HospitalInspections.org

During the survey tour of 09/09/2014, between the hours of 1330 and 1600, while accompanied by the Quality and Safety Manager, through observation and staff interview, it was discovered that the facility has failed to maintain the construction requirements for the classification of construction. The facility has a Type V (III) classification by NFPA 220. This has the potential for the spread of smoke and fire into the structure in the event of a fire. These findings were acknowledged by the Quality and Safety Manager.

The findings include but are not limited to:

1. Med. Room N. Wing Nurses Station missing ceiling tile.
2. Med. Room N. Wing Nurses Station - penetrations around IT / Phone wires through wall.

During the survey tour of 09/09/2014, between the hours of 1330 and 1600, while accompanied by the Quality and Safety Manager, through observation and staff interview, it was discovered that the facility to maintain doors protecting corridor openings in other than required enclosures of vertical openings, exits or hazardous areas. This prevents the doors from resisting the passage of smoke due to doors failing to close and latch or being prevented from closing due to impediments being in the doors travel path. This could result in smoke passing into the corridor or into rooms in the event of a fire. These findings were acknowledged by the Quality and Safety Manager.

The findings include but are not limited to:

1. Kitchen Storage-Freezer - Icemaker Room - door binding, failed to properly close and latch when tested.

During the survey tour of 09/09/2014, between the hours of 1330 and 1600, while accompanied by the Quality and Safety Manager, through observation and staff interview, it was discovered that the facility failed to maintain the ability of doors to be held open only by devices arranged to automatically close such doors upon activation of the fire alarm. In the event of a fire, this would allow for the passage of smoke and/or flames into or out of the stairwell meant to be protected by self-closing doors. This finding was acknowledged by the Quality and Safety Manager.

The findings include but are not limited to:

1. Cross-Corridor fire doors from Acute Care Wing into Business Wing failed to close and latch when tested.

Based upon a review of the facility fire drill records and staff interview with the Maintenance Manager during the record review portion of the facility survey of 09/09/2014, between the hours of 1015 and 1115, it was discovered that the facility has failed to conduct fire drills for staff. This could result in staff ' s failure to provide for the safety of patients and visitors through a failure to respond to a fire emergency in accordance with the facility ' s published fire procedures. These findings were acknowledged by the Maintenance Manager.

The findings are as follows:

1. Night Shift - missing 3rd Quarter 2013 & 2nd Quarter 2014 (due for 3rd Quarter 2014 by 09/30/14).
2. Day Shift - missing 1st Quarter 2014.

During the survey tour of 09/09/2014, between the hours of 1330 and 1600, while accompanied by the Quality and Safety Manager, through observation and staff interview, it was discovered that the facility failed to maintain the fire alarm system in accordance with the requirements of NFPA 72. This could allow for failure of the system to activate in the event of a fire, placing patients, visitors and staff at risk. This finding was acknowledged by the Quality and Safety Manager.

The findings include but are not limited to:

1. The CT trailer has its own FACP that was last tagged as tested 05/2012.

Based upon a review of the facility fire drill records and staff interview with the Maintenance Manager during the record review portion of the facility survey of 09/09/2014, between the hours of 1015 and 1115, it was discovered that the facility has failed to maintain smoke detectors in accordance with the requirements of the National Fire Alarm Code (NFPA 72). The facility has failed to conduct sensitivity testing of smoke detectors as required (Chapter 10). This could allow for a device to initiate nuisance alarms or failure of a device to initiate the fire alarm causing a delay in the reporting of a fire, putting patients, visitors and staff at risk. These findings were acknowledged by the Maintenance Manager.

The findings include but are not limited to:

There is no documentation or knowledge that sensitivity of smoke detectors has been tested in the last 5 years.

Based upon a review of the facility fire drill records and staff interview with the Maintenance Manager during the record review portion of the facility survey of 09/09/2014, between the hours of 1015 and 1115, it was discovered that the facility has failed to maintain the automatic fire sprinkler system in a reliable operating condition as required by NFPA 25. This could result in a failure of the proper operation of the automatic fire sprinkler system with the potential of fire spreading unchecked, placing patients and employees at risk. This finding was acknowledged by the Maintenance Manager.

The findings include but are not limited to:

1. Quarterly sprinkler inspections are not being accomplished in the required time frames: 2 tests were performed 1st Quarter; None in 2nd Quarter; 2 in 3rd Quarter 2013 and None in 4th Quarter 2013.

