurse call and medical gases to the room. Upon the electrician's arrival, no power to the tower was identified, however the electrician was asked to leave temporarily as the patient in the room was in the process of receiving an ultrasound. The electrician stated he went to the Bliss silo electrical room that feeds the intensive care unit, found no tripped breakers and called for the electrical shop foreman. The electrician and the foreman returned to room 5 after the patient's treatment was completed and found that electrical breakers 7, 10, and the main breaker to the tower in the room were all tripped. However all equipment in the room was plugged into a power strip and then to the wall quad outlet. The electricians trouble shot the tower by trying to reset breakers and all re-tripped except for the main breaker. The plugs were all examined from the exterior with no evident damage and as the electricians could go no further with a patient in the room, the tower was locked out and tagged out. The electrical shop foreman explained to the unit Nurse Manager that the electrical outlets on the tower were not useable, and unless the patient was moved, they could go no further, and the electrical shop staff would return when the room was vacant. The electrical shop foreman and electrician returned to the Bliss 11 I room 5 on 09/15/2020 at approximately 10:37 AM to investigate why the electrical breakers kept tripping and found outlets 7, 8 and 10 charred and melted, the wiring within the tower to the outlets had been melted off and the interior of the tower had evident heat and smoke damage. The electrical department with assistance from Biomedical engineering removed all the covers and then notified fire safety and all appropriate personnel of this incident.

Subsequent to these observations, the Director of Facilities and the Electrical Shop Foreman were asked for documentation of electrical receptacle testing and the surveyor was informed that none was available for Bliss 11 I.

In addition, a review of the hospital and facilities policies lacked intervals for testing as defined by documented performance data as required by NFPA 99, "Health Care Facility's Code" 6.3.4.1.2 and as part of the facility's preventive maintenance program and documentation of any history of electrical issues and or work orders returned with no issues or work orders prior to this incident.


b. On 09/16/20 at approximately 10:30 AM and times throughout the investigation, the surveyor, while accompanied by the Director of Facilities, the System Fire and Life Safety Manager and Hospital Administration observed that on Bliss Wing 11 th floor intensive care unit Room 5 had an electrical/medical gas patient utility tower that had an apparent fire. The plugs and wiring within the utility tower were melted and the breakers were tripped. A relocatable power tap (plug strip/power strip/extension cord) was identified on the window sill. Upon examination of the relocatable power tab, it was marked with Bliss 11 I. The hospital's policy on extension cord use identified that all power strips shall be UL listed for the intended purpose (hospital environment). This relocatable power tap was not hospital grade and/or listed for use in the patient care vicinity and/or for use on patient care medical devices in accordance with section #'s 10.2.3.6 & 10.2.4 of NFPA 99, "Health Care Facility's" and NFPA 70, "National Electrical Code" and UL Listed for the purpose of its use and when observed to be in use by facility staff not replaced with a proper relocatable power (power strip).

Interview with RN #3 on 9/17/20 at 9:30 AM identified that in the early morning hours on 9/14/20, there was an electrical failure in Bliss 11 I room #5, and Patient #1's ventilator alarm sounded. RN #3 identified that he was able to plug all patient care equipment into the wall outlet with the exception of the "heart monitor" which he placed on a travel pack. RN #3 requested that maintenance be contacted regarding the power failure, then got a power cord from the unit secretary and used it to plug in the "heart monitor". RN #3 was not aware that the power strip was not approved for patient care equipment. In addition, RN #3 identified that he did not smell any smoke associated with the electrical failure.


Interview with RN #1 on 9/16/20 at 11:18 AM identified that on 9/14/20, she noticed a power strip in use in Patient #1's room and there were 3 things plugged into it. In addition, RN #1 did not smell any smoke associated with the power failure.

Interview with RN #2 on 9/16/20 at 11:25 PM identified that on 9/16/20, she noticed a power strip in use in Patient #1's room and there were 3 things plugged into it. In addition, RN #1 did not smell any smoke associated with the power failure.

Interview with the Medical Director (ICU) on 9/17/20 at 10:00 AM identified that there was no disruption in care or services for Patient #1 during the time of the power failure.

Based upon a tour of the hospital, the facility failed to ensure that Hartford Hospital was in compliance with the requirements of the 2012 Life Safety Code to ensures Life Safety from Fire. The findings include:

On 09/16/20 - 09/22/2020 at approximately 10:30 AM and times throughout the investigation, the surveyor, while accompanied by the Director of Facilities, the System Fire and Life Safety Manager and Hospital Administration the following was observed:

a. The basement tunnels/ corridors throughout the facility were being utilized as storage areas and not separated by smoke resisting partitions as required by the 2012 Life safety Code 101-chapter 19 existing health care.

b. The ABP kitchen and storage room greater than 50 sq ft that opened to an egress corridor that had the door closer's removed and 100-gallon wheeled carts with combustible debris not maintaining the separation to the resistance to fire and/or smoke as required by the 2012 Life safety Code 101-chapter 19 existing health care and the cart was not located in a room protected as a hazardous area when not attended, as required.

c. The high building 7th floor north egress corridor was being utilized as a break area / waiting with a wing wall, chairs, wall mounted TV, refrigerator and a table and also being utilized as a sorting and folding area not maintaining the path of egress required by the 2012 Life safety Code 101-chapter 19 existing health care .

d. The high building north room 712 C contained 2000 ounces /15.625 gallons of alcohol Based Hand Rub (ABHR) that was stored stacked on open pallets and a cart open to a storage room filled with combustibles not in compliance with the 2012 Life safety Code 101-chapter 19 existing health care requirement that ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met and storage in a single smoke compartment greater than 5 gallons must comply with NFPA 30 flammable and combustible liquids code this is also non-compliant and not met.
e. The emergency room orange pod medical gas storage alcove was not in compliance with NFPA 99, "Health Care Facility's Code" section 11.3 cylinder and container storage requirements i.e. 61 e cylinders containing approximately 1403 CU ft of compressed oxygen aggerate total open to the corridor.

f. The high building 3rd floor corridor was observed to have waste chemical containers in a wheeled buggy greater than 32-gallon capacity and the bliss wing 3rd floor corridor had trash collection receptacles with capacities greater than 32 gallons were not located in a room protected as a hazardous area when not attended, as required.