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Based on observations made on July 15, 2013, the facility failed to provide for appropriate NO EXIT signs at locations that may be mistaken for an exit and do not lead to the public way. These deficiencies have the potential to affect more than a limited number of patients, residents, staff and visitors in two of the three smoke compartments on the main floor of the building.

The findings include:

Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads NO EXIT per section 7.10.8.1 of the Life Safety Code. Further, such sign shall have the word NO in letters 2 in. (5 cm) high with a stroke width of 3/8 in. (1 cm) and the word EXIT in letters 1 in. (2.5 cm) high, with the word EXIT below the word NO.
Exception: This requirement shall not apply to approved existing signs.

1. A door from the Physical Therapy suite of the Critical Access Hospital to an enclosed courtyard has the potential to be mistaken for an exit as observed at 1:50 p.m. on July 15, 2013. The enclosed courtyard does not lead to the public way. An appropriate sign denoting that this was NO EXIT was not posted at this door.

2. A door from the main dining room of the Nursing Home to an enclosed courtyard has the potential to be mistaken for an exit as observed at 2:40 p.m. on July 15, 2013. The enclosed courtyard does not lead to the public way. An appropriate sign denoting that this was NO EXIT was not posted at this door

3. A door from the activity room of the Nursing Home to an enclosed balcony has the potential to be mistaken for an exit as observed at 2:40 p.m. on July 15, 2013. The enclosed balcony does not lead to the public way. An appropriate sign denoting that this was NO EXIT was not posted at this door.

Based on observations made on July 15, 2013 and past survey information, the facility did not ensure that there were two acceptable remote exits provided in the basement. This deficiency has the potential to affect all staff and visitors in the basement of the Nursing Home as no residents use the basement zone.

The findings include:

Based on observations made at 4:00 p.m. on July 15, 2013 and information from previous surveys, the interior stairway by the service elevator was not considered as an acceptable exit due to the lack of fire rated doors protecting its vertical openings. The stairway discharged onto the main or upper level and did not open onto an exit passageway.

NOTE: There are two other exits available, one from the basement directly to the exterior and one by means of a horizontal exit to the basement of the Personal Care unit. However, both of these exits were adjacent to each other and did not meet the criteria for being considered as remote from each other per section 7.5.1.4 of the Life Safety Code.

Based on observations made on July 15, 2013, the facility failed to assure that portable fire extinguishers were mounted at the proper height. These deficiencies have the potential to affect more than a limited number of patients, staff and visitors in one of the three smoke compartments on the main level of the building.

The findings include:

Portable extinguishers other than wheeled types shall be securely installed on the hanger or bracket supplied with them or placed in cabinets or wall recesses. In no case shall the clearance between the bottom of the supported extinguisher and the floor be less than 4 inches per sections 1-6.7 and 1-6.10 of NFPA 10, 1998 Edition. Extinguishers weighing less than or equal to 40 lb shall be installed so that the top of the extinguisher is not more than 5 feet (60 inches) above the floor.

1. The portable fire extinguisher located in the Laboratory of the Critical Access Hospital was measured at 2:30 p.m. on July 15, 2013. The top of the extinguisher was found to be 63 inches from the floor.

2. The portable fire extinguisher located in the X-Ray room of the Critical Access Hospital was measured at 2:32 p.m. on July 15, 2013. The top of the extinguisher was found to be 68 inches from the floor.

Based on observations and review of generator testing records made on July 15 and 16, 2013, the facility failed to provide for a functioning Type I Essential Electrical System due to failure of emergency generator to start within 10 seconds and failed to assure that an annual load test of the generator was performed. These deficiencies have the potential to affect all patients, residents, staff and visitors in the building.

The findings include:

The emergency electrical system shall have an alternate source of power separate and independent from the normal source that will be effective for a minimum of 1 and 1/2 hours after loss of the normal source per section 3-6.3.1.1 of NFPA 99, 1999 Edition. Further, in accordance with 3-6.3.1.2 of NFPA 99 the emergency electrical system shall be so arranged that, in the event of failure of normal power source, the alternate source of power (emergency generator) shall be automatically connected to the load within 10 seconds.

1. An attempt was made to exercise the diesel powered "Generac 177 KW" emergency generator at 7:54 a.m. on July 16, 2013. The generator would not start after two attempts were made.

Generator sets in Level 1 and Level 2 emergency electrical systems shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods: (a) Under operating temperature conditions or at not less than 30 percent of the generator nameplate rating or (b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer per section 6-4.2 of NFPA 110, 1999 Edition. In accordance with 6-4.2.2 of NFPA 110 diesel-powered emergency generators that do not meet the requirements of 6-4.2 shall be exercised monthly with the available load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

2. The generator test records and service reports were reviewed at the facility on July 15 and 16, 2013. No documentation was available that the monthly load tests conducted by the facility met the 30 percent nameplate rating of the generator nor was there any documentation that the generator had been tested by an independent contractor to meet the requirements of 6-4.2 of NFPA 110 for an annual load test.

