HospitalInspections.org

Based on observation the facility failed to provide adequate smoke barriers.

The inspector observed, while accompanied by the Associate Administrator and the Plant Operations Manager during the hours of the inspection from 1:00 pm to 5:15 pm on 1/15/2014 that there were penetrations in the smoke barriers. They were in the following locations: 1) above exit light 09, 2) above exit light 07/08 (both sides), 3) above exit light 13/34 (both sides), 4) at outpatient surgery (both sides), and 5) both sides of exit light 16/17.

Based on observation the facility failed to provide adequate separation of hazardous areas.

The inspector observed, while accompanied by the Associate Administrator and the Plant Operations Manager during the hours of the inspection from 1:00 pm to 5:15 pm on 1/15/2014 that there were the following issues.

The following hazardous areas did not have closers: 1) the mechanical/telephone room, 2) Equipment Storage at 200 wing, and 3) Psych Storage Room.

The following hazardous areas had door stops: 1) Dry Good Storage, 2) Paper Goods Storage, and 3) Anesthesiology Closet Storage.

The following area the doors did not latch properly on their own: Delivery/Equipment Storage (both doors).

Based on observation the facility failed to provide adequate lighting at exterior exits.

The inspector observed, while accompanied by the Associate Administrator and the Plant Operations Manager during the hours of the inspection from 1:00 pm to 5:15 pm on 1/15/2014 that there were exits that did not have two sources of illumination. This may be two lamps in a single fixture or two fixtures that are on the Life Safety Branch of the EES.

Based on observation the facility failed to provide adequate medical gas storage.

The inspector observed, while accompanied by the Associate Administrator and the Plant Operations Manager during the hours of the inspection from 1:00 pm to 5:15 pm on 1/15/2014 that there were the following issues. They were: 1) the nitrous dioxide room had supply air coming into the closet but did not have an adequately sized exhaust (this produced a condition where a leak of the gas would not be vented but would be forced into adjacent spaces), 2) the nitrous dioxide room door did not close and latch on its own, and 3) the bulk oxygen tank required some means to keep parking at least 10 feet away from the enclosure.

Locations for supply systems of more than 3000 ft3 (85 m3) total capacity (connected and in storage) shall be vented to the outside by a dedicated mechanical ventilation system or by natural venting. If natural venting is used, the vent opening or openings shall be a minimum of 72 in.2 (0.05 m2) in total free area. Re. NFPA 99, 1999, 4-3.1.1.2(b)4.

Storage Within 18 " Below Head Deflectors

" A minimum clearance of 18 inches shall be maintained between the top of storage and sprinkler deflectors " - NFPA 13, 2002: 8.5.6.1.

Based on observation the facility failed to provide adequate clearance below the sprinkler deflectors.

The inspector observed, while accompanied by the Associate Administrator and the Plant Operations Manager during the hours of the inspection from 1:00 pm to 5:15 pm on 1/15/2014 that 18 inches clear below the sprinkler heads was not provided in the Surgical Storage.


Disaster or Emergency Plan:

A complete emergency plan is based on chapter 11 of NFPA 99, 1999. The plan shall be the responsibility of the emergency preparedness committee and shall be evaluated and revised as directed by senior management. The emergency preparedness committee shall model the emergency preparedness plan on the incident command system (ICS) in coordination with local emergency response agencies. The plan shall include the following: 1) identification of emergency response personnel, 2) continuity of essential building systems (electricity, water, ventilation, fire protection systems, fuel sources, medical gas and vacuum system, and communication systems), 3) staff management, 4) patient management, 5) logistics (pharmaceuticals, supplies, food, linen, and industrial and potable water), 6) security, 7) public affairs, 8) staff education, 9) drills, and 10) operational recovery. See chapter 11 of NFPA 99, 1999 for additional details of the above.

Based on observation the facility failed to provide adequate disaster drills.

The inspector observed, while accompanied by the Associate Administrator and the Plant Operations Manager during the hours of the inspection from 1:00 pm to 5:15 pm on 1/15/2014 that the facility had not been conducting disaster drills. At least one drill must be a mass casualty response and coordinated with local emergency response agencies. The other annual drill may be an in house drill.


