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Based on observation and interview, the facility failed to maintain the fire door in a two-hour fire barrier that separated the Hospital (healthcare) and the Clinic (business). This deficient practice would allow fire and smoke to migrate between the two separate occupancies. The facility has a capacity of 25 and a census of 18 patients at the time of the survey.

Findings are:
Observations on 1-29-18 at 9:35 am revealed, the east 1 ½ hour fire rated door separating the Hospital from the Clinic failed to latch within the door frame.

During an interview on 1-29-19 at 9:35 am, Administration Staff A confirmed the fire rated fire door failed to latch and stated, "it could be the air pressure". Administration Staff A did not want to test the door with the fire alarm, to verify that the air handling systems would shut down and door would close.

Based on observation and interview, the facility allowed the placement of "DO NOT ENTER" sign on the exit door leading into recovery. This deficient practice provided conflicting information as to the reliability of the exit and would create confusion, delaying occupants from evacuating in the event of a fire. The facility has a capacity of 25 and a census of 18 patients at the time of the survey.

Findings are:
Observation on 1-29-18 at 11:19 am revealed, the exit door leading into recovery, had a sign that was taped to the door hardware, which stated, "DO NOT ENTER".

During an interview on 1-29-19 at 1:19 am, Administration Staff A confirmed the sign and stated, it was to stop staff from entering the post op area.

Based on observation and interview, the facility failed to assure that the snow and ice was removed from the sidewalks, so that egress from the exit would not impede it to full instant use in the case of fire or other emergency. The facility has a capacity of 25 and a census of 18 patients at the time of the survey.

Findings are:
Observations on 1-29-19 at 10:45 am revealed, the sidewalk outside emergency department exit door was covered with snow and ice.

During an interview on 1-29-19 at 10:45 am, Administration Staff A confirmed the snow and ice covered sidewalk.

NFPA Standard:
2012 NFPA 101, 7.1.10.1
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on observation and interview, the facility failed to assure that doors in the path of egress did not have keyed locks. This deficient practice would delay egress. The facility has a capacity of 25 and a census of 18 patients at the time of the survey.

Findings are:
Observations on 1-29-19 at 10:07 am revealed, 2 of 2 sliding exit doors in the Rehab were equipped with key locks.

During an interview on 1-29-19 at 10:07 am, Administration Staff A confirmed the exit doors were equipped with a keyed lock.

Based on observation, interview and record review, the facility failed to assure that there were no dead-end corridors. This deficient practice would delay egress and cause confusion.
The facility has a capacity of 25 and a census of 18 patients at the time of survey.

Findings are:
Observations on 1-29-19 at 10:20 AM revealed, that the facility failed to post an exit sign above the smoke doors 1603 leading into the patient care area, which created a 56 feet dead end.

During record review and interview on 1-29-19 at 2:29 PM, Administration Staff A confirmed the distance of the dead end from facility floor plans and confirmed a dead end was created.

Based on observation and interview, the facility failed to maintain the exit corridor clear of obstructions. This deficient practice would delay egress. The facility has a capacity of 25 and a census of 18 patients at the time of the survey.

Findings are:
Observations on 1-29-19 at 10:23 am revealed, table and chairs located within the width of the corridor at the cafeteria.

During an interview on 1-29-19 at 10:23 am, Administration Staff A confirmed that the table and chairs were located in the clear width of the corridor, and stated "it was an ongoing issue with staff".

Based on observation and interview, the facility failed to provide an exit sign for the second required exit. This deficient practice had the potential to delay or cause confusion during an emergency as occupants would not be aware of the exit. The facility has a capacity of 25 and a census of 18 patients at the time of the survey.

Findings are:
Observations on 1-29-19 at 9:47 am and 10:22 am revealed:
1. While standing in corridor leading to the Clinic (1214) and looking south toward the smoke doors, no exit sign was provided to direct occupants to the second required exit.
2. While standing in the corridor next to the smoke doors next to room 1602, no exit sign was provided to direct occupants to the second required exit.

