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Based on observation, it was determined the facility failed to ensure required signage for exit egress were installed.


Findings:


On 07/19/2016, at 10:50 a.m., access to a unlocked single door with a one sided deadbolt lock leading into the center closed-in courtyard of the facility was not labled with exit signage. There was no visible sign indicating it was or was not an approved exit. In the event of a fire and/or other emergency the door may be used by visitors, patients and/or facility staff.


NFPA 101, 2000 Edition
Chapter 7
7.10.8 Special Signs.
7.10.8.1* No Exit.

Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows: NO EXIT

Such sign shall have the word NO in letters 2 in. (5 cm) high with a stroke width of 3/8 in. (1 cm) and the word EXIT in letters 1 in. (2.5 cm) high, with the word EXIT below the word NO.


NFPA 101, 2000 Edition
Chapter 19
Section 2.10.1

Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants. Doors, passages or stairways that are not a way of exit that are likely to be mistaken for an exit have a sign designating "No Exit".

Based on observation, it was determined the facility failed to ensure facility smoke/fire barriers were protected.


Findings:


On 07/14/2016m at 09:53 a.m., 5 penetrations were observed in the fire wall near the physical therapy department.


At 10:14 a.m., 8 penetrations were observed in the fire wall near emergency room #4.


At 10:39 a.m., 4 penetrations were observed to be in the fire wall near the maintenance/engineering breaker box closet.

Based on observation, it was determined the facility failed to ensure doorstops, sand bags and/or wedges were not used.


Findings:


On 07/12/2016, at 14:50, a tour of the facility was conducted. On tour, it was observed that wood wedges, rubber wedges, and sand bags were in use throughout the facility to hold corridor doors open.

Based on observation, it was determined the facility failed to ensure hazardous areas within the facility were protected.

Findings:

On 07/12/16, at 14:57, in the x-ray department, a room was repurposed into storage for x-ray acetates. Several wooden 4 shelve racks were observed to have paper folders with x-ray acetates stored. The door leading to the area did not have self-closing hardware. An open area leading into the x-ray office did not have a door with self-closing hardware room. A 50 gallon plastic drum was observed to be half filled with x-ray acetates.

At 15:03, the patient dressing room in the x-ray department appeared to be repurposed into a storage closet. In this patient dressing room a broken ceiling exhaust fan and broken light fixture base that would allow fire and smoke into attic space of the facility was observed.


At 15:23, the housekeeping closet in the x-ray department had no self-closing hardware, and would not positively latch.


On 07/13/2016, at 12:57 p.m., on tour of the facility boiler room a 5 gallon bucket of weatherall paint and a stack of several air filters were observed stored.


On 07/14/2016, at 10:55 a.m., on inspection of the auxillary storage closet a propane tank was observed to be stored in the closet.

Based on observation, it was determined the facility failed to ensure keyed locks, dead bolt locks and multi latching devices did not impede egress from habitable spaces.


Findings:


On 07/13/2016, at 09:46 a.m., a roller latch was observed on the door leading from the endoscopic procedure room to the dual sink scrub room.


At 09:48 a.m., a roller latch was observed on the door leading from the operating room to the dual sink scrub room.


At 09:49 a.m., dead bolt locks were observed to be installed on the doors of the operating room and the endoscopic procedure room.


At 10:00 a.m., dead bolt locks were observed to be on the door to the old PACU room now being used for storage.


NFPA 101, 2000 Edition
Chapter 7 Means of Egress
7.2 Means of Egress Components
7.2.1.5 Locks, Latches, and Alarm Devices.
7.2.1.5.1

Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.

Based on observation, staff interview, and record review it was determined the facility failed to ensure battery powered back-up emergency lighting was inspected and maintained.


Findings:


On 07/12/2016, at 15:32, kitchen staff advised the battery backed-up emergency light near the kitchen vent hood had not worked for some time.