Receptacle Testing in Patient Care Areas - NFFA 99, 1999, 3-3.3.3

(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

NFPA 99, 1999, 3-3.4.2.3(a) states that testing shall be performed after initial installation, replacement or servicing of a device, and that additional testing shall be performed at intervals defined by documented performance data. Since data is not typically available from the manufacturer, the facility may document the failure rates of the receptacles and provide a testing schedule that will safeguard their patients. This shall be done by the Safety Committee, approved by the Governing Board, and written into the safety policies and procedures. H.L.R. 2007, ?133.142. Until this assessment has been done, receptacle testing shall be performed in all general care areas every 12 months and in critical care areas every 6 months. (NFPA 99, 1984).

Based on observation the facility failed to provide a history of records for receptacle testing per NFPA 99: 3-3.3.3. in patient care areas.

The inspector observed, while accompanied by the Associate Administrator and the Plant Operations Manager during the hours of the inspection from 1:00 pm to 5:15 pm on 1/15/2014 that the retention force tests were not being conducted. All other tests were conducted.


Line Isolation Monitor Tests.

" The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following:
(a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated.
(b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.
(c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. " - N.F.P.A. 99, 1999, 3-3.3.4.2

Based on observation the facility failed to provide adequate Line Isolation Monitor, LIM, tests.

The inspector observed, while accompanied by the Associate Administrator and the Plant Operations Manager during the hours of the inspection from 1:00 pm to 5:15 pm on 1/15/2014 that the LIM test were not being conducted.


Fuel and Water Preferred Customer Status

" Continuity of Essential Building Systems. When designated by the emergency preparedness management plan to provide continuous service in a disaster or emergency, health care facilities shall establish contingency plans for the continuity of essential building systems, as applicable: (a) Electricity, (b) Water, (c) Ventilation, (d) Fire protection systems, (e) Fuel sources, (f) Medical gas and vacuum systems (if applicable), (g) Communications systems. " - NFPA 99, 1999, 11-5.3.2

Based on observation the facility failed to provide letters from vendors for emergency fuel.

Based on observation the facility may not have adequate load on the generators.

The inspector observed, while accompanied by the Associate Administrator and the Plant Operations Manager during the hours of the inspection from 1:00 pm to 5:15 pm on 1/15/2014 that it was not clear that the generator was being loaded to 30% of the name plate kW rating.

Based on observation the facility failed to provide a complete Essential Electrical System, EES.

The inspector observed, while accompanied by the Associate Administrator and the Plant Operations Manager during the hours of the inspection from 1:00 pm to 5:15 pm on 1/15/2014 that there were the following issues. They were: 1) The ATS were not labeled according to the branch that they serve. 2) The directories in E.3 (Critical) were not legible. 3) Panel E1 (Life Safety) had functions that were not allowed. Only those functions listed below for Life Safety may be present in a Life Safety Panel.

NFPA 70, 1999, 517-32. No function other than those listed in (a) through (f) shall be connected to the life safety branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment.
(a) Illumination of Means of Egress. Illumination of means of egress, such as lighting required for corridors, passageways, stairways, and landings at exit doors, and all necessary ways of approach to exits. Switching arrangements to transfer patient corridor lighting in hospitals from general illumination circuits to night illumination circuits shall be permitted provided only one of two circuits can be selected and both circuits cannot be extinguished at the same time.
FPN: See Life Safety Code, NFPA 101-1997, Sections 5-8 and 5-9.
(b) Exit Signs. Exit signs and exit directional signs.
FPN: See Life Safety Code, NFPA 101-1997, Section 5-10.
(c) Alarm and Alerting Systems. Alarm and alerting systems including the following:
1. Fire alarms
FPN: See Life Safety Code, NFPA 101-1997, Sections 7-6 and 12-3.4.
2. Alarms required for systems used for the piping of nonflammable medical gases
FPN: See Standard for Health Care Facilities, NFPA 99-1996, 12-3.4.1.
(d) Communications Systems. Hospital communications systems, where used for issuing instructions during emergency conditions.
(e) Generator Set Location. Task illumination battery charger for emergency battery-powered lighting unit(s) and selected receptacles at the generator set location.
(f) Elevators. Elevator cab lighting, control, communications, and signal systems.