Based on observations made on July 15, 2013, the facility failed to maintain the electrical system and/or its components in accordance with the standards of the National Electrical Code, NFPA 70, 1999 Edition or interpretations from the Centers for Medicare and Medicaid Services (CMS). These deficiencies have the potential to affect more than a limited number of patients, residents, staff and visitors in all three of the smoke compartments on the main level and staff and visitors in the basement of the building.

The findings include:

No overcurrent device shall be connected in series with any conductor that is intentionally grounded per Article 240-22 of NFPA 70. Note: UL listing guidelines for relocatable power taps/power strips, being XBYS, notes that these strips are not intended to be in series connected or daisy chained to other power strips or extension cords.

1. One power strip was plugged into another power strip (in series or daisy chained) in the Operating Room of the Critical Access Hospital as observed at 1:57 p.m. on July 13, 2013.

Fixtures, lampholders, and receptacles shall be securely supported per Article 410-15 of NFPA 70.

2. A junction box for electrical receptacles was hanging by its flexible conduit and not permanently mounted or secured to a surface in the Laboratory of the Critical Access Hospital as observed at 2:27 p.m. on July 15, 2013.

Extension cords (including power strips) or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings.

3. A multiple adaptor in use in the Nursing Home Solarium was not provided with a built-in circuit breaker as observed at 2:55 p.m. on July 15, 2013.

Fixtures, lampholders, lamps, and receptacles shall have no live parts normally exposed to contact per Article 410-3 of NFPA 70.

4. The wiring servicing the receptacle above the mirror in Nursing Home room 15 was covered with electrical tape and parts of the wire were exposed to contact due to not being placed in conduit as observed at 3:21 p.m. on July 15, 2013.

Listed or labeled equipment, including light fixtures, shall be installed and used in accordance with any instructions included in the listing or labeling of the equipment by the manufacturer per Article 110-3 of NFPA 70

5. The light fixtures in the basement medical records store room were examined at 4:16 p.m. on July 15, 2013. Four of the fixtures had tin type pie pans that had been cut to fit around the light bulbs to act as a reflective base for the lights. These tin type pie pans were not part of the listed fixture assembly for this type of light.

Based on observations made on July 15, 2013, the facility failed to provide for appropriate NO EXIT signs at locations that may be mistaken for an exit and do not lead to the public way. These deficiencies have the potential to affect more than a limited number of patients, residents, staff and visitors in two of the three smoke compartments on the main floor of the building.

The findings include:

Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads NO EXIT per section 7.10.8.1 of the Life Safety Code. Further, such sign shall have the word NO in letters 2 in. (5 cm) high with a stroke width of 3/8 in. (1 cm) and the word EXIT in letters 1 in. (2.5 cm) high, with the word EXIT below the word NO.
Exception: This requirement shall not apply to approved existing signs.

1. A door from the Physical Therapy suite of the Critical Access Hospital to an enclosed courtyard has the potential to be mistaken for an exit as observed at 1:50 p.m. on July 15, 2013. The enclosed courtyard does not lead to the public way. An appropriate sign denoting that this was NO EXIT was not posted at this door.

2. A door from the main dining room of the Nursing Home to an enclosed courtyard has the potential to be mistaken for an exit as observed at 2:40 p.m. on July 15, 2013. The enclosed courtyard does not lead to the public way. An appropriate sign denoting that this was NO EXIT was not posted at this door

3. A door from the activity room of the Nursing Home to an enclosed balcony has the potential to be mistaken for an exit as observed at 2:40 p.m. on July 15, 2013. The enclosed balcony does not lead to the public way. An appropriate sign denoting that this was NO EXIT was not posted at this door.

Based on observations made on July 15, 2013 and past survey information, the facility did not ensure that there were two acceptable remote exits provided in the basement. This deficiency has the potential to affect all staff and visitors in the basement of the Nursing Home as no residents use the basement zone.

The findings include:

Based on observations made at 4:00 p.m. on July 15, 2013 and information from previous surveys, the interior stairway by the service elevator was not considered as an acceptable exit due to the lack of fire rated doors protecting its vertical openings. The stairway discharged onto the main or upper level and did not open onto an exit passageway.

NOTE: There are two other exits available, one from the basement directly to the exterior and one by means of a horizontal exit to the basement of the Personal Care unit. However, both of these exits were adjacent to each other and did not meet the criteria for being considered as remote from each other per section 7.5.1.4 of the Life Safety Code.