At 15:36, the battery backed-up emergency lighting inspection log was requested and not provided. No documentation reviewed could confirm that the emergency lights were tested for 30 seconds each month, and 90 minutes each year.


On 07/12/2016, during the tour of the facility, staff could not identify which lights throughout the hospital corridors, at exit access, and exit discharge were on emergency generator power.



NFPA 101, 2000 Edition
Chapter 7 Means of Egress
7.9 Emergency Lighting
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 11/2 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.

Based on observation and record review, it was determined the facility failed to ensure their fire alarm system was maintained in accordance with NFPA 70 National Electric Code and NFPA 72 National fire Alarm Code.


Findings:


On 07/12/2016, at 16:11, the fire alarm control panel was observed to be yellow tagged. The yellow tag was placed on the FACP on 06/16/2016 by Mac Systems for the following impairments: 1) AHU #3 duct detector defective 2) pull station at the central sprinkler room exit not working/signaling 3) duct detector in sprinkler riser room by ladder to roof not working/signaling.


A yellow tag was observed to be in place on the prior inspection of the FACP dated 02/24/2015 for one impairment: 1) batteries 4 years old.



NFPA 70
NFPA 72

A fire alarm system required for life safety shall be, tested, and maintained in accordance with NFPA 70 National Electric Code and NFPA 72 National Fire Alarm Code and records kept readily available. The system shall have an approved maintenance and testing program complying with applicable requirement of NFPA 70 and 72. 9.6.1.4, 9.6.1.7,

Based on record review, it was determined the faclity failed to ensure all smoke detectors were inspected and maintained.


Findings:


On 07/12/2016, the smoke detector inspection reports were requested and not provided.

Based on observation and record review, it was determined the facility failed to ensure their automatic sprinkler system is inspected, continuosly maintained and tested periodically.


Findings:


On 07/12/2016, the annual automatic sprinkler inspection report was requested and not provided.


NFPA 25
Chapter 9
Section 7.5

Required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, NFPA 25,


NFPA 101, 2000 Edition
Chapter 19.7.6 Maintenance and Testing.
(See 4.6.12.)
4.6.12 Maintenance and Testing.
4.6.12.1

Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

4.6.12.2*

Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

4.6.12.3

Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.

4.6.12.4

Maintenance and testing shall be under the supervision of a responsible person who shall ensure that testing and maintenance are made at specified intervals in accordance with applicable NFPA standards or as directed by the authority having jurisdiction.



Based on observation, it was determined the facility failed to ensure escutcheons were in place.

Findings:

On 07/12/16, at 14:57, in the x-ray department a room was repurposed into storage for x-ray acetates. The sprinkler heads in this area did not have escutheons.

Based on observation and record review, it was determined the facility failed to ensure fire extinguishers were tested and maintained annually.

Findings:


On 07/12/2016, at 15:20, the annual inspection reports for the facility's fire extinguishers was requested and not provided. It was observed the facility fire extinguishers had tags that were out of date.

Based on observation and staff interview, the facility failed to ensure air quality was being monitored and documented, and the facility failed to provide and ensure heating, ventilating, and air-conditioning systems complied with the manufacturer's specifications and recommendations.


Findings:


On 07/12/15, at 9:59 a.m., the operating rooms air filter quality logs were not available when requested. Airflow manometer readings were not being recorded or documented. The airflow quality of the life of the final filters were not being documented or maintained.


On 07/19/16, at 12:57 p.m., test and balance report(s) for the facility were not provided on request from the surveyor.


At 10:00 a.m., the director of facility maintenance was interviewed. The physical plant manager was asked for the documentation of airflow quality for the operating rooms. He said the HVAC filters that serve the operating rooms are changed on observation and periodically. He stated he did not document manometer readings.


On 07/14/16, at 15:35, the exhaust vent in the soiled utility room in the emergency departments had no mechanical exhaust vent to provide a negative airflow area for the area. The walls did not terminate at the roof deck.


On 07/14/16, the chief operating officer acknowledged there were no mechanical vents in soiled linen closet.


