HospitalInspections.org

Based on observation and interview, the facility does not ensure that 4 of 4 fire doors close and latch. (two doors in the southwest stairwell, the door into the laboratory area, and the door entering the soiled utility room in the emergency department)

Findings include:

During tour on 3/4/15 at 2:00 PM, it was observed that the rated fire doors did not close completely in the southwest stairwell. Both doors in this stairwell, one from entrance A and fire door B, did not close completely to allow the fire door to latch. It was also observed that the rated door entering the soiled utility room in the emergency department did not close completely to allow the rated door to latch. This finding was verified by Maintenance Manager Staff #5 on 3/4/15 at 2:15 PM.

During tour on 3/6/15 at 12:00 PM of the clinical laboratory area, it was observed that the rated door entering this area was propped open. This finding was verified by CEO Staff #1 on 3/6/15 at 12:05 PM.

Based on document review and interview, the facility does not ensure that staff have adequate knowledge for the location of the fire-rated walls/barriers.

Findings include:

Review on 3/4/15 at 1:15 PM of the blueprints for the facility with Maintenance Manager Staff #5 revealed that the facility is not aware of where the fire-rated walls/barriers are located throughout the facility. Review of the provided blueprints did not reveal evidence that a complete set of prints, including Life Safety, was available.

During interview at that time, Staff #5 indicated that multiple additions have been added to the original structure, which was built in 1969, with the most recent addition having been added in 2001.

With the lack of knowledge regarding the location of the fire-rated walls/barriers, it is not possible to determine if adequate separation is provided and maintained where required.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 4/7/11.

Based on observation and interview, the facility does not ensure that a one-hour fire resistance rating is provided for 2 of 2 stairwell enclosures. (southwest and southeast stairwells)

Findings include:

During facility tour on 3/4/15 at 2:00 PM, it was observed that penetrations were present in the southwest and southeast stairwells, around electrical conduit lines and sprinkler lines.

During interview at that time, Maintenance Manager Staff #5 revealed that he was unsure of what the conduit lines were utilized for that entered the stairwells. With the penetrations present in these exit enclosures, the facility is not able to provide protection against fire or smoke from other areas of the facility.

Exit enclosures must be enclosed with construction or a fire rated compound having a fire resistance rating of at least one hour to allow facility occupants to have a continuous egress pathway.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 4/7/11.

Based on observation and interview, the facility does not ensure that maintenance is provided for the egress pathway from the emergency exit in the southwest stairwell for fire door B.

Findings include:

During facility tour on 3/4/15 at 2:00 PM, it was observed that southwest stairwell fire door B required an excessive amount of force for the door to be opened by Maintenance Manager Staff #5. Once the door was opened, it was observed that the egress pathway to a public way had a significant accumulation of ice and snow present.

Egress pathways must be maintained free of obstructions that would prevent the facility occupants from safely reaching a public way.

Based on observation, document review and interview, the facility does not ensure that 2 of 2 battery powered emergency lights are operational in the southeast stairwell, or that 90 minute testing is conducted annually on 18 of 18 emergency lights.

Findings include:

During facility tour on 3/4/15 at 2:30 PM, it was observed that the two battery powered emergency lights in the southeast stairwell were not operational. Review of the provided documentation indicated that monthly testing was last performed on the lights in 12/2014.

Review of the Emergency Light Testing Log on 3/3/15 at 3:00 PM did not show evidence that the emergency lights were tested annually for 90 minutes during 2014.

Review of this log indicated that monthly testing had been conducted on Operating Rooms (OR) #2 and 4 from 2/2014 through 12/2014. An interview with OR Nurse Manager Staff #29 on 3/5/15 at 10:00 AM revealed that OR #2 had been closed from 12/2013 through 1/2015 and the facility does not have an OR #4. Additionally, this report did not show evidence of the staff who performed the test or the date that the monthly testing occurred.

The 30-second testing must be performed monthly to ensure that immediate illumination is provided in these areas during the 10 second delay between the loss of normal power and the activation of emergency power. An annual 90 minute testing must be performed to ensure that continuous illumination is provided in the event of emergency power failure or in the event of an internal failure.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEYS COMPLETED 9/20/06 AND 4/7/11.

Based on document review and interview, the facility does not ensure that one fire drill/shift/quarter was performed during 2014 or that documented fire drills include informatin regarding the scenario, an evaluation, drill critique, staff participation and any follow-up activity that is performed.