In addition there were the additional issues. 4) The breaker for the FACP in the electrical room must be colored red and labeled " Fire Alarm " . 5) Also, in the electrical room, panel E2C must be labeled " CRITICAL " .

6) Critical outlets (red outlets) must be labeled with permanent labels in all critical areas with the panel and breaker suppling power to the receptacle. They were not labeled properly in the following areas: the E.R., outpatient PACU 401 and 402, ORs A and B, and the OR PACU.

" In critical care areas, emergency system receptacles must be identified, indicating the panel board and circuit number supplying them in accordance with NFPA 70, 2002: 517-19(a). Panel board and circuit numbers shall be permanently engraved on the cover plates or applied with laminated labels that have permanent adhesive. The face plate label shall be non-removable or engraved. " - HLR, 133.162 (d)(5)(H)(vi). Here non-removable means that it can not be pealed off with a fingernail.

7) All patient care areas must have hospital grade receptacles. This was missing in the following areas: the whole 100 wing and the 300 wing.

All receptacles, whether four or more, shall be listed " hospital grade " and so identified. Each receptacle shall be grounded by means of an insulted copper conductor sized in accordance the Table 250-122. NFPA 70, 1999, 517-18 (b).

8) There were locations where the patient beds did not have any critical receptacles. They were: the 100 wing, the 300 wing, and the outpatient PACU.

Electrical outlets powered from the critical branch shall be provided at all critical care areas that utilize anesthetizing gases, isolated power in special environments, general care beds, angiographic labs, cardiac catheterization labs, coronary care units, hemodialysis rooms or areas, emergency room treatment areas, human physiology labs, intensive care units, postoperative recovery rooms, and were needed for effective facility operation in accordance with NFPA 99, 2002, 4.4.2.2.2.3.

Based on observation the facility failed to provide adequate smoke barriers.

The inspector observed, while accompanied by the Associate Administrator and the Plant Operations Manager during the hours of the inspection from 1:00 pm to 5:15 pm on 1/15/2014 that there were penetrations in the smoke barriers. They were in the following locations: 1) above exit light 09, 2) above exit light 07/08 (both sides), 3) above exit light 13/34 (both sides), 4) at outpatient surgery (both sides), and 5) both sides of exit light 16/17.

Based on observation the facility failed to provide adequate separation of hazardous areas.

The inspector observed, while accompanied by the Associate Administrator and the Plant Operations Manager during the hours of the inspection from 1:00 pm to 5:15 pm on 1/15/2014 that there were the following issues.

The following hazardous areas did not have closers: 1) the mechanical/telephone room, 2) Equipment Storage at 200 wing, and 3) Psych Storage Room.

The following hazardous areas had door stops: 1) Dry Good Storage, 2) Paper Goods Storage, and 3) Anesthesiology Closet Storage.

The following area the doors did not latch properly on their own: Delivery/Equipment Storage (both doors).

Based on observation the facility failed to provide adequate lighting at exterior exits.

The inspector observed, while accompanied by the Associate Administrator and the Plant Operations Manager during the hours of the inspection from 1:00 pm to 5:15 pm on 1/15/2014 that there were exits that did not have two sources of illumination. This may be two lamps in a single fixture or two fixtures that are on the Life Safety Branch of the EES.

Based on observation the facility failed to provide adequate medical gas storage.

The inspector observed, while accompanied by the Associate Administrator and the Plant Operations Manager during the hours of the inspection from 1:00 pm to 5:15 pm on 1/15/2014 that there were the following issues. They were: 1) the nitrous dioxide room had supply air coming into the closet but did not have an adequately sized exhaust (this produced a condition where a leak of the gas would not be vented but would be forced into adjacent spaces), 2) the nitrous dioxide room door did not close and latch on its own, and 3) the bulk oxygen tank required some means to keep parking at least 10 feet away from the enclosure.