AIA Health Care Guidelines & ANI/ASHE Standard 170-208 Ventilation of Health Care Facilities requires the manometers to be used to determine the life of the filter. A 1.1 of ANI/ASHE Annex A states that filters shall be replaced on air pressure drop in accordance with the manometer readings.



Based on observation, staff interview, and record review, it was determined that the facility failed to ensure that inspection and maintenance of each of their operating rooms automatic smoke evacuation systems.


Findings:


On 07/12/16, at 10:56 a.m., the inspection reports for the facility's smoke evacuation systems were not provided when requested by the surveyor.


07/13/2016, at 09:40 a.m., a inspection label on each of the smoke evacuation systems in the surgical suite indicated a last inspection of 03/02/2015.

Based on observation and record review, it was determined the facility failed to ensure the facility's kitchen fire extinguishing system was properly installed.


Findings:


On 07/12/2016, at 15:39, a tour of the facility's kitchen was conducted. The hood extinguishing system was yellow tag with the impairment of having the wrong nozzels installed for the hood.


NFPA 96, 1998 Edition
Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations
Chapter 7 Fire-Extinguishing Equipment

Based on record review, it was determined the facility failed to ensure their medical gas systems was protected and inspected/maintained.


Findings:


On 07/12/2016, the medical gas maintenance and inspection reports were requested and not provided.



NFPA 101, 2000 Edition
Chapter 19
19.3.2.4 Medical Gas.

Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

Based on observation, it was determined the facility failed to ensure required signage for their medical gas storage area.


Findings:


On 07/12/2016, on inspection of the facility's medical gas storage no precautionary signage was observed.


NFPA 101, 2000 Edition
19.3.2.4 Medical Gas.

Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.


NFPA 99, 1999 Edition
Chapter 8
8-3.1.11 Storage Requirements.
8-3.1.11.1

Storage for nonflammable gases greater than 3000 ft3 (85 m3) shall comply with 4-3.1.1.2 and 4-3.5.2.2.


NFPA 99, 1999 Edition
Chapter 4
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement)


NFPA 99, 1999 Edition
4-3.5.2.2 Storage of Cylinders and Containers - Level 1

3. Cylinders stored in the open shall be protected against extremes of weather and from the ground beneath to prevent rusting. During winter, cylinders stored in the open shall be protected against accumulations of ice or snow. In summer, cylinders stored in the open shall be screened against continuous exposure to direct rays of the sun in those localities where extreme temperatures prevail.

Based on record review, it was determined the facility failed to ensure their emergency Type 1 generator was exercised under load for 30 minutes per month.


Findings:


On 07/12/2016, the monthly and annual generator inspection/exercise reports were requested. On review the monthly documentation indicated the facility tested under load the emergency generator for 15 minutes.


Generators inspected weekly and exercised under load for 30 minutes per month and shall be in accordance with NFPA 99 and NFPA 110.
3-4.4.1 and 8-4.2 (NFPA 99), Chapter 6 (NFPA 110)

Based on observation and staff interview, it was determined the facility failed to ensure temporary electrical wiring was not used in the facility.


Findings:


On 07/12/16, at 15:19, one power tap was observed to be in the x-ray office.


At 15:46, a power tap was observed to be in use on the counter top surface of the sink in the facility laboratory.


On 07/13/2016, at 10:31 a.m., a relocatable power tap was observed to be in use on a computer stored in the sterile supply room of the surgical suite.



Based on observation, it was determined the facility failed to ensure electrical receptacles near a water source were GFCI.


Findings:


On 07/12/16, at 16:04, a Hydrocollator was observed to be plugged into a non-GFCI electrical receptacle in the physical therapy room.



Based on observation, it was determined the facility failed to maintain closed junction boxes in the plenum space of the facility.


Findings:


On 07/12/16, at 14:20, in the plenum space above the drop ceiling above each of the magnetic locked fire barrier doors was observed to have 3 open junction boxes.


