HospitalInspections.org

Based on a recertification survey, tests to doors and observations made during the life safety from fire with the facility's Plant Manager (employee #6), it was determined that the smoke barrier doors on the first floors ASC area and Operating room are not arranged to automatically close and failed to close flush when released as required by the 2012 edition of the Life Safety Code of the NFPA Section 7.2.1.8.2.

Findings include:

1. The smoke barrier doors on the first floor were observed on 6/22/17 at 10:35 am and provided evidence that they are left opened, they do not have hold open devices and they do not have positive latching, this can permit smoke, fire and noxious gases to enter the smoke compartments in the event of a fire.

2. The smoke barrier door on the operating room area did not close flush to its frame as observed on 6/22/17 at 10:40 am, this can permit smoke, fire and noxious gases to enter the smoke compartments in the event of a fire.

3. The door in the recovery room uneven and do not close properly.

Based on a recertification survey, observations made during the survey for life safety from fire with the Physical plant director (employee #6) and safety officer (employee #13), it was determined that the facility failed to ensure that emergency lighting (battery operated lamps) which provides light for a period of 90 minutes, enabling those inside to move about safely in an emergency are provided in some areas of the nuclear medicine department, emergency room in the hall way of intensive care unit the facility is not testing existing emergency lighting of the acute dialysis unit and surgery department for 30 seconds monthly and 90 minutes at least once a year as required by the 2012 edition of the Life Safety Code of the NFPA Section 7.9.

Findings include:

1. The facility lacks emergency lighting (battery operated lamps) for a period of 90 minutes as determined by the observational tour from 6/20/17 through 6/21/17 from 8:30 am until 4:00 pm in the following areas:

a. The corridor that leads from the kitchen area.
b. The fast track area (Sample blood area) of the emergency room with broken emergency lighting.
c. The Annex #1the emergency room.
d. The nuclear medicine department.
e. Hallway of the intensive care unit
f, Provisional food storage at the kitchen area

(Emergency lamps are required to ensure adequate lighting until the essential electrical system (generator) turns on or in the event that the essential electrical system fails as required since March of 2006).

Based on a recertification survey, observations made during the survey for life safety from fire with the facility's engineer (employee #6), it was determined that the facility failed to ensure that exits sign in the Emergency room and intensive care unit #1 has proper lighting in accordance with the 2012 edition of the Life Safety Code of the NFPA Section 7.10.1.

Findings include:

The Annex B Gastro room, CPR #8, Annex 1 in the emergency room and the intensive care unit #1 was visited on 6/22/17 from 8:30 am until 4:00 pm and provided evidence that an illuminated exit sign over the front door was found with a bulb that did not work (the light bulb did not illuminate).

Based on a recertification survey, observations made during the survey for life safety from fire, it was determined that the facility failed to provide evidence of tests and maintenance of the fire alarm system in accordance with the applicable requirements of NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Findings include:

1. Written evidence reviewed on 6/23/10 at 10:40 am about the tests to the fire alarm system and its components provided evidence that the facility could not provide written evidence of the following tests:

a. Visual inspections to the main control panel to verify trouble signals and check battery electrolyte level (monthly).

b. Smoke detectors tested in place to ensure smoke entry into sensing chamber and an alarm response (performed twice a year).

c. Ability of batteries to meet standby and alarm requirements shall be verified for corrosion and leakage, tightness of connections and battery terminals shall be cleaned (monthly).

d. Location of pull-down stations and tests (monthly).

e. Visible (strobe lights) and audible signal tests (monthly).

f. Smoke detector sensitivity tests (performed every two years).

Based on a recertification survey, the review of written documents related to the preventive maintenance of the fire alarm system and its components during the survey for life safety from fire with the facility's engineer (employee #6) , it was determined that the facility is not performing visual inspections, sensing chamber tests or battery tests to the fire alarm system in accordance with the National Fire Protection Association 70 and 72.

Findings include:

1. Written evidence reviewed on 6/23/17 at 10:45 am about the tests to the fire alarm system and its components indicates that they are not performing monthly tests that include some important tests such as:

a. Visual inspections to the main control panel to verify trouble signals and check battery electrolyte level.

b. All smoke detectors must be tested in place to ensure smoke entry into sensing chamber and an alarm response.

c. Ability of batteries to meet standby and alarm requirements shall be verified, corrosion and leakage, tightness of connections and battery terminals shall be cleaned.

d. Location of pull-down stations and tests.

Based on a recertification survey, observations made during the life safety from fire, it was determined that the facility failed to ensure that at a portable fire extinguishers is available in the provisional storage area, disposable storage of the Kitchen, Annex 2 in ER surgical medical storage, general storage pantry of the operating room area as required by the 2012 edition of the Life Safety Code of the NFPA Section 9.7.4.1 and NFPA 10.

Findings include:

1. The provisional storage and disposable storage of the kitchen was visited on 6/20/17 from at 9:10 am until 10:15 am and it was found that this area contains a large amount of boxes. There is not a smoke detector in both area. The placement of the fire extinguisher should be place near the entrance of every room in order to facilitate its use.