Findings include:

Review on 3/5/15 at 4:00 PM of the Fire Drill Reports revealed that one fire drill/shift/quarter was not performed during 2014, as follows:
- On the first shift, a fire drill was not conducted during the 1st quarter of 2014;
- On the second shift, a fire drill was not conducted during the 1st, 3rd and 4th quarters of 2014;
- On the third shift, a fire drill was not conducted during the 3rd and 4th quarters of 2014.

Scheduled and unscheduled fire drills must be conducted to assure that the staff have received adequate training in the event of an actual emergency. Drill documentation must include the scenario, staff participation, evaluation, and follow-up activities.

Based on document review and interview, the facility does not ensure that sensitivity testing is performed on the photo smoke detectors.

Findings include:

Review on 3/3/15 at 2:30 PM of the facility's fire inspection reports did not reveal evidence that sensitivity testing has been performed on the photo smoke detectors, or the last time sensitivity testing had been performed.

Sensitivity testing must be performed within one year after installation of the device and every alternate year thereafter. After the second required testing, if the device sensitivity remains within the manufacturer's recommendations for sensitivity, the time between testing may be extended to a maximum of five years.

Based on observation, document review and interview, the facility does not ensure that the sprinkler system is continuously maintained in reliable operating condition and inspected and tested periodically; specifically:
1) The sprinkler system is not visually inspected and maintained as required, and 5 year maintenance is not performed.
2) Deficiencies identified when the sprinkler system is inspected are not corrected.

Findings include:

Finding #1:
During tour on 3/4/15 at 2:15 PM, it was observed that escutcheons were not present on the sprinkler heads in the X-ray patient toilet room or in the emergency department soiled utility room.

Review on 3/4/15 of the sprinkler inspection reports for 2014 did not reveal evidence of when the internal piping had been inspected for obstructions. This piping must be inspected every five years to ensure that the system piping is free from scale build-up, silt or other materials that may obstruct the flow of water through the sprinkler system.

This finding was verified by Maintenance Manager Staff #5 on 3/4/15 at 2:30 PM.

Findings #2:
Review on 3/4/15 at 12:00 PM of the sprinkler inspection report dated 1/22/15 revealed that the identified deficiencies for the Building 88 sprinkler system had not been corrected. The report indicated that the Trim Valves must be externally inspected monthly; the Trim Valve was not in the correct position. The report also indicated that the 4" Viking model H-2 alarm valve was leaking through the alarm line, and the alarm line valve was left in the closed position.

This finding was verified with Staff #5 on 3/10/15 at 9:30 AM.

Based on observation, document review and interview, the facility does not ensure that the heating, cooling, ventilation and air-conditioning (HVAC) system is maintained.

Findings include:

During facility tour on 3/4/15 at 2:15 PM, 3/5/15 at 3:30 PM, and 3/6/15 at 3:30 PM, it was observed that the HVAC system was not operational in the following areas:
- On 3/4/15, the return ventilation in the emergency department kitchen;
- On 3/5/15, the supply air in the sterilization area in the operating suite;
- On 3/6/15, the mechanical exhaust in the dietary housekeeping closet.

During facility tour on 3/4/15 at 3:00 PM, it was observed that the ventilation exiting the soiled utility room in the emergency department was labeled to indicate that the air from this room was being returned to the air handling unit (AHU). The air from this area cannot be returned to the AHU, but must be mechanically exhausted to the outside of the building.

Review on 3/5/15 at 4:30 PM of the provided facility documentation did not show evidence that maintenance was performed on the HVAC system. An operator's manual was also not provided. Without this documentation, it is not possible to determine if the HVAC system is maintained per manufacturer's recommendations.

These findings were verified by Maintenance Manager Staff #5 on 3/4/15, Operating Room Nurse Manager Staff #29 on 3/5/15 and Dietary Manager Staff #27 on 3/6/15.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 4/7/11.

Based on document review and interview, the facility does not ensure that maintenance is performed on the bulk oxygen system or the medical gas system.

Findings include:

Review on 3/4/15 at 12:00 PM of the provided documentation did not reveal evidence that annual maintenance is performed on the bulk oxygen system; the most recent annual maintenance was performed in 6/2013.