On 07/14/2016, at 10:39 a.m., 2 open junction boxes were observed to be in the drop down ceiling plenum space near the maintenance/engineering closet breaker box room.


On 07/12/16, the chief operating officer acknowledged the open junction boxes.


Based on observation and staff interview, it was determined the facility failed to ensure the kitchen thermostat was maintained.


Findings:


On 07/12/2016, at 15:37, the kitchen thermostat was observed to be missing and the wires connecting it where held together with two wires with alligator clips. There was a note taped to the wall beside the wires that instructed, "if you want to turn off and on... clamp the two wires that are twisted together "black clamp".


At 15:37, the cook stated the thermostat has been broken for 2 years.



Based on record review and staff interview it was determined the facility failed to ensure periodic testing and maintenance of the facility's 3 transfer switches.


Findings:


On 07/19/2016, 15:00, the inspection and maintenance reports for the facility's 3 transfer switches was requested and not provided.


At 15:00, the director of facility maintenance stated he has not had inspections done on the 3 generator transfer switches.



Based on observation and record review, it was determined the facility failed to ensure their Type 1 generator was inspected and maintained annually.


Findings:


On 07/12/2016, the annual Type 1 EES generator testing and inspection reports were requested and not provided.



Based on observation it was determined the facility failed to ensure current inspections on equipment in service.


Findings:


On 07/12/2016, at 15:47, an inspection label on the blood bank refrigerator was observed to be last inspected August 2015 and indicated a due date of November 2015.


Equipment in Laboratory:


On 07/12/2016, at 15:51, an inspection label on a Jordan double wide refrigerator indicated it was last inspected on May 2015 and due May 2016.


At 15:53, an inspection label on a refrigerator indicated it was last inspected on May 2015 and due on May 2016.


At 15:54, an inspection label on a hot point freezer indicated it was last inspected on May 2015 and due on May 2016.


On 07/12/2016, at 15:54, a inspection label on a Fisher Bacti incubator indicated it was last inspected on May 2015 and due on May 2016.


At 15:57, an inspection label on a plasma freezer indicated it was last inspected on August 2015 and due on Jan 2016.



Equipment in physical therapy room:


On 07/12/2016, at 16:04, an inspection label on a Hydrocullator indicated it was last inspected on Jan 2015 and due on Jan 2016.



Based on observation it was determined the facility failed to ensure the following equipment was inspected and maintained within the operating suite.


Findings:


On 07/13/2016, at 09:45 a.m., an inspection label on the LCD monitor in the endoscopic procedure room indicated it was last inspected on May 2015 and due May 2016.


At 09:45 a.m., an inspection label on an electronic vital signs machine indicated it was last inspected on November 2014 and due on November 2015.


At 09:50 a.m., an inspection label located on a power strip in use in the endoscopic procedure room indicated it was last inspected on Feb 2014 and due on Feb 2015.


At 10:20 a.m., an inspection label on the mindray gas module SE in the operating room on the anesthesia machine indicated it was last inspected on October 2013 and due October 2014.


At 10:22 a.m., an inspection label on the bear hugger unit model 505 in the operating room indicated it was last inspected on September 2015 and due on March 2016.


On 07/13/2016 at 10:24 a.m., an inspection label on a power strip located in the operating room indicated it was last inspected on January 2015 and due Feb. 2015.


At 10:43 a.m., an certificate of inspection from the department of labor indicated the sterilizer located in the surgical suite was last inspected on March 1, 2012 and due on Jan 31, 2013.


At 10:49 a.m., an inspection label on the Valleylab force 2 electrosurgical generator located in the endoscopic procedure room indicated it was last inspected on May 2, 2010.

Based on observation, it was determined the facility failed to ensure alcohol based hand rub dispensers (ABHR) were properly installed.


Findings:


On 07/13/2016, at 09:55 a.m., an ABHR was observed to be installed over a light switch in the dual scrub sink room in between the operating room and endoscopic procedure room within the surgical suite.


