HospitalInspections.org

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Based on the observation of all the corridor doors on 03/29/2016, the facility failed to provide positive latching hardware for a corridor door. Findings include:

The sliding glass corridor door for Cardiac Room 500 did not have positive latching hardware.

The deficiency impacted 1 of 3 smoke compartments.
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Review of 2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.

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Based on the observation of the corridor doors on 03/29/2016, the facility failed to provide positive latching hardware for the following corridor doors. Findings include:

1. The entrance to the Therapy Suite, two corridor doors did not have positive latching hardware.
2. The Gift Shop store front corridor door doors did not have positive latching hardware.

The deficiency impacted 1 of 2 smoke compartments.
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Review of 2000 NFPA 101, 18.3.6.3.2 Doors shall be provided with positive latching hardware. Roller latches shall be prohibited.

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Based on the observation of the means of egress on 03/29/2016, the facility failed to provide continuous illumination of a means of egress. Findings include:

The illumination of the means of egress at room 216 was not continuous, it was observed wired to a switch at the exit door. The illumination of the means of egress was capable of being switched off.

The deficiency impacted 1 of 3 smoke compartments.
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Review of 2000 NFPA 101, 19.2.8 Means of egress shall be illuminated in accordance with Section 7.8.

Review of 2000 NFPA 101, 7.8.1.2 Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use. Artificial lighting shall be employed at such locations and for such periods of time as required to maintain the illumination to the minimum criteria values herein specified.
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Based on the observation of the automatic sprinkler pipes on 03/29/2016, the facility failed to prohibit external loads from either resting on the pipe or hung from the pipe and maintaining the gauges on the sprinkler system. Findings include:

1. The Outside Boiler Room was observed with the following items either resting on the pipe or hung from the pipe:
a. A natural gas pipe going to the water heater
b. An approximately 4" electrical conduit going to the electrical panel


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2. Above the ceiling at the firewall near pharmacy a group of black wires were observed resting on the sprinkle branch lines.

3. Above the ceiling in the Bibb medical associates hallway an a/c duct line was observed resting on the sprinkler branch lines near the control doors.

4. Above the ceiling in the x-ray hallway a group of wires were observed resting on the sprinkler branch line.

5. Two gauges were observed dated 2010 on the sprinkler riser located in the sprinkler riser room.

The deficiency impacted 2 of 3 smoke compartments.
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2000 NFPA 101, 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.

NFPA 25, 2-2.2* Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.

1998 NFPA 25, 2-3.2* Gauges.
Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.
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Based on observation on 03/29/2016 the facility failed to maintain the fire sprinkler piping free of external loads by materials either resting on the pipe or hung from the pipe. Findings Include:

Above the ceiling in the hospital business hallway a wire from a light fixture was observed attached to the sprinkler branch line holding the light fixture in place.

This deficiency impacted 1 of 3 smoke compartments.
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2000 NFPA 101, 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.

NFPA 25, 2-2.2* Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
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Based on the observation of the windowless C-Section Room and interviews on 03/29/2016, the facility failed to provide an automatic smoke venting system in the anesthetizing locations and a system which prevents recirculation of smoke. Findings include:

The new windowless C-Section Room was observed with the following:
1. The exhaust fan for the smoke venting system which was controlled by a wall toggle switch on the back wall instead of operating automatically to vent smoke and products of combustion from the area.
2. The return side of the HVAC Unit continued to operate during the testing of the smoke ventilation system in the windowless C-Section Rooms.


The deficiency impacted 1 of 2 smoke compartments.
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Review of 1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.

Review of 1999 NFPA 99, 5-4.1.3 Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.

Review of 1999 NFPA 99, 5-4.1.4 The electric supply to the ventilating system shall be served by the equipment system of the essential electrical system specified in Chapter 3, " Electrical Systems. "

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Based on observation on 03/29/2016 the facility failed to maintain the electrical wiring in accordance with the National Electrical Code (NFPA 70). Findings include

1. The Nurse Practioner's Office was observed with a refrigerator plugged into an extension cord.


36148


2. Open spaces were observed in the electrical panel boxes in the following locations:

a. The generator transfer switch room in electrical panel box RP-LS.

b. The outside O.R. air handler room in electrical panel box PA.

c. In the kitchens electrical panel box Rp-K section 2.

This deficiency impacted 2 of 3 smoke compartments.
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Review of the printed statement on the 2567 for K- 147, Electrical wiring and equipment shall be in accordance with National Electrical Code (NFPA 70).

Review of 2000 NFPA 101, 9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

Review of 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

2000 NFPA 101, 9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

1999 NFPA 70, 373-4. Unused Openings Unused openings in enclosures within the scope of this article shall be effectively closed to afford protection substantially equivalent to that of the enclosures within the scope of this article. Where metal plugs or plates are used with nonmetallic cabinets or cutout boxes, they shall be recessed at least ¼ in. (6.35 mm) from the outer surface.
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Based on observation on 03/29-30/2016 the facility failed to maintain the electrical wiring in accordance with the National Electrical Code (NFPA 70). Findings include:

1. Above the the ceiling at the front hall at the outpatient entrance 2, two electrical junction boxes were observed missing their covers on 03/29/2016.

2. On 03/30/2016 the gift shop was observed using a 3-way electrical adapter.

This deficiency impacted 1 of 3 smoke compartments.
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Review of the printed statement on the 2567 for K- 147, Electrical wiring and equipment shall be in accordance with National Electrical Code (NFPA 70).

