HospitalInspections.org

Based upon observations and staff interviews on July 19, 2019 between approximately 0930 to 1330 hours the facility has failed to maintain records of testing for the emergency battery backup lighting. This could result in the failure of the battery powered backup lighting in the event of a power outage and render the means of egress dark. This could result in tripping and fall injuries to patients, staff and/or visitors.

The findings include:

The facility was unable to provide the 30 second monthly test and the 90 minute annual test.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview of July 19, 2019 between 0930 to 1330 hours the facility failed to maintain their laboratories in a safe and fire resistant manner in accordance with the referenced NFPAs. This could lead to the inability of staff or machinery to function as they should in the event of an emergency or exposed chemicals to magnify the effects of a fire.

The findings include:

The laboratory hood was past due for its annual servicing.

NFPA 45, 2011
8.13 Inspection, Testing, and Maintenance.
8.13.1* When installed or modified and at least annually thereafter, chemical fume hoods, chemical fume hood exhaust systems,
and laboratory special exhaust systems shall be inspected and tested as applicable, as follows:
(1) Visual inspection of the physical condition of the hood interior, sash, and ductwork (see 7.5.3)
(2) Measuring device for hood airflow
(3) Low airflow and loss-of-airflow alarms at each alarm location
(4) Face velocity
(5) Verification of inward airflow over the entire hood face
(6) Changes in work

The laboratory could not produce a fire plan.

NFPA 45, 2011
6.6.3* Emergency Plans.
6.6.3.1 Plans for laboratory emergencies shall be developed,
which shall include the following:
(1) Alarm activation
(2) Evacuation and building re-entry procedures
(3) Shutdown procedures or applicable emergency operations for equipment, processes, ventilation devices, and enclosures
(4) Fire-fighting operations
(5)*Non-fire hazards
(6) Information as required by the AHJ to allow the emergency responders to develop response tactics
6.6.3.2* Procedures for extinguishing clothing fires shall be established.

The above was discussed and acknowledged by the facility staff.

Based upon record review and staff interviews on July 19, 2019 between approximately 0930 to 1330 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:

The facility was unable to produce a heat test record.

NFPA 17A 5.2.1.3 Automatic detection and system actuation shall be in accordance with the manufactures design, installation and maintenance manual.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on July 19, 2019 between approximately 0930 to 1300 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 to people within the building not being notified of a fire.

The findings include:

The facility was unable to provide the names of the people who last tested the fire alarm system. The names on the annual fire alarm report were illigible and therefore their credientials were unable to be verified.

NFPA 72, 2010

10.4.3 Inspection, Testing, and Maintenance Personnel. (SIGTMS)
10.4.3.1* Service personnel shall be qualified and experienced in the inspection, testing, and maintenance of systems addressed
within the scope of this Code. Qualified personnel shall include, but not be limited to, one or more of the following:
(1)*Personnel who are factory trained and certified for the specific type and brand of system being serviced
(2)*Personnel who are certified by a nationally recognized certification organization acceptable to the authority having
jurisdiction
(3)*Personnel who are registered, licensed, or certified by a state or local authority to perform service on systems addressed
within the scope of this Code (4) Personnel who are employed and qualified by an organization
listed by a nationally recognized testing laboratory for the servicing of systems within the scope of this Code

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on July 19, 2019 between approximately 0930 to 1130 hours the facility has failed to provide fire sprinkler protection to all required areas of the facility. This could result in a fire not being contained to the area of origin and could endanger residents, staff and/or visitors.

The findings include:

The walk-in cooler auto-defrosts according to the dietary manager and the facilities director and has an ordinary sprinkler head.

8.3.2.5* The following practices shall be observed to provide sprinklers of other than ordinary-temperature classification
unless other temperatures are determined or unless high temperature sprinklers are used throughout, and temperature
selection shall be in accordance with Table 8.3.2.5(a), Table 8.3.2.5(b), and Figure 8.3.2.5: 10) Sprinklers in walk-in type coolers and freezers with automatic defrosting shall be of the intermediate-temperature classification or higher.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on July 19, 2019 between approximately 0930 to 1330 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:

The closet in the CT office had items touching the ceiling.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on July 19, 2019 between approximately 0930 to 1330 hours the facility failed to maintain their fire extinguishers in accordance with NFPA 10. This potentially delays a quick response to contain a fire from spreading which could expose and endanger patients, staff, and/or visitors within the facility.

The findings include:

The K class extinguisher in the kitchen did not have the required sign.

NFPA 10, 2010
5.5.5.3 *
A placard shall be conspicuously placed near the extinguisher that states that the fire protection system shall be actuated prior to using the fire extinguisher.