During an interview on 1-29-19 at 9:47 am and 10:22 am, Administration Staff A confirmed the lack of exit signage.

NFPA Standard:
NFPA 101, 2012, 7.10.2.1*
A sign complying with 7.10.3, with a directional indicator showing the direction of travel, shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.

7.10.5.2.1
Every sign required to be illuminated by 7.10.6.3, 7.10.7, and 7.10.8.1 shall be continuously illuminated as required under the provisions of Section 7.8, unless otherwise provided in 7.10.5.2.2.

Based on observation and staff interview, the facility failed to separate hazardous storage areas with smoke resistive doors. This deficient practice would allow smoke to enter the egress corridor. The facility has a capacity of 25 and a census of 18 patients at the time of the survey.

Findings are:
Observation on 1-29-19 at 10:56 am revealed, Room 1461 door was equipped with a self-closing device and the door failed to close and latch within the doorframe.

During an interview on 1-29-19 at 10:56 am, Administration Staff A confirmed the door failed to close and latch within the doorframe.

Based on observation and interview, the facility failed to minimize the possibility of a fire in the facility by not ensuring that the stovetop in Occupational therapy gym was equipped with safety devices to prevent unauthorized use. This deficient practice increases the potential for the stove to be left on resulting in an accidental fire to start or burns to residents. The facility has a capacity of 25 and a census of 18 patients at the time of the survey.

Findings are:
Observations on 1-29-19 at 10:04 am revealed:
1. The cook top in the Therapy Gym was not in use, the power to the cook top was not turned off and when the control knobs were turned to the on position, the coils got hot.
2. The facility failed to provide a lockout switch to deactivate the power to the cook top when not in use.
3. The facility failed to provide a procedure for the cook top in the facility.

During an interview on 1-29-19 at 10:04 am, Administration Staff A confirmed the power to the cook top was not turned off and that the facility failed to provide a policy for the use of the cook top.

Based on record review and interview, the facility did not assure that a complete policy was in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than ten hours in any twenty-four hour period. The lack of a complete written policy and procedure would result in staff failing to implement interim safety measures in the event of an emergency. This deficient practice affected all residents. The facility has a capacity of 25 and a census of 18 patients at the time of the survey.

Findings are:
Record review on 1-29-19 at 1:52 PM, of the fire watch procedures revealed the facility did not have a complete policy regarding the procedures to be taken in the event that the sprinkler system was out of service for more than ten hours in a twenty-four hour period. The policy provided failed include that in a preplanned fire watch would contact the property owner/representative, insurance company, authorities having jurisdiction and alarm company. The policy failed to list unplanned fire watch for the emergency impairments would include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping and equipment failure.

During an interview on 1-29-19 at 1:52 PM, Maintenance Staff A confirmed the lack of specific items in the fire watch policy.

NFPA Standard:
NFPA 25, 2011
15.5* Preplanned Impairment Programs.
15.5.1 All preplanned impairments shall be authorized by the impairment coordinator.
15.5.2 Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented:
(1) The extent and expected duration of the impairment have been determined.
(2) The areas or buildings involved have been inspected and the increased risks determined.
(3) Recommendations have been submitted to management or the property owner or designated representative.
(4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following:
(a) Evacuation of the building or portion of the building affected by the system out of service
(b)*An approved fire watch
(c)*Establishment of a temporary water supply
(d)*Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire
(5) The fire department has been notified.
(6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified.
(7) The supervisors in the areas to be affected have been notified.
(8) A tag impairment system has been implemented. (See Section 15.3.)
(9) All necessary tools and materials have been assembled on the impairment site.

15.6 Emergency Impairments.
15.6.1 Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure.
15.6.2 When emergency impairments occur, emergency action shall be taken to minimize potential injury and damage.
15.6.3 The coordinator shall implement the steps outlined in Section 15.5.

Based on observation and interview, the facility failed to assure smoke barrier doors closed and sealed to prevent the passage of smoke and gases. This deficient practice would allow smoke and gases to migrate into the exit corridor and migrate to another smoke compartment. The facility has a capacity of 25 and a census of 18 patients at the time of the survey.