2000 NFPA 101, 9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

1999 NFPA 70, 370-28. (c) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110.
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Based on the observation of all the corridor doors on 03/29/2016, the facility failed to provide positive latching hardware for a corridor door. Findings include:

The sliding glass corridor door for Cardiac Room 500 did not have positive latching hardware.

The deficiency impacted 1 of 3 smoke compartments.
______________

Review of 2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.

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Based on the observation of the corridor doors on 03/29/2016, the facility failed to provide positive latching hardware for the following corridor doors. Findings include:

1. The entrance to the Therapy Suite, two corridor doors did not have positive latching hardware.
2. The Gift Shop store front corridor door doors did not have positive latching hardware.

The deficiency impacted 1 of 2 smoke compartments.
______________

Review of 2000 NFPA 101, 18.3.6.3.2 Doors shall be provided with positive latching hardware. Roller latches shall be prohibited.

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Based on the observation of the means of egress on 03/29/2016, the facility failed to provide continuous illumination of a means of egress. Findings include:

The illumination of the means of egress at room 216 was not continuous, it was observed wired to a switch at the exit door. The illumination of the means of egress was capable of being switched off.

The deficiency impacted 1 of 3 smoke compartments.
______________

Review of 2000 NFPA 101, 19.2.8 Means of egress shall be illuminated in accordance with Section 7.8.

Review of 2000 NFPA 101, 7.8.1.2 Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use. Artificial lighting shall be employed at such locations and for such periods of time as required to maintain the illumination to the minimum criteria values herein specified.
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Based on the observation of the automatic sprinkler pipes on 03/29/2016, the facility failed to prohibit external loads from either resting on the pipe or hung from the pipe and maintaining the gauges on the sprinkler system. Findings include:

1. The Outside Boiler Room was observed with the following items either resting on the pipe or hung from the pipe:
a. A natural gas pipe going to the water heater
b. An approximately 4" electrical conduit going to the electrical panel


36148


2. Above the ceiling at the firewall near pharmacy a group of black wires were observed resting on the sprinkle branch lines.

3. Above the ceiling in the Bibb medical associates hallway an a/c duct line was observed resting on the sprinkler branch lines near the control doors.

4. Above the ceiling in the x-ray hallway a group of wires were observed resting on the sprinkler branch line.

5. Two gauges were observed dated 2010 on the sprinkler riser located in the sprinkler riser room.

The deficiency impacted 2 of 3 smoke compartments.
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2000 NFPA 101, 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.

NFPA 25, 2-2.2* Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.

1998 NFPA 25, 2-3.2* Gauges.
Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.
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Based on observation on 03/29/2016 the facility failed to maintain the fire sprinkler piping free of external loads by materials either resting on the pipe or hung from the pipe. Findings Include:

Above the ceiling in the hospital business hallway a wire from a light fixture was observed attached to the sprinkler branch line holding the light fixture in place.

This deficiency impacted 1 of 3 smoke compartments.
____________________

2000 NFPA 101, 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.

NFPA 25, 2-2.2* Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
.

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Based on the observation of the windowless C-Section Room and interviews on 03/29/2016, the facility failed to provide an automatic smoke venting system in the anesthetizing locations and a system which prevents recirculation of smoke. Findings include:

The new windowless C-Section Room was observed with the following:
1. The exhaust fan for the smoke venting system which was controlled by a wall toggle switch on the back wall instead of operating automatically to vent smoke and products of combustion from the area.
2. The return side of the HVAC Unit continued to operate during the testing of the smoke ventilation system in the windowless C-Section Rooms.


The deficiency impacted 1 of 2 smoke compartments.
______________

Review of 1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.

Review of 1999 NFPA 99, 5-4.1.3 Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.

Review of 1999 NFPA 99, 5-4.1.4 The electric supply to the ventilating system shall be served by the equipment system of the essential electrical system specified in Chapter 3, " Electrical Systems. "

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Based on observation on 03/29/2016 the facility failed to maintain the electrical wiring in accordance with the National Electrical Code (NFPA 70). Findings include

1. The Nurse Practioner's Office was observed with a refrigerator plugged into an extension cord.


36148


2. Open spaces were observed in the electrical panel boxes in the following locations:

a. The generator transfer switch room in electrical panel box RP-LS.

b. The outside O.R. air handler room in electrical panel box PA.

c. In the kitchens electrical panel box Rp-K section 2.

This deficiency impacted 2 of 3 smoke compartments.
___________________________
Review of the printed statement on the 2567 for K- 147, Electrical wiring and equipment shall be in accordance with National Electrical Code (NFPA 70).

Review of 2000 NFPA 101, 9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

Review of 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

2000 NFPA 101, 9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

1999 NFPA 70, 373-4. Unused Openings Unused openings in enclosures within the scope of this article shall be effectively closed to afford protection substantially equivalent to that of the enclosures within the scope of this article. Where metal plugs or plates are used with nonmetallic cabinets or cutout boxes, they shall be recessed at least ¼ in. (6.35 mm) from the outer surface.
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Based on observation on 03/29-30/2016 the facility failed to maintain the electrical wiring in accordance with the National Electrical Code (NFPA 70). Findings include:

1. Above the the ceiling at the front hall at the outpatient entrance 2, two electrical junction boxes were observed missing their covers on 03/29/2016.

2. On 03/30/2016 the gift shop was observed using a 3-way electrical adapter.

This deficiency impacted 1 of 3 smoke compartments.
___________________________
Review of the printed statement on the 2567 for K- 147, Electrical wiring and equipment shall be in accordance with National Electrical Code (NFPA 70).

2000 NFPA 101, 9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

1999 NFPA 70, 370-28. (c) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110.
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