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Based on observation and interview, failed to attach the furniture that had been placed in exit the corridor to the wal or floor. This deficient practice allowed for the relocation of furniture during an emergency which would slow evacuation from the facility during an emergency. Facility census was 5 patients.

Findings are:
Observations on 1-10-17 between 10:10 am and 1:02 am revealed several rows of chairs were placed in the Main Lobby/Waiting area, which is part of the exit corridor, that were not secured to the wall or floor.

During an interview on 1-10-17 between 10:10 am and 1:02 pm, Maintenance Staff A confirmed the furniture in the waiting area/lobby were not affixed.

NFPA Standard:
2012 NFAP 101, 19.2.3.4 (5)
(5) Where the corridor width is at least 8 ft, projections into the required width shall be
permitted for fixed furniture, provided that all of the following conditions are met:
a. The fixed furniture is securely attached to the floor or to the wall.
b. The fixed furniture does not reduce the clear unobstructed corridor width to less than 6 ft, except as permitted by 19.2.3.4(2).
c. The fixed furniture is located only on one side of the corridor.
d. The fixed furniture is grouped such that each grouping does not exceed an area of 50 ft2.
e. The fixed furniture groupings addressed in 19.2.3.4(5)(d) are separated from each other by a distance of at least 10 ft .
f. (f)*The fixed furniture is located so as to not obstruct access to building service and fire protection equipment.
g. Corridors throughout the smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with19.3.4, or the fixed furniture spaces are arranged and located to allow direct supervision by the facility staff from a nurses ' station or similar space.
h. The smoke compartment is protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.8.

Based on observation and interview, the facility failed to maintain the emergency light in the CT Room and Dock area. This deficient practice would leave the areas in darkness during a power outage and cause confusion and delay egress. The facility census was 5 patients.

Findings are:
Observations on 1-10-17 at 11:23 am and 12:19 pm revealed:
1. The emergency light in the CT Room failed to illuminate when the test button was depressed.
2. The emergency light above the Dock exit door failed to illuminate when the test button was depressed.

During an interview on 1-10-17 at 11:23 am and 12:19 pm, Maintenance Staff A confirmed the emergency lights failed to operate when test button was depressed.

Based on interview and documentation review, the facility failed to implement an annual inspection and testing program of all fire rated doors throughout the facility. This deficient practice did not ensure the fire doors would contain and prevent the spread of fire and smoke throughout the facility. The facility census was 5 patients.

Findings are:
Documentation review on 1-10-17 at 12:44 pm revealed he facility could not provide documentation of inspection and testing of all the fire rated doors throughout the facility.

During an interview on 1-10-17 at 12:44 pm, Maintenance Staff A confirmed the lack of a complete fire rated door inspections.

NFPA Standard:
2010 NFPA 80, 5.2* 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.5.2.2* Performance-Based Option.5.2.2.1 As an alternate means of compliance with 5.2.1, subject to the AHJ, fire door assemblies shall be permitted to be inspected, tested, and maintained under a written performance based program.5.2.2.2 Goals established under a performance-based program shall provide assurance that the fire door assembly will perform its intended function when exposed to fire conditions.5.2.2.3 Technical justification for inspection, testing, and maintenance intervals shall be documented.5.2.2.4 The performance-based option shall include historical data acceptable to the AHJ.
5.2.3 Functional Testing.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.5.2.3.2 Before testing, a visual inspection shall be performed to identify any damaged or missing parts that can create a hazard during testing or affect operation or resetting.
5.2.4 Swinging Doors with Builders Hardware or Fire Door Hardware.5.2.4.1 Fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly.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 at the door edge to the frame, on the pull side of the door, do not exceed clearances listed in 4.8.4 and 6.3.1.(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 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.

Based on observation and staff interview, the facility failed to separate hazardous areas from other areas of the building by smoke resistive partitions. This deficient practice would allow smoke to migrate from the hazardous areas to the exit corridor. The facility census was 5 patients.

Findings are:
Observation on 1-10-17 at 10:40 am and 12:29 pm revealed:
1. The OR Storage room equipped which was equipped with a self-closing device failed to latch within the door frame.
2. Patient Room 515 was being used as a storage room. The facility failed to provide a self-closing device for the room door.