At 09:59 a.m., an ABHR was observed to be installed over the light switch in the old PACU room that is now being used as storage.


CFR 403.744, 418.110, 460.72, 482.41, 483.70, 485.623

Based on observation, it was determined the facility failed to ensure required signage for exit egress were installed.


Findings:


On 07/19/2016, at 10:50 a.m., access to a unlocked single door with a one sided deadbolt lock leading into the center closed-in courtyard of the facility was not labled with exit signage. There was no visible sign indicating it was or was not an approved exit. In the event of a fire and/or other emergency the door may be used by visitors, patients and/or facility staff.


NFPA 101, 2000 Edition
Chapter 7
7.10.8 Special Signs.
7.10.8.1* No Exit.

Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows: NO EXIT

Such sign shall have the word NO in letters 2 in. (5 cm) high with a stroke width of 3/8 in. (1 cm) and the word EXIT in letters 1 in. (2.5 cm) high, with the word EXIT below the word NO.


NFPA 101, 2000 Edition
Chapter 19
Section 2.10.1

Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants. Doors, passages or stairways that are not a way of exit that are likely to be mistaken for an exit have a sign designating "No Exit".

Based on observation, it was determined the facility failed to ensure facility smoke/fire barriers were protected.


Findings:


On 07/14/2016m at 09:53 a.m., 5 penetrations were observed in the fire wall near the physical therapy department.


At 10:14 a.m., 8 penetrations were observed in the fire wall near emergency room #4.


At 10:39 a.m., 4 penetrations were observed to be in the fire wall near the maintenance/engineering breaker box closet.

Based on observation, it was determined the facility failed to ensure doorstops, sand bags and/or wedges were not used.


Findings:


On 07/12/2016, at 14:50, a tour of the facility was conducted. On tour, it was observed that wood wedges, rubber wedges, and sand bags were in use throughout the facility to hold corridor doors open.

Based on observation, it was determined the facility failed to ensure hazardous areas within the facility were protected.

Findings:

On 07/12/16, at 14:57, in the x-ray department, a room was repurposed into storage for x-ray acetates. Several wooden 4 shelve racks were observed to have paper folders with x-ray acetates stored. The door leading to the area did not have self-closing hardware. An open area leading into the x-ray office did not have a door with self-closing hardware room. A 50 gallon plastic drum was observed to be half filled with x-ray acetates.

At 15:03, the patient dressing room in the x-ray department appeared to be repurposed into a storage closet. In this patient dressing room a broken ceiling exhaust fan and broken light fixture base that would allow fire and smoke into attic space of the facility was observed.


At 15:23, the housekeeping closet in the x-ray department had no self-closing hardware, and would not positively latch.


On 07/13/2016, at 12:57 p.m., on tour of the facility boiler room a 5 gallon bucket of weatherall paint and a stack of several air filters were observed stored.


On 07/14/2016, at 10:55 a.m., on inspection of the auxillary storage closet a propane tank was observed to be stored in the closet.

Based on observation, it was determined the facility failed to ensure keyed locks, dead bolt locks and multi latching devices did not impede egress from habitable spaces.


Findings:


On 07/13/2016, at 09:46 a.m., a roller latch was observed on the door leading from the endoscopic procedure room to the dual sink scrub room.


At 09:48 a.m., a roller latch was observed on the door leading from the operating room to the dual sink scrub room.


At 09:49 a.m., dead bolt locks were observed to be installed on the doors of the operating room and the endoscopic procedure room.


At 10:00 a.m., dead bolt locks were observed to be on the door to the old PACU room now being used for storage.


NFPA 101, 2000 Edition
Chapter 7 Means of Egress
7.2 Means of Egress Components
7.2.1.5 Locks, Latches, and Alarm Devices.
7.2.1.5.1

Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.

Based on observation, staff interview, and record review it was determined the facility failed to ensure battery powered back-up emergency lighting was inspected and maintained.


