HospitalInspections.org

K-0018
Based on observation and staff interview during the survey, it was determined that the facility failed to maintained corridor doors in accordance with Life Safety Code Section 19.3..3 This deficient practice could affect all residents and staff in the Emergency wing core smoke compartment by allowing the spread of fire and smoke to the adjoining compartments. This was evidenced by the following:

Corridor doors were not maintained to close and positively latch, as required.
CT-Scan Room, the door latching mechanism was non-functional and would not latch into the door frame.

The Maintenance Director acknowledge the door condition during the tour of the facility.

Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as those constructed of 1 3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Doors are provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are permitted.

K-0021
Based on observation and staff interview during the survey, it was determined that the facility failed to arrange doors protecting hazardous areas to automatically close upon activation of the fire alarm system in accordance with Life Safety Code Section 19.3.2.6 This deficient practice could affect all residents through-out the core smoke compartments by allowing the spread of fire and smoke to the adjoining compartments. This was evidenced by the following:

1) Room 82 the door closer arm has been disconnected from the self-closing device.
2) Trauma Room located in the ER, the door closer arm has been disconnected from the self-closing device.

The Maintenance Director acknowledge the condition of the door closers during the tour of the facility.

Life Safety Code, Section 19.3.2.1 hazards Areas. Any hazardous area shall be safeguarded by fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the area shall be separated from other spaces by smoke-resistive partitions and doors. The doors shall be self-closing or automatic-closing.

K-0046
Based on record review and staff interviews of the emergency lighting, the battery-powered emergency lights have not been monthly and annually tested in accordance with Life Safety Code, Section 7.9.3 and 19.2.9.1. This deficient practice could affect all residents and staff throughout the facility in the event of the loss of primary power. This was evidenced by the following:
1. No documentation was available during record review of the facility required testing of the battery-powered emergency lighting system at 30 day intervals for not less than 30 seconds.

2. No documentation was available during record review of the facility required annual testing of the battery-powered emergency lighting system for not less than 1 ½ hours

The Maintenance Director acknowledge the required testing of the emergency lighting during the tour of the facility.

Life Safety Code, Section 7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30 day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 ½ hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

K-0050
Based on record review during the survey, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.2 and 4.7. This deficient practice could affect residents when staff are not trained in the emergency actions required during unusual condition that can occur in an actual emergency. This was evidenced by the following:

Fire drills were not conducted as follows:
1) No fire drills conducted on the 1st shift third quarter.
2) No fire drills conducted on the 3rd shift first quarter.

The Director of Facility Maintenance and Maintenance Director acknowledge the conditions of fire drills deficiency during record review of the facility.

Life Safety Code, Section 19.7.1.2 requires, in part, that fire drills be conducted quarterly on each shift to familiarize personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 pm and 6:00 am, a coded announcement shall be permitted to be used instead of audible alarms. Section 4.7.5 requires that drills be held unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.

K-0062
Based on observation, staff interview and record review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13 and Standard 25. This deficient practice could affect all residents, staff and visitors should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant maintenance. This was evidence by the following.

1) Locate on the sprinkler riser #2 the gauges are past their 5 year maintenance, last maintenance was
performed in 2008.
2) Riser gauge #2, bottom gauge missing cover lens and appears to be non-functional.

The Maintenance Director acknowledge the lack of maintenance and testing of the automatic sprinkler system deficiency during record review of the facility.

NFPA 101Life Safety Code Standards required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

K-0069
During the review of the facility records, with the staff, documentation was not available to confirm that the facility had a kitchen-hood-exhaust-system cleaning schedule as required by NFPA 96, (Chapter 8, Section 8-3). This deficient practice could affect all residents, and staff should a fire occur due to grease build-up in the exhaust system and fail to operate effectively due to non-code compliant cleaning and maintenance. This was evidence by the following.

No documentation of the kitchen exhaust system being cleaned, the last documented cleaning of the exhaust system was August 2001.

The Maintenance Director acknowledge the lack of cleaning of the system, and stated they were having trouble with locating a cleaning company to service the area during record review.

NFPA 96, Chapter 8, Section 8-3.1 Hoods, grease removal devices, fans, ducts and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surface becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire system shall be inspected by a properly trained, qualified and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1.

K-70
Based on observation and staff interview it was determined that the facility failed to maintain fire safe environment in the Administration Offices. This deficient practice could affect all patients, staff and visitors should a fire occur by the non-rated space heaters. This was evidence by the following.

Located in the following areas undocumented space heaters were being utilized as a primary heat source.
1) 5- Undocumented spaces heater in Business office.
2) 1- Undocumented space heater in Medical Record office.
3) 1- Undocumented space heater in Doctors sleep area.