During interview on 3/5/15 at 3:30 PM, Maintenance Manager Staff #5 revealed that maintenance is not performed on the medical gas system. Staff #5 did not know when maintenance was last performed on the system.

Routine and periodic maintenance must be performed on the master, area and local alarm signal panel systems, air intake pressure gauges, shut off valves, all warning systems, all visual and audible alarm indicators and station outlets to ensure adequate flow, and that external leakage is not present. This maintenance is required in order to provide an indication of a developing problem, to avoid a possible shutdown of the medical gas system and to avoid a disruption in patient care.

Based on document review, interview and observation, the facility does not ensure that 19 of 20 emergency eyewash stations are identified with the location, in order to ensure all are tested as required, or that 20 of 20 of the emergency eyewash stations and the emergency drench shower in the laboratory are tested weekly.

Findings include:

Review on 3/5/15 at 1:00 PM of the EYEWASH STATION INSPECTION reports revealed that the reports do not indicate the location of each eye wash device that was tested. Only 4 of 20 devices had documentation that indicated the year in which they were tested. This finding was verified by Maintenance Manager Staff #5 on 3/6/15 at 9:30 AM.

Review on 3/6/15 at 12:30 PM of the inspection tag on the emergency drench shower in the laboratory did not reveal evidence that the shower had been tested since 8/14/14. This finding was verified by Medical Technician Staff #41 at the time of inspection.

These devices must be tested weekly by opening water flow through the nozzles to verify that sufficient water is available. It is also required that an annual inspection, checking flow rates through the supply line, is performed to ensure that adequate pressure and flow are provided.

Based on document review and interview, the facility does not ensure that notification is provided when 1 of 2 sprinkler systems is out of service. (Building 69 system)

Findings include:

Review on 3/4/15 at 12:00 PM of the sprinkler inspection reports revealed that the Building 69 sprinkler system could not be inspected during January 2014 due to the system being frozen.

During interview on 3/11/15 at 9:30 AM, Maintenance Manager Staff #5 revealed that the sprinkler system was out of service from 1/11/14 through 1/25/14. Staff #5 was not aware of the requirement to notify the authority having jurisdiction when a sprinkler system is out of service for more than four hours, or that a fire watch must be performed for the areas that are left unprotected until the system has been returned to service.

Based on observation and interview, the facility does not ensure that 4 of 4 fire doors close and latch. (two doors in the southwest stairwell, the door into the laboratory area, and the door entering the soiled utility room in the emergency department)

Findings include:

During tour on 3/4/15 at 2:00 PM, it was observed that the rated fire doors did not close completely in the southwest stairwell. Both doors in this stairwell, one from entrance A and fire door B, did not close completely to allow the fire door to latch. It was also observed that the rated door entering the soiled utility room in the emergency department did not close completely to allow the rated door to latch. This finding was verified by Maintenance Manager Staff #5 on 3/4/15 at 2:15 PM.

During tour on 3/6/15 at 12:00 PM of the clinical laboratory area, it was observed that the rated door entering this area was propped open. This finding was verified by CEO Staff #1 on 3/6/15 at 12:05 PM.

Based on document review and interview, the facility does not ensure that staff have adequate knowledge for the location of the fire-rated walls/barriers.

Findings include:

Review on 3/4/15 at 1:15 PM of the blueprints for the facility with Maintenance Manager Staff #5 revealed that the facility is not aware of where the fire-rated walls/barriers are located throughout the facility. Review of the provided blueprints did not reveal evidence that a complete set of prints, including Life Safety, was available.

During interview at that time, Staff #5 indicated that multiple additions have been added to the original structure, which was built in 1969, with the most recent addition having been added in 2001.

With the lack of knowledge regarding the location of the fire-rated walls/barriers, it is not possible to determine if adequate separation is provided and maintained where required.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 4/7/11.

Based on observation and interview, the facility does not ensure that a one-hour fire resistance rating is provided for 2 of 2 stairwell enclosures. (southwest and southeast stairwells)

Findings include:

During facility tour on 3/4/15 at 2:00 PM, it was observed that penetrations were present in the southwest and southeast stairwells, around electrical conduit lines and sprinkler lines.

During interview at that time, Maintenance Manager Staff #5 revealed that he was unsure of what the conduit lines were utilized for that entered the stairwells. With the penetrations present in these exit enclosures, the facility is not able to provide protection against fire or smoke from other areas of the facility.