During an interview on 1-10-17 at 10:40 am and 12:29 pm, Maintenance Staff A confirmed the OR Storage room door failed to latch and stated the patient room was being used to store equipment for a new nurse call system.

Based on observation and interview, the facility failed to ensure the doors to the corridors were capable of resisting the pasage of smoke and allowed doors to be held open by unapproved means. This deficient practice would allow smoke and fire to migrate into the exit corridors. The facility census was 5 patients.

Findings are:
Observations on 1-10-17 between 10:24 am and 11:19 am revealed:
1. The gap between the double doors to the Dining Room was greater than 1/8 inch.
2. The gap between the double doors to Surgery/ER was greater than 1/8 inch.
3. Office 510 door was being held in the open position with a bench.
4. The newly installed sliding door at Mammo/Dressing room area failed to provide latching hardware.

During an interview on 1-10-17 at 10:24 am and 11:19 am, Maintenance Staff A confirmed the gaps between the doors were greater than 1/8 inch and that the office door was held open and the newly installed sliding door failed to provide latching hardware.

Based on documentation review and interview, the facility failed to hold fire drills under varied conditions during 1st, 2nd and 3rd shifts reviewed and at shift change. This condition did not provide simulated training for staff to respond to a fire emergency during various activities and staffing levels, which would affect fire procedure response. The facility census was 5 patients.

Findings are:
Fire drill documentation review on 1-10-17 at 12:20 pm revealed:
1. First shift fire drills were conducted at 1:05pm and 2:10pm.
2. Second shift fire drills were conducted at 3:20pm, 4:00pm and 5:10pm
3. Third shift fire drills were conducted at 11:00pm, 10:30pm, 6:00am and 5:00am.
4. 4 fire drills reviewed were conducted at shift change, which failed to simulate actual staffing levels.

During an interview on 1-10-17 at 12:20 pm, Maintenance Staff A confirmed the drills failed to be conducted during varied conditions.

Based on observation and interview, the facility failed to monitor and prohibit the use of portable space heaters in the facility. This deficient practice increased the potential of a fire. Facility census was 5 patients.

Findings are:
Observations on 1-10-17 at 11:39 am revealed a portable space heater located under the desk in the Human Recourses office. The facility could not confirm the heating element of the device did not exceed 212 degrees Farenheit.

During an interview on 1-10-17 at 11:39 am, Maintenance A stated that they unaware that the space heater was in the room and stated the facility has a policy against the use of space heaters.

Based on record review and interview, the facility failed to conduct retention tests on non-hospital receptacles at patient bed locations or where anesthesia is administered. This deficient practice had the potential to affect how equipment operates which could result in an electrical fire and harm to the patient. The facility census was 5 patients.

Findings are:
Documentation review on 1-10-17 at 12:48 pm revealed, that no retention testing had been conducted on the non-hospital grade receptacles at patient care areas.

During an interview on 1-10-17 at 12:48 pm, Maintenance Staff A confirmed the findings and stated that they were unaware of the requirements.

NFPA Standard:
2012 NFPA 99
6.3.4.1.1 Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device.
6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.
6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.
6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modification.

Based on observation and interview, the facility allowed storage to obstruct access to the electrical disconnect box. This deficient practice could cause a delay in turning off the power during an electrical issue emergency. The facility census was 5 patients.

Findings are:
Observations on 1-10-17 at 10:55 am and 11:55 am revealed:
1. Medical equipment was placed in front of the LIM panel box in OR 1.
2. Two floor cleaners were stored in front of panel boxes in the Housekeeping Storage Room.

During an interview on 1-10-17 at 10:55 am and 11:55 am, Maintenance Staff A confirmed the items obstructing the panel boxes.

Based on observation and interview, the facility faile to monitor and restrict the use of extension cords in lieu of permanent wiring. This deficient practice increased the potential to overload the circuit and cause an electrical fire. Facility census was 5 patients.

Findings are:
Observations on 1-10-17 at 11:10 am revealed, an extension cord was being used to provide power for a treadmill in the Cardio/PT area.

During an interview on 1-10-17 at 11:10 am, Maintenance Staff stated they were not aware of the extension cord.