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Based on observation the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter Chapter 18, Section 18.3.6.3.1, 18.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 18.18.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 18, 18.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On June 21, 2011 the surveyor, accompanied by the Facility Engineer observed the following corridor doors would not positively latch when tested three out of three times.

1. Rooms 202, 205, 206, 210, 212, 213, 324
2. The double corridor doors between the Administration hallway and Emergency area a gap was observed in between the rated double doors of approximately 1/4 to inch when the doors were closed.
3. MRI/CTscan room the corridor double doors were observed to have a gap in between the double doors when closed of approximately 1/4 to 1/2 inch.

During the exit conference on June 21, 2011 the above findings were again acknowledged by the Interim President/CEO and the Director of Facilities Management.

In time of a fire, failing to protect patients from heat and smoke could cause harm to the patients.

Based on observations the facility failed to fill penetrations in the smoke barriers.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of at least ? hour." (1 Hour New) Chapter 6, Section 8.3.6. "Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:"

(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke
barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.

(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the
smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

(b) It shall be protected by an approved device that is designed for the specific purpose.

(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the
following conditions:
(a) It shall be made on either side of the smoke barrier.

(b) It shall be made by an approved device that is designed for the specific purpose.

Findings Include:

On June 21, 2011 the surveyor accompanied by the Facility Engineer observed unsealed penetrations in the smoke barriers.

1. Smoke barriers penetrations by the the 2nd floor staff elevators and the doors did not latch three out of three times when tested.
2. Smoke barrier penetrations by the 2nd floor nurses station.

During the exit conference on June 21, 2011 the above findings were again acknowledged by the Interim President /CEO and the Director of Facilities Management

Smoke from a fire will involve other wings or possibly the whole facility if the smoke barriers provided are penetrated which will cause harm to residents/patients.

Based on observations the facility did not maintain the integrity, smoke resistance, of walls, doors or ceilings in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 18, Section 18.9.3.2.1 Requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls and doors must be able to resist the passage of smoke.

Findings include:

On June 21, 2011 the surveyors, accompanied by either the Facility Engineer or the Director of Facilities Management observed the following locations had either conduit penetrations, holes in walls or the doors were not smoke resistant.

1. Central Sterilization conduit penetrations
2. Fourth floor main electrical room conduit penetrations
3. IT Data room conduit penetrations
4. The lab storage room rated door had the door latching mechanism removed from the door.
5. The Pharmacy storage room rated door was tied in the open position and the latching mechanism was taped over with tape.
6. The Cath Lab storage room rated door was propped open with a table.
7. The rated door from the grill to the kitchen had the self closure removed from the door.

During the exit conference on June 21, 2011 the above findings were again acknowledged by the Interim President/CEO and the Director of Facilities Management

The pipe chases or holes could allow heat and smoke to spread into walls, attics, or exit corridors which could cause harm to the patients. Impediments to doors or propping doors in the open position or removing door closures on rated doors will allow smoke and heat to effect other areas of the facility which could cause harm to the patients.

Based on observation the facility failed to assure that exits from the building were each illuminated by more than a single light source.

NFPA 101 Life Safety Code 2000, Chapter 18, Section 18.2.1 Section 18.2.1 "Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7", Section 7.8.1.4, "Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2 Lux) in any designated area.

Findings Include:

On June 21, 2011 the surveyors, accompanied by the Facility Engineer and the Director of Facilities Management observed the exit discharge lighting at the exits in the hospital. The surveyor upon talking to the Director of Facilities Management after checking a few exits advised there are about ten exits with only one bulb at the exit discharge illuminated by a single-bulb light fixture."

During the exit conference on June 21, 2011 the above findings were again acknowledged by the Interim President/CEO and the Director of Facilities Management

In an emergency, the failure of the one bulb could result in harm to the residents.

Based on records review the facility failed to document monthly and annual testing of the battery back up emergency lighting units in the operating rooms.

NFPA 101, Life Safety Code, 2000, Chapter 18, Section 18.2.9.1, "Emergency lighting shall be provided in accordance with Section 7.9". Section 7.9.3 " Periodic Testing of Emergency Lighting Equipment" " A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction."