Exit enclosures must be enclosed with construction or a fire rated compound having a fire resistance rating of at least one hour to allow facility occupants to have a continuous egress pathway.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 4/7/11.

Based on observation and interview, the facility does not ensure that maintenance is provided for the egress pathway from the emergency exit in the southwest stairwell for fire door B.

Findings include:

During facility tour on 3/4/15 at 2:00 PM, it was observed that southwest stairwell fire door B required an excessive amount of force for the door to be opened by Maintenance Manager Staff #5. Once the door was opened, it was observed that the egress pathway to a public way had a significant accumulation of ice and snow present.

Egress pathways must be maintained free of obstructions that would prevent the facility occupants from safely reaching a public way.

Based on observation, document review and interview, the facility does not ensure that 2 of 2 battery powered emergency lights are operational in the southeast stairwell, or that 90 minute testing is conducted annually on 18 of 18 emergency lights.

Findings include:

During facility tour on 3/4/15 at 2:30 PM, it was observed that the two battery powered emergency lights in the southeast stairwell were not operational. Review of the provided documentation indicated that monthly testing was last performed on the lights in 12/2014.

Review of the Emergency Light Testing Log on 3/3/15 at 3:00 PM did not show evidence that the emergency lights were tested annually for 90 minutes during 2014.

Review of this log indicated that monthly testing had been conducted on Operating Rooms (OR) #2 and 4 from 2/2014 through 12/2014. An interview with OR Nurse Manager Staff #29 on 3/5/15 at 10:00 AM revealed that OR #2 had been closed from 12/2013 through 1/2015 and the facility does not have an OR #4. Additionally, this report did not show evidence of the staff who performed the test or the date that the monthly testing occurred.

The 30-second testing must be performed monthly to ensure that immediate illumination is provided in these areas during the 10 second delay between the loss of normal power and the activation of emergency power. An annual 90 minute testing must be performed to ensure that continuous illumination is provided in the event of emergency power failure or in the event of an internal failure.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEYS COMPLETED 9/20/06 AND 4/7/11.

Based on document review and interview, the facility does not ensure that one fire drill/shift/quarter was performed during 2014 or that documented fire drills include informatin regarding the scenario, an evaluation, drill critique, staff participation and any follow-up activity that is performed.

Findings include:

Review on 3/5/15 at 4:00 PM of the Fire Drill Reports revealed that one fire drill/shift/quarter was not performed during 2014, as follows:
- On the first shift, a fire drill was not conducted during the 1st quarter of 2014;
- On the second shift, a fire drill was not conducted during the 1st, 3rd and 4th quarters of 2014;
- On the third shift, a fire drill was not conducted during the 3rd and 4th quarters of 2014.

Scheduled and unscheduled fire drills must be conducted to assure that the staff have received adequate training in the event of an actual emergency. Drill documentation must include the scenario, staff participation, evaluation, and follow-up activities.

Based on document review and interview, the facility does not ensure that sensitivity testing is performed on the photo smoke detectors.

Findings include:

Review on 3/3/15 at 2:30 PM of the facility's fire inspection reports did not reveal evidence that sensitivity testing has been performed on the photo smoke detectors, or the last time sensitivity testing had been performed.

Sensitivity testing must be performed within one year after installation of the device and every alternate year thereafter. After the second required testing, if the device sensitivity remains within the manufacturer's recommendations for sensitivity, the time between testing may be extended to a maximum of five years.

Based on observation, document review and interview, the facility does not ensure that the sprinkler system is continuously maintained in reliable operating condition and inspected and tested periodically; specifically:
1) The sprinkler system is not visually inspected and maintained as required, and 5 year maintenance is not performed.
2) Deficiencies identified when the sprinkler system is inspected are not corrected.

Findings include:

Finding #1:
During tour on 3/4/15 at 2:15 PM, it was observed that escutcheons were not present on the sprinkler heads in the X-ray patient toilet room or in the emergency department soiled utility room.

Review on 3/4/15 of the sprinkler inspection reports for 2014 did not reveal evidence of when the internal piping had been inspected for obstructions. This piping must be inspected every five years to ensure that the system piping is free from scale build-up, silt or other materials that may obstruct the flow of water through the sprinkler system.

This finding was verified by Maintenance Manager Staff #5 on 3/4/15 at 2:30 PM.