Findings are:
Observations on 1-29-19 at 10:25 am revealed, the north smoke door at 1526 Kitchen Dietician Office, equipped with latching device failed to latch within the doorframe.

During an interview on 1-29-19 at 10:25 am, Administration Staff A confirmed the smoke door failed to latch within the doorframe.

Based on observation and interview, the facility allowed storage to obstruct access to the electrical disconnects boxes. This deficient practice could cause a delay and injury when turning off the power during an electrical issue emergency. The facility has a capacity of 25 and a census of 18 patients at the time of the survey.

Findings are:
Observations on 1-29-19 between 9:36 AM and 11:07 am revealed:
1. Rolling carts stored in front of the electrical panel box UPS Out in electrical room 1112A.
2. Boxes of lights and a ladder stored in front of the electrical panel box GQLI in electrical room 1604.
3. Two plastic totes on a wooden palled and 5 gallon container of cleaning liquid stored in front of the electrical panel box in the electrical room 1475.

During an interview on 1-29-19 between 9:36 AM and 11:07 AM, Administration Staff A confirmed the items stored in front of the electrical panel boxes.

NFPA Standard:
2011 NFPA 70, 110.26
Sufficient access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment.

Based on record review and staff interview, the facility failed to inspect and test fire doors annually throughout the facility as required by the code. This deficient practice could allow the spread of fire through faulty fire doors that would otherwise contain a fire. The facility has a capacity of 25 and a census of 18 patients at the time of the survey.

Findings are:
Record review on 1-29-19 at 2:31 PM revealed a preventative maintenance plan to inspect and test fire doors annually failed to include all eleven items required by the code.

During an interview on 1-29-19 at 2:31 PM, Administration Staff A confirmed the fire door testing was not complete.

NFPA Standard:
NFPA 80, 2010, 5.2* Inspections.
5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.

5.2.4 Swinging Doors with Builders Hardware or Fire Door
Hardware.
5.2.4.1 Fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly.
5.2.4.2 As a minimum, the following items shall be verified:
(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.

Based on observation and interview, the facility failed to provide the required amount of receptacles at critical care areas in the facility. This deficient practice would affect patients in those areas, as there would not be an adequate amount of receptacles as required by the older version of the code. The facility has a capacity of 25 and a census of 18 patients at the time of the survey.

Findings are:
Observations on 1-29-19 at 11:12 AM and 11:46 AM revealed:
1. 4 of 4 Recovery rooms failed to provide six receptacles as required by the NFPA 99, 1999 edition.
2. 12 of 12 Same day surgery recovery rooms failed to provide six receptacles as required by the NFPA 99, 1999 edition.

During an interview on 1-29-19 at 11:12 AM and 11:46 AM, Administration Staff A confirmed that only two duplex receptacles were provided in the critical care areas and that the building was constructed in 2012.

NFPA Standard:
1999 NFPA 99, 3-3.2.1.2
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.
a. Receptacles for Patient Bed Locations in General Care Areas.
Each patient bed location shall be provided with a minimum of four receptacles.
b. Receptacles for Patient Bed Locations in Critical Care Areas.
Each patient bed location shall be provided with a minimum of six receptacles.

Based on record review and interview, the facility failed to test patient bed receptacles annually throughout the facility. This deficient practice increased the risk that the outlets would not be in working order and would increase the potential for electric shock or fire. The facility has a capacity of 25 and a census of 18 patients at the time of the survey.

Findings are:
Record review on 1-29-19 at 2:48 PM revealed:
1. Documentation of annual patient bed location receptacle testing was not provided.

In an interview on 1-29-19 at 2:48 PM, Maintenance Staff A confirmed the receptacle testing failed to be implemented and stated that documentation of the performance data from the manufacture was not available.