The facility will verify that they have the correctly sized fire extinguisher at the heliport.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on July 19, 2019 between approximately 0930 to 1330 hours the facility has failed to maintain corridors construction as capable of resisting smoke. This could result in toxic products of combustion getting into the room or into the exit corridor in the event of a fire which would endanger the patients, staff and/or visitors within the smoke compartment.

The findings include:

The fire wall above the tiles in the corridor by the kitchen in the lobby have conduits that have not been sealed with caulk or pillows.


The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on July 19, 2019 between approximately 0930 to 1330 hours the facility has failed to maintain doors without impediments to their closing and latching. This could result in a delay in getting the door to the room closed in the event of a fire. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the patients, staff and/or visitors within the smoke compartment.

The findings include:

The roll-down fire door in the corridor to the radiology area had failed per the last fire alarm report. When tested at the inspection, it did not close. Fixed at the time of inspection.

The cross-corridor fire doors next to the nurses station to the Med-Surgery area by room 110 did not close and latch. The double doors both had penetrations where the hinges used to be and rating had been removed.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on July 19, 2019 between approximately 0930 to 1330 hours the facility has failed to maintain electric and gas equipment in a safe manner and in accordance with NFPA 54 and NFPA 70. This could endanger people in the building by risk of fire, electrocution, or other harm.

The findings include:

The electrical panel K in the endoscope area was blocked by a shred bin and a water cooler.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on July 19, 2019 between approximately 0930 to 1330 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:

The facility was unable to produce a fire/smoke damper inspection log.



The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on July 11, 2019 between approximately 0930 to 1130 hours the facility has failed to maintain a written plan for the protection of all residents, staff and visitors and for their evacuation in the event of an emergency. At a minimum a written care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarms to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire

The findings include:

The fire plan did not include a partial evacuation.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on July 19, 2019 between approximately 0930 to 1330 hours the facility failed to prohibit the use of combustible decorations of flammable material. 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:

The door from Triage to the ED (3/4 hour door) had hanging storage unit on the door. The unit covered approximately 75% of the door.

The door in the ambulance entrance to the storage room (3/4 hour door) had a closet organizer handing on the door. It covered approximately 50% of the door.


NFPA 101, 2012

19.7.5.6 Combustible decorations shall be prohibited in any health care occupancy, unless one of the following criteria is
met:

(c) Decorations do not exceed 30 percent of the wall, ceiling, and door areas inside any room or space of a smoke compartment that is protected throughout by an approved supervised automatic sprinkler system in accordance with Section 9.7.


The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on July 19, 2019 between approximately 0930 to 1330 hours the facility has failed to test all fire rated doors in accordance with NFPA 80. This could lead to the doors not functioning as required in a fire, endangering those inside the building.

The findings include:

The facility stated that they did test the doors, but they did not have documetation that showed they tested the doors in accordance with NFPA 80.

NFPA 80, 2010

5.2.4.2 As a minimum, the following items shall be verified:
(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.

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 inspection by the AHJ.



The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on July 19, 2019 between approximately 0930 to 1330 hours the facility failed to maintain their medical gas equipment through testing and inspection possible leading to a problem not being detected.

The findings include:

The facility was unable to produce a med-gas testing report. The facilities director stated that he did not believe that the system had ever been tested.



The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on July 19, 2019 between approximately 0930 to 1330 hours the facility failed to keep records or conduct maintenance on their hospital grade receptacles, non-hospital grade receptacles, and Line Isolation Monitors. This could cause an increased risk of fire due to the non-maintenance of the electrical system.

The findings include:

The facility did not have records of testing of their hospital or non-hospital grade receptacles.


The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on July 19, 2019 between approximately 0930 to 1330 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 residents, staff, and/or visitors within the facility.

The findings include:

The annual fuel report for the main tank had the following "Immediate Action Required: sediment and water at filter plugging and fuel degredation increase. REMEDIATE

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on July 19, 2019 between approximately 0930 to 1330 hours the facility failed to restrict the use of extension cords and non-approved power strips in their facility. This could endanger people in the facility due to the increased fire risk.

The findings include:

There was an extension cord zip-tied to the pipes in the laundry room behind the dryers. The facility laundry staff stated that they had been there for a very long time.

The nurses lounge had a toaster, oven, microwave in a power strip and the power-strip was hanging by its tail.

The shipping and receiving office had a Keurig, microwave, and refrigerator in a power-strip.



The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on July 19, 2019 between approximately 0930 to 1330 hours the facility has failed to provide policies for the testing, repairs, and modifications of patient care related electrical equipment as required. This could result in the failure of the patient care related electrical equipment to operate properly which would endanger the patients, staff, and/or visitors within the facility.

The findings include:

The facility could not produce a policy in regards to PCREE testing, repairs, and maintenance.



The above was discussed and acknowledged by the facility staff.