2.The storage room located on room #B in the Annex 2 it was observed on 6/20/17 at 11:05 am and it was found that the storage lack of smoke detector and fire extinguisher.

3. The general store was observed on 6/21/2017 from 8:52 am to 9:06 am, it was observed that there is only one extinguisher in an area of 3 compartments filled with boxes and surgical medical materials.

Based on a recertification survey, tests to doors and observations made during the survey for life safety from fire, it was determined that patient's doors protecting corridors at rooms #118 and #122 do not close completely (do not latch) as required by the 2012 edition of the Life Safety Code of the NFPA Section 19.3.6.3.

Findings include:

1.During the tour for life safety from fire on 6/22/17 at 2:40 pm, patient's sleeping room doors were tested it was found that patient's sleeping rooms #301 (open all the time with a trash can), #302, #303 (uneven)#306 (opened with trash can).

Interview with the Intensive Cardiovascular supervisor (employee # 35) on 6/22/17 at 3:10 pm stated "We maintain the doors open all the time because the patients ask for it. The patients says that they feel lonely when we close the doors. We know that the doors have to be close to prevent smoke escape in case of fire".

2.During the tour for life safety from fire on 6/22/17 from 10:30 am from 4:00 pm patient's sleeping room doors were tested it was found that patient's sleeping rooms and #400, #401 (broken lock), #403, #405, #407, #412 (Uneven door it was open all the time), #413 (uneven door open all the time), #414, #417, #501 (the door do not latch because there was a tape holding the lock), #502 (broken lock), #503 (uneven door open all the time), #505 (isolation room), #507 (broken lock), #509 (broken lock) and #515 (broken lock) do not latch when the doors are closed, this can permit smoke, fire and noxious gases to enter the rooms in the event of a fire. All doors at the hospital must be verified at least monthly and appropriate documentation must be available upon request.

Based on a recertification survey, observations and documents reviewed during the survey for life safety from fire with the physical plant engineer (employee #6) , it was determined that the facility failed to test electrical receptacles that are supplied by the essential electrical system at least twice a year in accordance with NFPA 99 Section 7-6.2.1.2.

Findings include:

Written evidence was reviewed on 6/23/17 at 10:40 am about preventive maintenance to the receptacles indicates that they are testing the receptacles supplied by the generator once a year. However, receptacles that are supplied by the essential electrical system (generator) supply power to critical care areas and equipment (cardiac monitors, life support equipment, Intensive Care Unit equipment and wet locations). Equipment or wiring faults can cause abnormal temperature increases, these abnormal temperatures may cause fire and explosions. Critical care areas, wet locations and areas where critical care equipment are plugged into the essential electrical receptacles are required to be tested in intervals not exceeding six months because even brief interruptions of power can cause malfunctions of some equipment and appliances.

Based on a recertification survey, observations made during the survey for life safety from fire with the facility's Physical Plant Director (employee # 6) and Safety officer (employee #13), it was determined that the facility failed to ensure that the emergency room and other wards have written plans for staff to follow with respect to their duties in the event of an emergency as required by the 2012 edition of the Life Safety Code of the NFPA Section 18.7.1.1.

Findings include:

No evidence was found on 6/23/17 at 10:00 am that emergency room personnel and ward personnel have a plan or assignments with specific tasks in the event of an emergency related to extinguisher use, circuit breaker shut off and oxygen valve shut off. All emergency personnel must be instructed related to their assignments and periodically tested for its implementation and the assignment must be posted for review by staff.

Interview with emergency room (ER) supervisor (employee # 1) on 6/21/17 at 9:45 am stated: "Here in this area we do not have oxygen valve. Everybody here have the knowledge of what to do in case of fire". Surveyor asked for the task distribution and employee #1 sated: "we do not have task distribution in case of fire or Evacuation of patients".

Based on a recertification survey, observations during the survey for Life safety from fire with the physical plant engineer (employee #6) and safety officer (employee #13), it was determine that the facility does not comply with other Life Safety Code requirements not in CMS-2786-R related to the storage of oxygen tanks, the lack of floor plans in the Emergency Room for adult, fire extinguisher test, defibrillator plugged into a receptacle that is supplied by the essential electrical system, Television and clock without being inspected by the facility.

Findings include:

1. Lack of floor plans were found in the Emergency Room adult department on 6/20/17 from 9:00 am until 4:00 pm.

2. When oxygen cylinders are not in use (connected to a patient), they are to be stored in an appropriate area as stated in the National Fire Protection Association (NFPA) 99. However, during the observational tour of the surgery area on 6/22/17 at 2:00 pm 1 type H oxygen tanks were found laydown on the floor on OR #A.

3. Television and clock were observed in the Cardiology intensive area as observed on 6/22/17 at 11:00 a.m. A total of one television and clock were observed in the cardiology intensive area without being inspected by the facility's safety officer and the infection control coordinator.