Locations for supply systems of more than 3000 ft3 (85 m3) total capacity (connected and in storage) shall be vented to the outside by a dedicated mechanical ventilation system or by natural venting. If natural venting is used, the vent opening or openings shall be a minimum of 72 in.2 (0.05 m2) in total free area. Re. NFPA 99, 1999, 4-3.1.1.2(b)4.

Storage Within 18 " Below Head Deflectors

" A minimum clearance of 18 inches shall be maintained between the top of storage and sprinkler deflectors " - NFPA 13, 2002: 8.5.6.1.

Based on observation the facility failed to provide adequate clearance below the sprinkler deflectors.

The inspector observed, while accompanied by the Associate Administrator and the Plant Operations Manager during the hours of the inspection from 1:00 pm to 5:15 pm on 1/15/2014 that 18 inches clear below the sprinkler heads was not provided in the Surgical Storage.


Disaster or Emergency Plan:

A complete emergency plan is based on chapter 11 of NFPA 99, 1999. The plan shall be the responsibility of the emergency preparedness committee and shall be evaluated and revised as directed by senior management. The emergency preparedness committee shall model the emergency preparedness plan on the incident command system (ICS) in coordination with local emergency response agencies. The plan shall include the following: 1) identification of emergency response personnel, 2) continuity of essential building systems (electricity, water, ventilation, fire protection systems, fuel sources, medical gas and vacuum system, and communication systems), 3) staff management, 4) patient management, 5) logistics (pharmaceuticals, supplies, food, linen, and industrial and potable water), 6) security, 7) public affairs, 8) staff education, 9) drills, and 10) operational recovery. See chapter 11 of NFPA 99, 1999 for additional details of the above.

Based on observation the facility failed to provide adequate disaster drills.

The inspector observed, while accompanied by the Associate Administrator and the Plant Operations Manager during the hours of the inspection from 1:00 pm to 5:15 pm on 1/15/2014 that the facility had not been conducting disaster drills. At least one drill must be a mass casualty response and coordinated with local emergency response agencies. The other annual drill may be an in house drill.


Receptacle Testing in Patient Care Areas - NFFA 99, 1999, 3-3.3.3

(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

NFPA 99, 1999, 3-3.4.2.3(a) states that testing shall be performed after initial installation, replacement or servicing of a device, and that additional testing shall be performed at intervals defined by documented performance data. Since data is not typically available from the manufacturer, the facility may document the failure rates of the receptacles and provide a testing schedule that will safeguard their patients. This shall be done by the Safety Committee, approved by the Governing Board, and written into the safety policies and procedures. H.L.R. 2007, ?133.142. Until this assessment has been done, receptacle testing shall be performed in all general care areas every 12 months and in critical care areas every 6 months. (NFPA 99, 1984).

Based on observation the facility failed to provide a history of records for receptacle testing per NFPA 99: 3-3.3.3. in patient care areas.

The inspector observed, while accompanied by the Associate Administrator and the Plant Operations Manager during the hours of the inspection from 1:00 pm to 5:15 pm on 1/15/2014 that the retention force tests were not being conducted. All other tests were conducted.


Line Isolation Monitor Tests.

" The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following:
(a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated.
(b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.
(c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. " - N.F.P.A. 99, 1999, 3-3.3.4.2

Based on observation the facility failed to provide adequate Line Isolation Monitor, LIM, tests.

The inspector observed, while accompanied by the Associate Administrator and the Plant Operations Manager during the hours of the inspection from 1:00 pm to 5:15 pm on 1/15/2014 that the LIM test were not being conducted.


Fuel and Water Preferred Customer Status

" Continuity of Essential Building Systems. When designated by the emergency preparedness management plan to provide continuous service in a disaster or emergency, health care facilities shall establish contingency plans for the continuity of essential building systems, as applicable: (a) Electricity, (b) Water, (c) Ventilation, (d) Fire protection systems, (e) Fuel sources, (f) Medical gas and vacuum systems (if applicable), (g) Communications systems. " - NFPA 99, 1999, 11-5.3.2

Based on observation the facility failed to provide letters from vendors for emergency fuel.

