HospitalInspections.org

Based on record review and interviews, it was determined the facility failed to provide documentation of a local fire inspections. An annual local fire inspection ensures the building remains within the building codes and fire safety codes. Failure to have an annual fire inspection could bring harm to patients and staff during an emergency.

CMS State Operations Manuel Appendix A- Interpretive Guidelines §482.11 The hospital must ensure that all applicable Federal, State and local law requirements are met.. The facility and its staff must operate and furnish services in compliance with applicable Federal, State, and local laws and regulations pertaining to licensure and any other relevant health and safety requirements. NFPA 101 2012 Life Safety Code Section 4.6.12. Maintenance, Inspection, and Testing. 4.6.12 Maintenance, inspection and testing shall be performed under supervision of a responsible person who shall ensure that testing, inspection, and maintenance are made at specified intervals in accordance with applicable NFPA standards or as directed by the authority having jurisdiction.

Findings include:

Records reviewed on Aug 23-25, 2021 revealed the facility failed to provide required documentation of an annual local fire inspection since 2019.

Employee #1, #11 and #19 confirmed during the exit conference that the facility failed to provide required documentation of an annual local fire inspection.

Based on the requirement to minimum NFPA 101 chapter 19 fire protection features such as 2 hour separation, sprinkler and alarm function for the hospital . The facility failed to meet this requirement for the pharmacy in the adjoining building. Failure to provide the minimum fire protection features could cause serious injury or death in the event of a fire

NFPA 101: Life Safety Code, 2012 Edition - Chapter 19 Existing Health Care Occupancies
19.1.2 Classification of Occupancy.
6.1.5.1 * Definition - Health Care Occupancy.
An occupancy used to provide medical or other treatment or care simultaneously to four or more patients on an inpatient basis, where such patients are mostly incapable of self-preservation due to age, physical or mental disability, or because of security measures not under the occupants' control.
19.1.3.4 Contiguous Non-Health Care Occupancies.
19.1.3.4.1 * Ambulatory care facilities, medical clinics, and similar facilities that are contiguous to health care occupancies, but are primarily intended to provide outpatient services, shall be permitted to be classified as business occupancies or ambulatory health care facilities, provided that the facilities are separated from the health care occupancy by not less than 2-hour fire resistance-rated construction, and the facility is not intended to provide services simultaneously for four or more in patients who are litter borne.
19.1.3 Multiple Occupancies.
19.1.3.3 * Sections of health care facilities shall be permitted to be classified as other occupancies, provided that they meet all of the following conditions:
1. They are not intended to provide services simultaneously for four or more inpatients for purposes of housing, treatment, or customary access by inpatients incapable of self-preservation.
2. They are separated from areas of health care occupancies by construction having a minimum 2-hour fire resistance rating in accordance with Chapter 8.
3. For other than previously approved occupancy separation arrangements, the entire building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.

NFPA 101 2012 Edition, Section 8.2 Construction and Compartmentation.

8.2.1.1 Buildings or structures occupied or used in accordance with the individual occupancy chapters, Chapters 11 through 43, shall meet the minimum construction requirements of those chapters.
8.2.1.2 * NFPA 220, Standard on Types of Building Construction, shall be used to determine the requirements for the construction classification.
8.2.1.3 Where the building or facility includes additions or connected structures of different construction types, the rating and classification of the structure shall be based on one of the following:
(1) Separate buildings, if a 2-hour or greater vertically aligned fire barrier wall in accordance with NFPA 221, Standard for High Challenge Fire Walls, Fire Walls, and Fire Barrier Walls, exists between the portions of the building.
(2) Separate buildings, if provided with previously approved separations.
(3) Least fire-resistive construction type of the connected portions, if separation as specified in 8.2.1.3(1) or (2) is not provided.
dings:

Findings include:

Observations made while on tour on August 23-25,2021 revealed the facilities Pharmacy was located inside an adjacent area of the hospital that is designated as a provider based entity of the hospital. The pharmacy located in this provider based entity functions as the pharmacy that supports all hospital operations for pharmaceutical management. The building that houses the pharmacy does not have any sprinkler protection, fire alarm systems and does not have fire wall separation.

The surveyor's tour conducted on 08/25/2021 revealed there were no fire extinguishers or smoke detectors located in the area.

Employee #1, #11 and #19 confirmed during the exit conference conducted on August 25,2021 that the facility's pharmacy is not located within the hospital proper and the adjoining building does not meet the requirements of NFPA 101 chapter 19 Existing Health Care Occupancies.

Based on record review and interviews, it was determined that the facility failed to perform the monthly inspection for the facility's sprinklers systems. Failing to perform the required inspections may cause harm to patients and staff.


NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.1. "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, 2011 Edition, "Standard for the Inspection, Testing , and Maintenance of Water-Based Fire Protection Systems." NFPA 25, 2011 Edition, "Water Based Extinguishment Systems," requires monthly, quarterly and annual testing of automatic sprinkler systems.

Findings Include:

Observations while on tour August 23-25, 2021 revealed the facility failed to show proof of monthly testing of the sprinkler systems in accordance with NFPA 25 Standard for the Inspection,Testing, and Maintenance of Water-Based Fire Protection Systems.


Employee #1, #11 and #19 confirmed during the exit conference conducted on August 25th, 2021 that the facility failed to conduct the required monthly testing of the sprinkler systems.

Based on Observation and interview, it was determined the facility allowed the use of a multiple outlet adapters, power strips and extension cords as evidenced by, improper use and presence of electrical cords and adaptors in 10 different locations throughout the hospital supporting heavy load drawing appliances. Failure to properly use power cords and outlets could lead to electrical overload or fire which could cause harm to the patients and staff.

NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2 , "All Patient Care Areas," Sections 6.3.2.2..6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings include:

Observations while on tour August 23-25, 2021, revealed many locations throughout the facility with improper use of extension cords and power strips and one multi plug adaptor. Extension cords used as permanent equipment, multi plug adaptors without surge protection and 10 different locations had heavy load drawing appliance (refrigerators, microwaves and large printers) plugged into power strips. A policy titled "Utilities management Plan 2021...Security section" describes power strips as "Relocatable Power Taps" and states "RPTs must be permanently mounted" some were laying on the floor the policy also also stated "Extension cords are not used as a substitute for fixed wiring in a building" contrary to this policy extension cords were found in four location as permanent fixtures.

During the exit conference conducted on August 25, 2021,, Employee #1, #11 and #19 confirmed the improper use of power strips, extension cords and multi plug adaptors without surge protection.

Based on observation and staff interview, the facility failed to provide a record of electrical equipment tests, repairs, and modifications as evidenced by the hospital personnel not ensuring the checking for leakage current on equipment that makes contact with the facilities patients was tested. Failing to conduct maintenance on patient care appliances could cause harm to the resident if the appliance malfunctions.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 10, Section 10.5.6 Record Keeping-Patient Appliances Electrical Equipment - Testing and Maintenance Requirements
"The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training."

Findings include:

Observation, record review and staff interviews on August 23-25, 2021, revealed the facility was unable to produce policies or protocols or documentation to identify all electrical equipment tests, repairs, and modifications. The facility provided documentation of a visual inspection of patient care related electrical equipment but stated they were unaware of checking for leakage current on other equipment that make contact with the facility's patients. The facility uses a contractor to perform this task. The documents reviewed revealed the purpose of the program is to prevent electrical hazards but does not describe which equipment in this facility was to be tested.

Employee #1, #11 and #19 confirmed during the exit conference on August 25, 2021,the facility failed to test electrical equipment for leakage current.