HospitalInspections.org

Based upon observations and staff interviews on 11/21/2024 between approximately 0930 to 1530 hours the facility has failed to maintain all means of egress continuously free of obstructions. This could inhibit the orderly exit of patients, staff, and visitors out of the building during an emergency and may prevent emergency responders from entering.

The findings include:

Emergency exit in operating room hallway blocked by equipment

The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on 11/21/2024 between approximately 0930 to 1530 hours the facility has failed to conduct testing/maintenance of the hood and duct fire suppression equipment protecting the commercial cooking equipment. This could result in the failure of the system to operate properly which would endanger the patients, staff and/or visitors within the facility.

The findings include:

Facility failed to provide strain protection on kitchen cooking devices that are on casters and gas fueled.
Facility failed to privde to new employees on hiring and to all employees annually on the use of portable fire extinguishers and the manual actuation of the fire-extinguishing system.
Facility failed to provide signage on the exhaust hood or system cabinet, indicating the type and arrangement of cooking appliances protected by the automatic fire-extinguishing system. Signage shall indicate appliances from left to right, be durable, and the size, color, and lettering shall be approved.
The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on 11/21/2024 between approximately 0930 to 1530 hours the facility has failed to have appropriate testing of the fire alarm system which result in the failure to notify staff of a problem with the fire alarm system. This could lead to the system not functioning as intended and lead patients, staff, and visitors within the building not being notified of a fire.

The findings include:

OR hallway pull station found blocked by table.

Facility shall provide semi annual fire alarm testing.

The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on 11/21/2024 between approximately 0930 to 1530 hours the facility has failed to maintain the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire and allow the fire to increase in size and intensity which would endanger the patients, staff, and/or visitors within the facility.

The findings include:
Facility failed to provide 5 year internal inspection and 5 year FDC hydrostatic inspection report.
Pressure switch needs replaced per fire sprinkler report.
Fire sprinkler name plate are faded and illegible, unknown system demand.
The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on 11/21/2024 between approximately 0930 to 1530 hours the facility has failed to properly maintain fire/smoke barriers doors within the facility as capable of resisting the passage of smoke. This could result in the products of combustion traveling from one smoke compartment to another which would endanger the patients, staff, and/or visitors within the facility.

The findings include:

OR cross corridor fire door found to have excessive gap.

The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on 11/21/2024 between approximately 0930 to 1530 hours the facility has failed to maintain electric equipment in a safe manner and in accordance with NFPA 70. This could endanger patients, staff, and visitors in the building by risk of fire, electrocution, or other harm.

The findings include:

Electrical junction box in operating room found to be open.

The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on 11/21/2024 between approximately 0930 to 1530 hours the facility has failed to ensure dampers in the facility were inspected and provided necessary maintenance at least every four years in accordance with NFPA 90A. LSC 9.2.1 requires heating, ventilating and air conditioning (HVAC), ductwork and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems.

NFPA 90A, 2012 Edition, Section 5.4.8.1 states fire dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. NFPA 80, 2010 Edition, Section 19.4.1 states each damper shall be tested and inspected 1 year after installation. The test and inspection frequency shall be every 4 years. If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in-place if so equipped. The damper shall not be blocked from closure in any way. All inspections and testing shall be documented, indicating the location of the fire damper, date of inspection, name of inspector and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected. This deficient practice could affect all patients, staff, and visitors.

The findings include:

Fire dampers were found to be inspected/repairs/replaced and have not had a 1 year inspection conducted after.

The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on 11/21/2024 between approximately 0930 to 1530 hours the facility has failed to provide fire drill records reflecting drills being conducted on all shifts for each quarter for the past 12 months. This could potentially result in the staff not responding in a coordinated manner in the event of a fire or other emergency and endangering patients, staff and/or visitors.

The findings include:

The facility failed to provide documentation of a fire drill during the third quarter of 2024 on night shift.
The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on 11/21/2024 between approximately 0930 to 1530 hours the facility failed to maintain a maintenance program for their medical gas equipment. This could lead to the equipment malfunctioning endangering patients, staff, and visitors.

The findings include:
The facility failed to have a medical gas, vacuum, WAGD, or support gas systems having a documented maintenance program. The program includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets. Inspection and maintenance schedules are established through risk assessment considering manufacturer recommendations. Inspection procedures and testing methods are established through risk assessment. Persons maintaining systems are qualified as demonstrated by training and certification or credentialing to the requirements of AASE 6030 or 6040.


The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on 11/21/2024 between approximately 0930 to 1530 hours the facility failed to maintain their medical gas equipment through testing and inspection possible leading to a problem not being detected, and thus place patients, staff, and visitors to the threat of an accelerated fire.

The findings include:

The facility failed to inspect and test gas and vacuum systems as part of a maintenance program and include the required elements.

The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on 11/21/2024 between approximately 0930 to 1530 hours the facility has failed to provide signage where oxygen or other medical gases are in use or stored. This could result in the rapid spread of smoke and fire in the event of ignition which could potentially endanger the patients, staff, and/or visitors within the facility.

The findings include:

Shutoff valves failed to identify room or area served. Shut off valves in operating hallway found blocked.

The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on 11/21/2024 between approximately 0930 to 1530 hours the facility has failed to maintain and test the emergency generator in accordance with NFPA 110. This could result in a failure of the emergency power system which would leave the facility without egress and task lighting in the event of a power failure which would endanger the patients, staff, and/or visitors within the facility.

The findings include:

Facility failed to provide records for every 36 months testing for 4 continuous hour exercise on each generator.

NFPA 110 8.4.7 EPSS circuit breakers for Level 1 system usage, including main and feed breakers between the EPS and the transfer switch load terminals, shall be exercised annually with the EPS in the "off" position.

NFPA 99 6.4.4.1.2.1* Circuit Breakers. Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer ' s recommendations.


NFPA 8.4.7.1 Circuit breakers rated in excess of 600 volts for Level 1 system usage shall be exercised every 6 months and shall be tested under simulated overload conditions every 2 years.


NFPA 99 6.4.4.1.2.1* Circuit Breakers. Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer 's recommendations.

Facility failed to conduct conduce testing and specific gravity testing on generator batteries

The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on 11/21/2024 between approximately 0930 to 1530 hours the facility failed to maintain a written policy or regulation for fire loss in operating rooms. This could result in the ignition of gases; endanger the staff and patients within the room.


The findings include:

Facility failed to provide education and training to OR surgeons for chemical spills, and extinguishment of drapery, clothing and equipment fires.

Facility failed to remove solution-soaked materials have been removed from the OR prior to draping and use of surgical devices.

The above was discussed and acknowledged by the facility staff.