Based upon a review of the facility fire drill records and staff interview with the Maintenance Manager during the record review portion of the facility survey of 09/09/2014, between the hours of 1015 and 1115, it was discovered that the facility is out of compliance with NFPA 96. This could result in failure of the kitchen hood suppression system to function properly, putting staff at risk. This finding was acknowledged by the Maintenance Manager.

The deficiency is as follows:

1. Documentation shows the system was inspected by Cascade 03/14 and 09/14 documenting the gas shut-off is not functioning, but there is no record of repairs per NFPA 96.

During the survey tour of 09/10/2014, between the hours of 0945 and 1015, while accompanied by the Quality and Safety Manager, through observation and staff interview with the Lab Manager, it was discovered that the facility has failed to provide spill kits in the laboratory itself.

The finding is as follows:

Lab staff are relying on Housekeeping for spill containment and clean-up. However, Housekeeping staff are not always available at off times when lab techs may be called in to run tests.

During the survey tour of 09/10/2014, between the hours of 0945 and 1015, while accompanied by the Quality and Safety Manager, through observation and staff interview with the Lab Manager, it was discovered that the facility has failed to provide safety education for laboratory staff.

The finding is as follows:

1. Lab staff are relying on Housekeeping for spill containment and clean-up. However, Housekeeping staff are not always available at off times when lab techs may be called in to run tests.
2. There is no knowledge or records of training of laboratory staff regarding spill handling other than to call Housekeeping.

During the survey tour of 09/09/2014, between the hours of 1115 and 1215, while accompanied by the Maintenance Manager, through observation and staff interview, it was discovered that the facility failed to maintain their emergency generator in accordance with the requirements of National Fire Protection Association (NFPA) Standard 110. This could compromise the ability of the emergency power supply to operate in the event of a power outage. These findings were acknowledged by the Maintenance Manager.

The findings are as follows:
1. Generator is lacking a Remote Stop Switch (per NFPA 110 3-5.5.6)

During the survey tour of 09/09/2014, between the hours of 1330 and 1600, while accompanied by the Quality and Safety Manager, through observation and staff interview, it was discovered that the facility failed to comply with NFPA 70, also known as the National Electric Code (NEC). This could allow for electrical arcing starting a fire, placing patients, staff and visitors at risk. The findings were acknowledged by the Quality and Safety Manager.

The findings include, but are not limited to:
1. Med. Room N. Wing Nurses ' Station; above the ceiling tiles - open junction box.
2. Bone Density " Sleep-Room " - refrigerator, microwave oven, television and CD player plugged into a multi-strip adapter.

During the survey tour of 09/09/2014, between the hours of 1330 and 1600, while accompanied by the Quality and Safety Manager, through observation and staff interview, it was discovered that the facility has failed to maintain the construction requirements for the classification of construction. The facility has a Type V (III) classification by NFPA 220. This has the potential for the spread of smoke and fire into the structure in the event of a fire. These findings were acknowledged by the Quality and Safety Manager.

The findings include but are not limited to:

1. Med. Room N. Wing Nurses Station missing ceiling tile.
2. Med. Room N. Wing Nurses Station - penetrations around IT / Phone wires through wall.

During the survey tour of 09/09/2014, between the hours of 1330 and 1600, while accompanied by the Quality and Safety Manager, through observation and staff interview, it was discovered that the facility to maintain doors protecting corridor openings in other than required enclosures of vertical openings, exits or hazardous areas. This prevents the doors from resisting the passage of smoke due to doors failing to close and latch or being prevented from closing due to impediments being in the doors travel path. This could result in smoke passing into the corridor or into rooms in the event of a fire. These findings were acknowledged by the Quality and Safety Manager.

The findings include but are not limited to:

1. Kitchen Storage-Freezer - Icemaker Room - door binding, failed to properly close and latch when tested.

During the survey tour of 09/09/2014, between the hours of 1330 and 1600, while accompanied by the Quality and Safety Manager, through observation and staff interview, it was discovered that the facility failed to maintain the ability of doors to be held open only by devices arranged to automatically close such doors upon activation of the fire alarm. In the event of a fire, this would allow for the passage of smoke and/or flames into or out of the stairwell meant to be protected by self-closing doors. This finding was acknowledged by the Quality and Safety Manager.