The Maintenance Director acknowledge the deficiency of the prohibited space heaters during the facility tour.

Life Safety Code, Section 19.7.8. Portable space-heating devices shall be prohibited in all heath care occupancies. Exception: Portable space-heating devices shall be permitted to be used in non-sleeping staff and employee ' s areas where the heating elements of such devices do not exceed 212° F (100° C).

K0074
Through observation and record review during the survey, it was determined that the facility failed to provide curtains that comply with NFPA 701 in all areas. This deficient practice could affect all patients, staff and visitors should a fire occur by the non-rated curtains. This was evidence by the following.

(1) Emergency Room, Exam rooms 1, 2, and 3 has undocumented, untreated or tagged draperies.
(2) Mammography room had (1) undocumented, untreated or tagged drapery.

The Maintenance Director acknowledge the deficiency of the draperies during the facility tour.

Life Safety Code, Section 10.3.1. Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decoration shall be flame resistant as demonstrated by testing in accordance with NFPA 701, standards Methods of Fire test for Flame Propagation of Textiles and Films.

K-144
Based on observation, staff interview, during the course of the survey, it was determined that the facility failed to maintain emergency power systems in accordance with section 19.2.9.1 of the Life safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems 1999 edition Chapter 3 and 5 This deficient practice has the potential to affect all residents, staff and visitors in the event of power loss. . This was evidence by the following.


The facility failed to maintain the emergency power system:

(a) The diesel fueled emergency generator failed to have a remote alarm annunciator in a location readily observed by operating personnel. Per 19.2.9.1, 7.9.2.3 and 2000 Edition of NFPA 110 section 3-5.6.1 " A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2(d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel. "

(b) Generator was not equipped with battery-powered lighting. 5-3.1 The Level I and Level 2 EPS equipment location shall be provided with batty-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

The emergency power supply system deficiency item was discussed with the Maintenance Director during the tour of the facility.

K-0211

Based on observation and staff interview, it was determined that the facility failed to provide a safe location to install Alcohol Base Hand Rub dispenser in accordance with Life Safety Code Chapter 19, Section 19.3.2.7(6). This deficient practice could affect all residents should an electrical fault occur igniting the dispenser.

During the walkthrough of the facility, with the Maintenance Director, alcohol based hand rub dispensers (ABHR) were located above an electrical igniting source in the following areas.

Residents rooms; 103, 104, 105, 107, 108, 109, 110, 111, 112, 119, 121, 122, 123, 124, 125, 126, 127, 128 and X-ray room.

The Administrator and Maintenance Director acknowledged the (ABHR) location during a tour of the facility.

Life Safety Code Chapter 19, Section 19.3.2.7(6) "The dispensers shall not be installed over or directly adjacent to an ignition source."

K-0018
Based on observation and staff interview during the survey, it was determined that the facility failed to maintained corridor doors in accordance with Life Safety Code Section 19.3..3 This deficient practice could affect all residents and staff in the Emergency wing core smoke compartment by allowing the spread of fire and smoke to the adjoining compartments. This was evidenced by the following:

Corridor doors were not maintained to close and positively latch, as required.
CT-Scan Room, the door latching mechanism was non-functional and would not latch into the door frame.

The Maintenance Director acknowledge the door condition during the tour of the facility.

Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as those constructed of 1 3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Doors are provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are permitted.

K-0021
Based on observation and staff interview during the survey, it was determined that the facility failed to arrange doors protecting hazardous areas to automatically close upon activation of the fire alarm system in accordance with Life Safety Code Section 19.3.2.6 This deficient practice could affect all residents through-out the core smoke compartments by allowing the spread of fire and smoke to the adjoining compartments. This was evidenced by the following:

1) Room 82 the door closer arm has been disconnected from the self-closing device.
2) Trauma Room located in the ER, the door closer arm has been disconnected from the self-closing device.

The Maintenance Director acknowledge the condition of the door closers during the tour of the facility.

Life Safety Code, Section 19.3.2.1 hazards Areas. Any hazardous area shall be safeguarded by fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the area shall be separated from other spaces by smoke-resistive partitions and doors. The doors shall be self-closing or automatic-closing.

K-0046
Based on record review and staff interviews of the emergency lighting, the battery-powered emergency lights have not been monthly and annually tested in accordance with Life Safety Code, Section 7.9.3 and 19.2.9.1. This deficient practice could affect all residents and staff throughout the facility in the event of the loss of primary power. This was evidenced by the following:
1. No documentation was available during record review of the facility required testing of the battery-powered emergency lighting system at 30 day intervals for not less than 30 seconds.