Findings:


On 07/12/2016, at 15:32, kitchen staff advised the battery backed-up emergency light near the kitchen vent hood had not worked for some time.


At 15:36, the battery backed-up emergency lighting inspection log was requested and not provided. No documentation reviewed could confirm that the emergency lights were tested for 30 seconds each month, and 90 minutes each year.


On 07/12/2016, during the tour of the facility, staff could not identify which lights throughout the hospital corridors, at exit access, and exit discharge were on emergency generator power.



NFPA 101, 2000 Edition
Chapter 7 Means of Egress
7.9 Emergency Lighting
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 11/2 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.

Based on observation and record review, it was determined the facility failed to ensure their fire alarm system was maintained in accordance with NFPA 70 National Electric Code and NFPA 72 National fire Alarm Code.


Findings:


On 07/12/2016, at 16:11, the fire alarm control panel was observed to be yellow tagged. The yellow tag was placed on the FACP on 06/16/2016 by Mac Systems for the following impairments: 1) AHU #3 duct detector defective 2) pull station at the central sprinkler room exit not working/signaling 3) duct detector in sprinkler riser room by ladder to roof not working/signaling.


A yellow tag was observed to be in place on the prior inspection of the FACP dated 02/24/2015 for one impairment: 1) batteries 4 years old.



NFPA 70
NFPA 72

A fire alarm system required for life safety shall be, tested, and maintained in accordance with NFPA 70 National Electric Code and NFPA 72 National Fire Alarm Code and records kept readily available. The system shall have an approved maintenance and testing program complying with applicable requirement of NFPA 70 and 72. 9.6.1.4, 9.6.1.7,

Based on record review, it was determined the faclity failed to ensure all smoke detectors were inspected and maintained.


Findings:


On 07/12/2016, the smoke detector inspection reports were requested and not provided.

Based on observation and record review, it was determined the facility failed to ensure their automatic sprinkler system is inspected, continuosly maintained and tested periodically.


Findings:


On 07/12/2016, the annual automatic sprinkler inspection report was requested and not provided.


NFPA 25
Chapter 9
Section 7.5

Required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, NFPA 25,


NFPA 101, 2000 Edition
Chapter 19.7.6 Maintenance and Testing.
(See 4.6.12.)
4.6.12 Maintenance and Testing.
4.6.12.1

Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

4.6.12.2*

Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

4.6.12.3

Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.

4.6.12.4

Maintenance and testing shall be under the supervision of a responsible person who shall ensure that testing and maintenance are made at specified intervals in accordance with applicable NFPA standards or as directed by the authority having jurisdiction.



Based on observation, it was determined the facility failed to ensure escutcheons were in place.

Findings:

On 07/12/16, at 14:57, in the x-ray department a room was repurposed into storage for x-ray acetates. The sprinkler heads in this area did not have escutheons.

Based on observation and record review, it was determined the facility failed to ensure fire extinguishers were tested and maintained annually.

Findings:


On 07/12/2016, at 15:20, the annual inspection reports for the facility's fire extinguishers was requested and not provided. It was observed the facility fire extinguishers had tags that were out of date.

Based on observation and staff interview, the facility failed to ensure air quality was being monitored and documented, and the facility failed to provide and ensure heating, ventilating, and air-conditioning systems complied with the manufacturer's specifications and recommendations.


Findings:


On 07/12/15, at 9:59 a.m., the operating rooms air filter quality logs were not available when requested. Airflow manometer readings were not being recorded or documented. The airflow quality of the life of the final filters were not being documented or maintained.


On 07/19/16, at 12:57 p.m., test and balance report(s) for the facility were not provided on request from the surveyor.


At 10:00 a.m., the director of facility maintenance was interviewed. The physical plant manager was asked for the documentation of airflow quality for the operating rooms. He said the HVAC filters that serve the operating rooms are changed on observation and periodically. He stated he did not document manometer readings.