The findings include but are not limited to:

1. Cross-Corridor fire doors from Acute Care Wing into Business Wing failed to close and latch when tested.

Based upon a review of the facility fire drill records and staff interview with the Maintenance Manager during the record review portion of the facility survey of 09/09/2014, between the hours of 1015 and 1115, it was discovered that the facility has failed to conduct fire drills for staff. This could result in staff ' s failure to provide for the safety of patients and visitors through a failure to respond to a fire emergency in accordance with the facility ' s published fire procedures. These findings were acknowledged by the Maintenance Manager.

The findings are as follows:

1. Night Shift - missing 3rd Quarter 2013 & 2nd Quarter 2014 (due for 3rd Quarter 2014 by 09/30/14).
2. Day Shift - missing 1st Quarter 2014.

During the survey tour of 09/09/2014, between the hours of 1330 and 1600, while accompanied by the Quality and Safety Manager, through observation and staff interview, it was discovered that the facility failed to maintain the fire alarm system in accordance with the requirements of NFPA 72. This could allow for failure of the system to activate in the event of a fire, placing patients, visitors and staff at risk. This finding was acknowledged by the Quality and Safety Manager.

The findings include but are not limited to:

1. The CT trailer has its own FACP that was last tagged as tested 05/2012.

Based upon a review of the facility fire drill records and staff interview with the Maintenance Manager during the record review portion of the facility survey of 09/09/2014, between the hours of 1015 and 1115, it was discovered that the facility has failed to maintain smoke detectors in accordance with the requirements of the National Fire Alarm Code (NFPA 72). The facility has failed to conduct sensitivity testing of smoke detectors as required (Chapter 10). This could allow for a device to initiate nuisance alarms or failure of a device to initiate the fire alarm causing a delay in the reporting of a fire, putting patients, visitors and staff at risk. These findings were acknowledged by the Maintenance Manager.

The findings include but are not limited to:

There is no documentation or knowledge that sensitivity of smoke detectors has been tested in the last 5 years.

Based upon a review of the facility fire drill records and staff interview with the Maintenance Manager during the record review portion of the facility survey of 09/09/2014, between the hours of 1015 and 1115, it was discovered that the facility has failed to maintain the automatic fire sprinkler system in a reliable operating condition as required by NFPA 25. This could result in a failure of the proper operation of the automatic fire sprinkler system with the potential of fire spreading unchecked, placing patients and employees at risk. This finding was acknowledged by the Maintenance Manager.

The findings include but are not limited to:

1. Quarterly sprinkler inspections are not being accomplished in the required time frames: 2 tests were performed 1st Quarter; None in 2nd Quarter; 2 in 3rd Quarter 2013 and None in 4th Quarter 2013.

Based upon a review of the facility fire drill records and staff interview with the Maintenance Manager during the record review portion of the facility survey of 09/09/2014, between the hours of 1015 and 1115, it was discovered that the facility is out of compliance with NFPA 96. This could result in failure of the kitchen hood suppression system to function properly, putting staff at risk. This finding was acknowledged by the Maintenance Manager.

The deficiency is as follows:

1. Documentation shows the system was inspected by Cascade 03/14 and 09/14 documenting the gas shut-off is not functioning, but there is no record of repairs per NFPA 96.

During the survey tour of 09/09/2014, between the hours of 1115 and 1215, while accompanied by the Maintenance Manager, through observation and staff interview, it was discovered that the facility failed to maintain their emergency generator in accordance with the requirements of National Fire Protection Association (NFPA) Standard 110. This could compromise the ability of the emergency power supply to operate in the event of a power outage. These findings were acknowledged by the Maintenance Manager.

The findings are as follows:
1. Generator is lacking a Remote Stop Switch (per NFPA 110 3-5.5.6)

During the survey tour of 09/09/2014, between the hours of 1330 and 1600, while accompanied by the Quality and Safety Manager, through observation and staff interview, it was discovered that the facility failed to comply with NFPA 70, also known as the National Electric Code (NEC). This could allow for electrical arcing starting a fire, placing patients, staff and visitors at risk. The findings were acknowledged by the Quality and Safety Manager.

The findings include, but are not limited to:
1. Med. Room N. Wing Nurses ' Station; above the ceiling tiles - open junction box.
2. Bone Density " Sleep-Room " - refrigerator, microwave oven, television and CD player plugged into a multi-strip adapter.