2. No documentation was available during record review of the facility required annual testing of the battery-powered emergency lighting system for not less than 1 ½ hours

The Maintenance Director acknowledge the required testing of the emergency lighting during the tour of the facility.

Life Safety Code, Section 7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30 day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 ½ hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

K-0050
Based on record review during the survey, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.2 and 4.7. This deficient practice could affect residents when staff are not trained in the emergency actions required during unusual condition that can occur in an actual emergency. This was evidenced by the following:

Fire drills were not conducted as follows:
1) No fire drills conducted on the 1st shift third quarter.
2) No fire drills conducted on the 3rd shift first quarter.

The Director of Facility Maintenance and Maintenance Director acknowledge the conditions of fire drills deficiency during record review of the facility.

Life Safety Code, Section 19.7.1.2 requires, in part, that fire drills be conducted quarterly on each shift to familiarize personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 pm and 6:00 am, a coded announcement shall be permitted to be used instead of audible alarms. Section 4.7.5 requires that drills be held unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.

K-0062
Based on observation, staff interview and record review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13 and Standard 25. This deficient practice could affect all residents, staff and visitors should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant maintenance. This was evidence by the following.

1) Locate on the sprinkler riser #2 the gauges are past their 5 year maintenance, last maintenance was
performed in 2008.
2) Riser gauge #2, bottom gauge missing cover lens and appears to be non-functional.

The Maintenance Director acknowledge the lack of maintenance and testing of the automatic sprinkler system deficiency during record review of the facility.

NFPA 101Life Safety Code Standards required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

K-0069
During the review of the facility records, with the staff, documentation was not available to confirm that the facility had a kitchen-hood-exhaust-system cleaning schedule as required by NFPA 96, (Chapter 8, Section 8-3). This deficient practice could affect all residents, and staff should a fire occur due to grease build-up in the exhaust system and fail to operate effectively due to non-code compliant cleaning and maintenance. This was evidence by the following.

No documentation of the kitchen exhaust system being cleaned, the last documented cleaning of the exhaust system was August 2001.

The Maintenance Director acknowledge the lack of cleaning of the system, and stated they were having trouble with locating a cleaning company to service the area during record review.

NFPA 96, Chapter 8, Section 8-3.1 Hoods, grease removal devices, fans, ducts and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surface becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire system shall be inspected by a properly trained, qualified and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1.

K-70
Based on observation and staff interview it was determined that the facility failed to maintain fire safe environment in the Administration Offices. This deficient practice could affect all patients, staff and visitors should a fire occur by the non-rated space heaters. This was evidence by the following.

Located in the following areas undocumented space heaters were being utilized as a primary heat source.
1) 5- Undocumented spaces heater in Business office.
2) 1- Undocumented space heater in Medical Record office.
3) 1- Undocumented space heater in Doctors sleep area.

The Maintenance Director acknowledge the deficiency of the prohibited space heaters during the facility tour.

Life Safety Code, Section 19.7.8. Portable space-heating devices shall be prohibited in all heath care occupancies. Exception: Portable space-heating devices shall be permitted to be used in non-sleeping staff and employee ' s areas where the heating elements of such devices do not exceed 212° F (100° C).

K0074
Through observation and record review during the survey, it was determined that the facility failed to provide curtains that comply with NFPA 701 in all areas. This deficient practice could affect all patients, staff and visitors should a fire occur by the non-rated curtains. This was evidence by the following.

(1) Emergency Room, Exam rooms 1, 2, and 3 has undocumented, untreated or tagged draperies.
(2) Mammography room had (1) undocumented, untreated or tagged drapery.

The Maintenance Director acknowledge the deficiency of the draperies during the facility tour.

Life Safety Code, Section 10.3.1. Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decoration shall be flame resistant as demonstrated by testing in accordance with NFPA 701, standards Methods of Fire test for Flame Propagation of Textiles and Films.

K-144
Based on observation, staff interview, during the course of the survey, it was determined that the facility failed to maintain emergency power systems in accordance with section 19.2.9.1 of the Life safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems 1999 edition Chapter 3 and 5 This deficient practice has the potential to affect all residents, staff and visitors in the event of power loss. . This was evidence by the following.


The facility failed to maintain the emergency power system:

(a) The diesel fueled emergency generator failed to have a remote alarm annunciator in a location readily observed by operating personnel. Per 19.2.9.1, 7.9.2.3 and 2000 Edition of NFPA 110 section 3-5.6.1 " A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2(d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel. "

(b) Generator was not equipped with battery-powered lighting. 5-3.1 The Level I and Level 2 EPS equipment location shall be provided with batty-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

The emergency power supply system deficiency item was discussed with the Maintenance Director during the tour of the facility.