On 07/14/16, at 15:35, the exhaust vent in the soiled utility room in the emergency departments had no mechanical exhaust vent to provide a negative airflow area for the area. The walls did not terminate at the roof deck.


On 07/14/16, the chief operating officer acknowledged there were no mechanical vents in soiled linen closet.


AIA Health Care Guidelines & ANI/ASHE Standard 170-208 Ventilation of Health Care Facilities requires the manometers to be used to determine the life of the filter. A 1.1 of ANI/ASHE Annex A states that filters shall be replaced on air pressure drop in accordance with the manometer readings.



Based on observation, staff interview, and record review, it was determined that the facility failed to ensure that inspection and maintenance of each of their operating rooms automatic smoke evacuation systems.


Findings:


On 07/12/16, at 10:56 a.m., the inspection reports for the facility's smoke evacuation systems were not provided when requested by the surveyor.


07/13/2016, at 09:40 a.m., a inspection label on each of the smoke evacuation systems in the surgical suite indicated a last inspection of 03/02/2015.

Based on observation and record review, it was determined the facility failed to ensure the facility's kitchen fire extinguishing system was properly installed.


Findings:


On 07/12/2016, at 15:39, a tour of the facility's kitchen was conducted. The hood extinguishing system was yellow tag with the impairment of having the wrong nozzels installed for the hood.


NFPA 96, 1998 Edition
Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations
Chapter 7 Fire-Extinguishing Equipment

Based on record review, it was determined the facility failed to ensure their medical gas systems was protected and inspected/maintained.


Findings:


On 07/12/2016, the medical gas maintenance and inspection reports were requested and not provided.



NFPA 101, 2000 Edition
Chapter 19
19.3.2.4 Medical Gas.

Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

Based on observation, it was determined the facility failed to ensure required signage for their medical gas storage area.


Findings:


On 07/12/2016, on inspection of the facility's medical gas storage no precautionary signage was observed.


NFPA 101, 2000 Edition
19.3.2.4 Medical Gas.

Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.


NFPA 99, 1999 Edition
Chapter 8
8-3.1.11 Storage Requirements.
8-3.1.11.1

Storage for nonflammable gases greater than 3000 ft3 (85 m3) shall comply with 4-3.1.1.2 and 4-3.5.2.2.


NFPA 99, 1999 Edition
Chapter 4
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement)


NFPA 99, 1999 Edition
4-3.5.2.2 Storage of Cylinders and Containers - Level 1

3. Cylinders stored in the open shall be protected against extremes of weather and from the ground beneath to prevent rusting. During winter, cylinders stored in the open shall be protected against accumulations of ice or snow. In summer, cylinders stored in the open shall be screened against continuous exposure to direct rays of the sun in those localities where extreme temperatures prevail.

Based on record review, it was determined the facility failed to ensure their emergency Type 1 generator was exercised under load for 30 minutes per month.


Findings:


On 07/12/2016, the monthly and annual generator inspection/exercise reports were requested. On review the monthly documentation indicated the facility tested under load the emergency generator for 15 minutes.


Generators inspected weekly and exercised under load for 30 minutes per month and shall be in accordance with NFPA 99 and NFPA 110.
3-4.4.1 and 8-4.2 (NFPA 99), Chapter 6 (NFPA 110)

Based on observation and staff interview, it was determined the facility failed to ensure temporary electrical wiring was not used in the facility.


Findings:


On 07/12/16, at 15:19, one power tap was observed to be in the x-ray office.


At 15:46, a power tap was observed to be in use on the counter top surface of the sink in the facility laboratory.


On 07/13/2016, at 10:31 a.m., a relocatable power tap was observed to be in use on a computer stored in the sterile supply room of the surgical suite.



Based on observation, it was determined the facility failed to ensure electrical receptacles near a water source were GFCI.


Findings:


On 07/12/16, at 16:04, a Hydrocollator was observed to be plugged into a non-GFCI electrical receptacle in the physical therapy room.