Based on observation the facility may not have adequate load on the generators.

The inspector observed, while accompanied by the Associate Administrator and the Plant Operations Manager during the hours of the inspection from 1:00 pm to 5:15 pm on 1/15/2014 that it was not clear that the generator was being loaded to 30% of the name plate kW rating.

Based on observation the facility failed to provide a complete Essential Electrical System, EES.

The inspector observed, while accompanied by the Associate Administrator and the Plant Operations Manager during the hours of the inspection from 1:00 pm to 5:15 pm on 1/15/2014 that there were the following issues. They were: 1) The ATS were not labeled according to the branch that they serve. 2) The directories in E.3 (Critical) were not legible. 3) Panel E1 (Life Safety) had functions that were not allowed. Only those functions listed below for Life Safety may be present in a Life Safety Panel.

NFPA 70, 1999, 517-32. No function other than those listed in (a) through (f) shall be connected to the life safety branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment.
(a) Illumination of Means of Egress. Illumination of means of egress, such as lighting required for corridors, passageways, stairways, and landings at exit doors, and all necessary ways of approach to exits. Switching arrangements to transfer patient corridor lighting in hospitals from general illumination circuits to night illumination circuits shall be permitted provided only one of two circuits can be selected and both circuits cannot be extinguished at the same time.
FPN: See Life Safety Code, NFPA 101-1997, Sections 5-8 and 5-9.
(b) Exit Signs. Exit signs and exit directional signs.
FPN: See Life Safety Code, NFPA 101-1997, Section 5-10.
(c) Alarm and Alerting Systems. Alarm and alerting systems including the following:
1. Fire alarms
FPN: See Life Safety Code, NFPA 101-1997, Sections 7-6 and 12-3.4.
2. Alarms required for systems used for the piping of nonflammable medical gases
FPN: See Standard for Health Care Facilities, NFPA 99-1996, 12-3.4.1.
(d) Communications Systems. Hospital communications systems, where used for issuing instructions during emergency conditions.
(e) Generator Set Location. Task illumination battery charger for emergency battery-powered lighting unit(s) and selected receptacles at the generator set location.
(f) Elevators. Elevator cab lighting, control, communications, and signal systems.

In addition there were the additional issues. 4) The breaker for the FACP in the electrical room must be colored red and labeled " Fire Alarm " . 5) Also, in the electrical room, panel E2C must be labeled " CRITICAL " .

6) Critical outlets (red outlets) must be labeled with permanent labels in all critical areas with the panel and breaker suppling power to the receptacle. They were not labeled properly in the following areas: the E.R., outpatient PACU 401 and 402, ORs A and B, and the OR PACU.

" In critical care areas, emergency system receptacles must be identified, indicating the panel board and circuit number supplying them in accordance with NFPA 70, 2002: 517-19(a). Panel board and circuit numbers shall be permanently engraved on the cover plates or applied with laminated labels that have permanent adhesive. The face plate label shall be non-removable or engraved. " - HLR, 133.162 (d)(5)(H)(vi). Here non-removable means that it can not be pealed off with a fingernail.

7) All patient care areas must have hospital grade receptacles. This was missing in the following areas: the whole 100 wing and the 300 wing.

All receptacles, whether four or more, shall be listed " hospital grade " and so identified. Each receptacle shall be grounded by means of an insulted copper conductor sized in accordance the Table 250-122. NFPA 70, 1999, 517-18 (b).

8) There were locations where the patient beds did not have any critical receptacles. They were: the 100 wing, the 300 wing, and the outpatient PACU.

Electrical outlets powered from the critical branch shall be provided at all critical care areas that utilize anesthetizing gases, isolated power in special environments, general care beds, angiographic labs, cardiac catheterization labs, coronary care units, hemodialysis rooms or areas, emergency room treatment areas, human physiology labs, intensive care units, postoperative recovery rooms, and were needed for effective facility operation in accordance with NFPA 99, 2002, 4.4.2.2.2.3.