NFPA Standard:
NFPA 99, 2012, 6.3.4.1.1
Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device.
6.3.4.1.2
Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.
6.3.4.1.3
Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.
6.3.3.2 Receptacle Testing in Patient Care Rooms.
6.3.3.2.1
The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2
The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3
Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4
The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

Based on record review and interview, the facility failed to document the time to transfer from normal power to generator power was less than 10 seconds. This deficient practice increased the risk that the generator was not operating in normal conditions. The facility has a capacity of 25 and a census of 18 patients at the time of the survey.

Findings are:
Record review on 1-29-19 at 1:48 PM revealed:
1. The facility failed to document the time to transfer on the generator inspection reports.

In an interview on 1-29-19 at 1:48 PM, Maintenance Staff A confirmed the lack of documentation was unaware of the requirement to document time to transfer.

Based on observation and interview, the facility failed to prohibit the use of electrical adaptors and power strips as a substitute for adequate wiring and failed to prohibit power taps to be plugged into each other or "piggybacked". These deficient practices would increase the potential for an electrical fire. The facility census was 19 patients.

Findings are:
Observations on 1-29-19 between 9:55 AM and 10:59 AM revealed:
1. Refrigerator plugged into a power strip in room 1348 in the northeast corner.
2. Refrigerator plugged into a power strip in the northwest corner of Rehab workroom.
3. Refrigerator plugged into a power strip in the Medication Room.
4. Three-plex electrical adaptor used for a toaster and coffee maker in Radiology breakroom.
5. Power strip under the ED nurse station desk were piggy backed to each other.

During an interview on 1-29-19 between 9:55 AM and 10:59 AM, Administration Staff A confirmed multiple power strips and the electrical adaptor.

UL Standard:
Relocatable power taps are not intended to be piggybacked or daisy chained. UL 1363 User Guide for Relocatable Power Taps

NFPA Standard:
NFPA 70, 2011, 400.8
Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B)
(5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings
(6) Where installed in raceways, except as otherwise permitted in this Code
(7) Where subject to physical damage UL Standard: Relocatable power taps are not intended to be piggybacked or daisy chained. UL 1363 User Guide for Relocatable Power Taps

Based on record review and interview, the facility failed to assess the integrity, resistance, leakage current, and appropriate UL listing of power-strips used on medical equipment. This deficient practice would increase electrical injury and fire hazards. The facility has a capacity of 25 and a census of 18 patients at the time of the survey.

Findings are:
Record review on 1-29-19 at 1:45 PM, revealed the facility failed to provide an assessment of power strips before being placed into service, after modification or repair and at least annually thereafter.

During an interview on 1-29-19 at 1:45 PM, Administration Staff A stated that they were not aware of the requirement and failed to implement assessments of power strips.

NFPA Standard:
2012 NFPA 99
10.3 Testing Requirements - Fixed and Portable.
10.3.1* Physical Integrity. The physical integrity of the power cord assembly composed of the power cord, attachment plug, and cord-strain relief shall be confirmed by visual inspection.
10.3.2* Resistance.
10.3.2.1 For appliances that are used in the patient care vicinity, the resistance between the appliance chassis, or any exposed conductive surface of the appliance, and the ground pin of the attachment plug shall be less than 0.50 ohm under the following conditions:
(1) The cord shall be flexed at its connection to the attachment plug or connector.
(2) The cord shall be flexed at its connection to the strain relief on the chassis.
10.3.2.2 The requirement of 10.3.2.1 shall not apply to accessible metal parts that achieve separation from main parts by double insulation or metallic screening or that are unlikely to become energized (e.g., escutcheons or nameplates, small screws).
10.3.3* Leakage Current Tests.
10.3.3.1 General.
10.3.3.1.1 The requirements in 10.3.3.2 through 10.3.3.4 shall apply to all tests.
10.3.3.1.2 Tests shall be performed with the power switch ON and OFF.
10.3.3.2 Resistance Test. The resistance tests of 10.3.3.3 shall be conducted before undertaking any leakage current measurements.
10.3.3.3* Techniques of Measurement. The test shall not be made on the load side of an isolated power system or separable isolation transformer.
10.3.3.4* Leakage Current Limits. The leakage current limits in 10.3.4 and 10.3.5 shall be followed.