Based on observation, it was determined the facility failed to maintain closed junction boxes in the plenum space of the facility.


Findings:


On 07/12/16, at 14:20, in the plenum space above the drop ceiling above each of the magnetic locked fire barrier doors was observed to have 3 open junction boxes.


On 07/14/2016, at 10:39 a.m., 2 open junction boxes were observed to be in the drop down ceiling plenum space near the maintenance/engineering closet breaker box room.


On 07/12/16, the chief operating officer acknowledged the open junction boxes.


Based on observation and staff interview, it was determined the facility failed to ensure the kitchen thermostat was maintained.


Findings:


On 07/12/2016, at 15:37, the kitchen thermostat was observed to be missing and the wires connecting it where held together with two wires with alligator clips. There was a note taped to the wall beside the wires that instructed, "if you want to turn off and on... clamp the two wires that are twisted together "black clamp".


At 15:37, the cook stated the thermostat has been broken for 2 years.



Based on record review and staff interview it was determined the facility failed to ensure periodic testing and maintenance of the facility's 3 transfer switches.


Findings:


On 07/19/2016, 15:00, the inspection and maintenance reports for the facility's 3 transfer switches was requested and not provided.


At 15:00, the director of facility maintenance stated he has not had inspections done on the 3 generator transfer switches.



Based on observation and record review, it was determined the facility failed to ensure their Type 1 generator was inspected and maintained annually.


Findings:


On 07/12/2016, the annual Type 1 EES generator testing and inspection reports were requested and not provided.



Based on observation it was determined the facility failed to ensure current inspections on equipment in service.


Findings:


On 07/12/2016, at 15:47, an inspection label on the blood bank refrigerator was observed to be last inspected August 2015 and indicated a due date of November 2015.


Equipment in Laboratory:


On 07/12/2016, at 15:51, an inspection label on a Jordan double wide refrigerator indicated it was last inspected on May 2015 and due May 2016.


At 15:53, an inspection label on a refrigerator indicated it was last inspected on May 2015 and due on May 2016.


At 15:54, an inspection label on a hot point freezer indicated it was last inspected on May 2015 and due on May 2016.


On 07/12/2016, at 15:54, a inspection label on a Fisher Bacti incubator indicated it was last inspected on May 2015 and due on May 2016.


At 15:57, an inspection label on a plasma freezer indicated it was last inspected on August 2015 and due on Jan 2016.



Equipment in physical therapy room:


On 07/12/2016, at 16:04, an inspection label on a Hydrocullator indicated it was last inspected on Jan 2015 and due on Jan 2016.



Based on observation it was determined the facility failed to ensure the following equipment was inspected and maintained within the operating suite.


Findings:


On 07/13/2016, at 09:45 a.m., an inspection label on the LCD monitor in the endoscopic procedure room indicated it was last inspected on May 2015 and due May 2016.


At 09:45 a.m., an inspection label on an electronic vital signs machine indicated it was last inspected on November 2014 and due on November 2015.


At 09:50 a.m., an inspection label located on a power strip in use in the endoscopic procedure room indicated it was last inspected on Feb 2014 and due on Feb 2015.


At 10:20 a.m., an inspection label on the mindray gas module SE in the operating room on the anesthesia machine indicated it was last inspected on October 2013 and due October 2014.


At 10:22 a.m., an inspection label on the bear hugger unit model 505 in the operating room indicated it was last inspected on September 2015 and due on March 2016.


On 07/13/2016 at 10:24 a.m., an inspection label on a power strip located in the operating room indicated it was last inspected on January 2015 and due Feb. 2015.


At 10:43 a.m., an certificate of inspection from the department of labor indicated the sterilizer located in the surgical suite was last inspected on March 1, 2012 and due on Jan 31, 2013.


At 10:49 a.m., an inspection label on the Valleylab force 2 electrosurgical generator located in the endoscopic procedure room indicated it was last inspected on May 2, 2010.