Findings #2:
Review on 3/4/15 at 12:00 PM of the sprinkler inspection report dated 1/22/15 revealed that the identified deficiencies for the Building 88 sprinkler system had not been corrected. The report indicated that the Trim Valves must be externally inspected monthly; the Trim Valve was not in the correct position. The report also indicated that the 4" Viking model H-2 alarm valve was leaking through the alarm line, and the alarm line valve was left in the closed position.

This finding was verified with Staff #5 on 3/10/15 at 9:30 AM.

Based on observation, document review and interview, the facility does not ensure that the heating, cooling, ventilation and air-conditioning (HVAC) system is maintained.

Findings include:

During facility tour on 3/4/15 at 2:15 PM, 3/5/15 at 3:30 PM, and 3/6/15 at 3:30 PM, it was observed that the HVAC system was not operational in the following areas:
- On 3/4/15, the return ventilation in the emergency department kitchen;
- On 3/5/15, the supply air in the sterilization area in the operating suite;
- On 3/6/15, the mechanical exhaust in the dietary housekeeping closet.

During facility tour on 3/4/15 at 3:00 PM, it was observed that the ventilation exiting the soiled utility room in the emergency department was labeled to indicate that the air from this room was being returned to the air handling unit (AHU). The air from this area cannot be returned to the AHU, but must be mechanically exhausted to the outside of the building.

Review on 3/5/15 at 4:30 PM of the provided facility documentation did not show evidence that maintenance was performed on the HVAC system. An operator's manual was also not provided. Without this documentation, it is not possible to determine if the HVAC system is maintained per manufacturer's recommendations.

These findings were verified by Maintenance Manager Staff #5 on 3/4/15, Operating Room Nurse Manager Staff #29 on 3/5/15 and Dietary Manager Staff #27 on 3/6/15.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 4/7/11.

Based on document review and interview, the facility does not ensure that maintenance is performed on the bulk oxygen system or the medical gas system.

Findings include:

Review on 3/4/15 at 12:00 PM of the provided documentation did not reveal evidence that annual maintenance is performed on the bulk oxygen system; the most recent annual maintenance was performed in 6/2013.

During interview on 3/5/15 at 3:30 PM, Maintenance Manager Staff #5 revealed that maintenance is not performed on the medical gas system. Staff #5 did not know when maintenance was last performed on the system.

Routine and periodic maintenance must be performed on the master, area and local alarm signal panel systems, air intake pressure gauges, shut off valves, all warning systems, all visual and audible alarm indicators and station outlets to ensure adequate flow, and that external leakage is not present. This maintenance is required in order to provide an indication of a developing problem, to avoid a possible shutdown of the medical gas system and to avoid a disruption in patient care.

Based on document review, interview and observation, the facility does not ensure that 19 of 20 emergency eyewash stations are identified with the location, in order to ensure all are tested as required, or that 20 of 20 of the emergency eyewash stations and the emergency drench shower in the laboratory are tested weekly.

Findings include:

Review on 3/5/15 at 1:00 PM of the EYEWASH STATION INSPECTION reports revealed that the reports do not indicate the location of each eye wash device that was tested. Only 4 of 20 devices had documentation that indicated the year in which they were tested. This finding was verified by Maintenance Manager Staff #5 on 3/6/15 at 9:30 AM.

Review on 3/6/15 at 12:30 PM of the inspection tag on the emergency drench shower in the laboratory did not reveal evidence that the shower had been tested since 8/14/14. This finding was verified by Medical Technician Staff #41 at the time of inspection.

These devices must be tested weekly by opening water flow through the nozzles to verify that sufficient water is available. It is also required that an annual inspection, checking flow rates through the supply line, is performed to ensure that adequate pressure and flow are provided.

Based on document review and interview, the facility does not ensure that notification is provided when 1 of 2 sprinkler systems is out of service. (Building 69 system)

Findings include:

Review on 3/4/15 at 12:00 PM of the sprinkler inspection reports revealed that the Building 69 sprinkler system could not be inspected during January 2014 due to the system being frozen.

During interview on 3/11/15 at 9:30 AM, Maintenance Manager Staff #5 revealed that the sprinkler system was out of service from 1/11/14 through 1/25/14. Staff #5 was not aware of the requirement to notify the authority having jurisdiction when a sprinkler system is out of service for more than four hours, or that a fire watch must be performed for the areas that are left unprotected until the system has been returned to service.