Findings include:

On June 21, 2011 the surveyor, accompanied by the Director of Facilities Management, advised the surveyor there was no current or past documentation for the testing of the battery backup emergency lighting units for operating rooms one through four.

During the exit conference on June 21, 2011 the above findings were again acknowledged by the Interim President /CEO and the Director of Facilities Management

Failing to test and maintain emergency lighting units could cause harm to the patients in a power outage.

Based on observations the facility failed to provide a written plan for the protection of all patients in time of a fire or emergency.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.7.1.1 "The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of a fire, for their evacuation to areas of refuge, and from the evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator's position or at the security center.

Findings Include:

On June 21, 2011 the surveyors, accompanied by the Facility Engineer and the Director of Facilities Management asked to see the written emergency policy manual at the nurse's stations throughout the hospital floors two and three and the emergency room. The written fire and emergency policy manual was not found at the nursing stations at these locations. The staff at the nurses stations throughout the hospital when asked "where is the fire procedure manual," answered the fire procedures were on the computers." There are no manuals at these locations." This was also confirmed by the Director of Facilities Management while reviewing documentation for the facility. He advised a manual is only on the first floor at the Main nurses office.

During the exit conference on June 21, 2011 the above findings were again acknowledged by the Interim President /CEO/Director Network of Facilities Management.

In time of a fire, or emergency, an emergency policy manual must be readily available for the staff. Patients could be harmed if the Staff is not trained or is unable to locate the emergency evacuation policy manual.

Based on observations the facility failed to clean the kitchen exhaust hood system, filters and grease drip tray.

NFPA 101 Life Safety Code 2000, Chapter 18, Section 18.3.2.6 "Cooking facilities shall be protected in accordance with 9-2.3" Section 9-2.3 "Commercial cooking equipment shall be installed in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations." , Chapter 8, Section 8-3.1, " Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge".

Findings include:

On June 21, 2011 the surveyor accompanied by the Facility Engineer, Executive Chef and Line Cook observed the kitchen short order fry line and the patient service line exhaust system hood, filters and grease drip tray area had an excessive amount of grease buildup on the hood baffle plates."The chef and line cook when asked how often they are cleaned advised the hood baffle plates are cleaned only once a week."

During the exit conference on June 21, 2011 the above findings were again acknowledged by the Interim President /CEO/Director Network of Facilities Management.

Failing to keep the entire kitchen exhaust hood system clean from grease could cause a fire, which could cause damage to the kitchen and could cause harm to the patients.

Based on observations the facility failed to provide a medical gas cylinder storage rooms or areas free of combustible materials and failed to mount electrical receptacles five feet above the floor in several oxygen storage locations in the hospital.

NFPA 101 Life Safety Code, Chapter 18, Section 18.3.2.4 " Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 Chapter 8, Storage Requirements, Section 8-3.1.11.2 Storage for nonflammable gases less than 3000 cubic feet." (a) "Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. (c) "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by: (c) (2) A minimum distance of 5 ft. if the entire storage location is protected by an automatic sprinkler system..." NFPA 99 Chapter 8 Storage requirements, Section 8-3.1.11.2 Storage for nonflammable gases less than 3000 cubic feet. (f) Electrical fixtures in storage locations shall meet 4-3.1.1.2 (a) 11d. Section 4-3.1.1.2 (a) 11(d) Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft. (1.5m) above the floor to avoid physical damage.

Findings include:

On June 21, 2011 the surveyors, accompanied by the Facility Engineer and the Director of Facilities Management observed oxygen bottles being stored next to combustibles i.e. medical supplies/storage/ boxes, trash containers, wood pallets etc:were stored adjacent to wall mounted electric light switches or receptacles outlets which were mounted approximately two to three and a half feet (3.5ft) above the floor. in the following locations:

1.1st floor main delivery room crash carts being stored with oxygen and next to combustible storage.
2. Pacu storage North and South 1st floor
3. Cath Lab clean Utility room 1st floor
4. The 1st floor main medical gas storage room did not have signs posted to indicate the empty and full oxygen bottles.
5. Respiratory Clean Therapy 2nd floor
6. Clean Utility in Radiology

During the exit conference on June 21, 2011 the above findings were again acknowledged by the Interim President /CEO and the Director of Facilities Management

Leaking oxygen will penetrate combustible material and create an extreme fire hazard, which could cause harm to the patients. During movement of medical gases cylinders electrical receptacles mounted below five feet could be damaged which could cause a short or a fire which could cause harm to the patients.