Based on observations made on July 15, 2013, the facility failed to assure that portable fire extinguishers were mounted at the proper height. These deficiencies have the potential to affect more than a limited number of patients, staff and visitors in one of the three smoke compartments on the main level of the building.

The findings include:

Portable extinguishers other than wheeled types shall be securely installed on the hanger or bracket supplied with them or placed in cabinets or wall recesses. In no case shall the clearance between the bottom of the supported extinguisher and the floor be less than 4 inches per sections 1-6.7 and 1-6.10 of NFPA 10, 1998 Edition. Extinguishers weighing less than or equal to 40 lb shall be installed so that the top of the extinguisher is not more than 5 feet (60 inches) above the floor.

1. The portable fire extinguisher located in the Laboratory of the Critical Access Hospital was measured at 2:30 p.m. on July 15, 2013. The top of the extinguisher was found to be 63 inches from the floor.

2. The portable fire extinguisher located in the X-Ray room of the Critical Access Hospital was measured at 2:32 p.m. on July 15, 2013. The top of the extinguisher was found to be 68 inches from the floor.

Based on observations and review of generator testing records made on July 15 and 16, 2013, the facility failed to provide for a functioning Type I Essential Electrical System due to failure of emergency generator to start within 10 seconds and failed to assure that an annual load test of the generator was performed. These deficiencies have the potential to affect all patients, residents, staff and visitors in the building.

The findings include:

The emergency electrical system shall have an alternate source of power separate and independent from the normal source that will be effective for a minimum of 1 and 1/2 hours after loss of the normal source per section 3-6.3.1.1 of NFPA 99, 1999 Edition. Further, in accordance with 3-6.3.1.2 of NFPA 99 the emergency electrical system shall be so arranged that, in the event of failure of normal power source, the alternate source of power (emergency generator) shall be automatically connected to the load within 10 seconds.

1. An attempt was made to exercise the diesel powered "Generac 177 KW" emergency generator at 7:54 a.m. on July 16, 2013. The generator would not start after two attempts were made.

Generator sets in Level 1 and Level 2 emergency electrical systems shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods: (a) Under operating temperature conditions or at not less than 30 percent of the generator nameplate rating or (b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer per section 6-4.2 of NFPA 110, 1999 Edition. In accordance with 6-4.2.2 of NFPA 110 diesel-powered emergency generators that do not meet the requirements of 6-4.2 shall be exercised monthly with the available load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

2. The generator test records and service reports were reviewed at the facility on July 15 and 16, 2013. No documentation was available that the monthly load tests conducted by the facility met the 30 percent nameplate rating of the generator nor was there any documentation that the generator had been tested by an independent contractor to meet the requirements of 6-4.2 of NFPA 110 for an annual load test.

Based on observations made on July 15, 2013, the facility failed to maintain the electrical system and/or its components in accordance with the standards of the National Electrical Code, NFPA 70, 1999 Edition or interpretations from the Centers for Medicare and Medicaid Services (CMS). These deficiencies have the potential to affect more than a limited number of patients, residents, staff and visitors in all three of the smoke compartments on the main level and staff and visitors in the basement of the building.

The findings include:

No overcurrent device shall be connected in series with any conductor that is intentionally grounded per Article 240-22 of NFPA 70. Note: UL listing guidelines for relocatable power taps/power strips, being XBYS, notes that these strips are not intended to be in series connected or daisy chained to other power strips or extension cords.

1. One power strip was plugged into another power strip (in series or daisy chained) in the Operating Room of the Critical Access Hospital as observed at 1:57 p.m. on July 13, 2013.

Fixtures, lampholders, and receptacles shall be securely supported per Article 410-15 of NFPA 70.

2. A junction box for electrical receptacles was hanging by its flexible conduit and not permanently mounted or secured to a surface in the Laboratory of the Critical Access Hospital as observed at 2:27 p.m. on July 15, 2013.

Extension cords (including power strips) or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings.

3. A multiple adaptor in use in the Nursing Home Solarium was not provided with a built-in circuit breaker as observed at 2:55 p.m. on July 15, 2013.

Fixtures, lampholders, lamps, and receptacles shall have no live parts normally exposed to contact per Article 410-3 of NFPA 70.

4. The wiring servicing the receptacle above the mirror in Nursing Home room 15 was covered with electrical tape and parts of the wire were exposed to contact due to not being placed in conduit as observed at 3:21 p.m. on July 15, 2013.

Listed or labeled equipment, including light fixtures, shall be installed and used in accordance with any instructions included in the listing or labeling of the equipment by the manufacturer per Article 110-3 of NFPA 70

5. The light fixtures in the basement medical records store room were examined at 4:16 p.m. on July 15, 2013. Four of the fixtures had tin type pie pans that had been cut to fit around the light bulbs to act as a reflective base for the lights. These tin type pie pans were not part of the listed fixture assembly for this type of light.