Based on record review the facility failed to document the required testing of the emergency generator.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.9.7.6 " Maintenance and Testing (See 4.6.12) Section 4.6.12.2 " Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 99 "HEALTH CARE FACILITIES". Chapter 3, Section 3-5.4.1.1 (a) and Section 3-4.4.1.1 (b) "Generator sets shall be tested twelve (12) times a year... Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Chapter 6, Section 6-4.1 "Level 1 and Level 2 EPSSs, including all appurtenant components shall be inspected weekly and shall be exercised under load at least monthly. NFPA 110, Chapter 6, Section 6-4.2 "Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes...
Chapter 3, Section 3-4.1.1.8. (Level/Type 1) "The generator sets shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power.
or Section 3-5.3.1 (Level/Type 2) "The emergency system shall be installed and connected to the alternate source of power specified in 3-4.1.1.2 and 3-4.1.1.3 so that all functions specified herein for the emergency system will be automatically restored to operation within 10 seconds after interruption of the normal source."

Findings Include:

On June 21, 2011, the surveyor, accompanied by the Director of Facilities Management reviewed the generator test records. No documentation of weekly inspections were documented from 2010 to the second week of June 2011 indicating the oil, water, fuel, belts, hoses, and battery were visually checked except for the week of January 05, 2010. There was no transfer time from normal power to emergency power the number of seconds 10 seconds or less for the month of July 2010 documented on the generator form shown to the surveyor.

During the exit conference on June 21, 2011 the above findings were again acknowledged by the Interim President /CEO/Director Network of Facilities Management.

Failure to test the emergency generator under load, inspect weekly, and document time from normal power to emergency power could result in harm to patients during lighting system failures.

Based on record review the facility failed to test and document the monthly testing of the Line Isolation Monitor tests/Isolated Electrical Panels.

NFPA 101, Life Safety Code, 2000 Edition, Chapter 18. Section 18.7.6 Maintenance and Testing (See 4.6.12) "Maintenance and Testing "Section 4.6.12.1, "Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction."

"NFPA 99 1999 Edition, Health Care Facilities Section 3-3.3.4.2 The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following: (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 that 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators."

Findings include:

On June 21, 2011 the surveyor, accompanied by the Director of Facilities Management, advised the surveyor during the documentation review there was no current or past documentation to indicate the testing of the Line Isolation Tests for the Isolated Electrical Panels in operation rooms one through four

During the exit conference on June 21, 2011 the above findings were again acknowledged by the Interim President /CEO and the Director of Facilities Management

Failing to test and maintain documentation on the Line Isolation Tests/Isolated Electrical Panels could cause harm to the patients in an emergency or power outage.

Based on record review the facility failed to provide documentation of the monthly elevator recall testing.

NFPA 101 Life Safety Code, Chapter 18, Section 18.5.3. Elevators, Escalators and Conveyors. Elevators, escalators and conveyors shall comply with the provisions of Section 9.4 Section 9.4.6 Elevator testing Elevators shall be subject to routine and periodic inspections and tests as specified in ASME/ANSI A17.1, Safety Code for Elevators and Escalators. All elevators equipped with firefighter service in accordance with 9.44 and 9.4.5 shall be subject to a monthly operation with a written record of the findings made ans kept on the premises as required by ASME/ANSI A17.1 Safety Code for Elevators and Escalators.

Findings include:

On June 21, 2011 the surveyor, accompanied by the Director of Facilities Management, advised the surveyor during the documentation review there was no current or past documentation to indicate the testing of the facility monthly recall testing for the elevators.

During the exit conference on June 21, 2011 the above findings were again acknowledged by the Interim President /CEO and the Director of Facilities Management

Failing to conduct monthly tests and maintain records could cause harm to the patients in an emergency.