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Based on observation, the facility failed to keep the means of egress open to full and instant use in accordance with NFPA 101, 2012 Edition, Sections 7.1.10.1.

Findings include:

1. 1. During an observation on 08/21/2023 at 3:11 p.m., the back service corridor emergency exit door was observed. Black duct tape was observed attached to the bottom of the door, restricting the door from being able to open.

2. During an observation on 08/22/2023 at 6:10 a.m., the surgery clean-side emergency exit door was observed. Duct tape was observed attached to the bottom of the door, restricting the door from being able to open.

3. During an observation on 08/22/2023 at 6:45 a.m., the cafe was inspected. The emergency exit doors were observed. One of the exits was blocked from access by a shelving unit with food being stored in front of it.

Based on observation, the facility failed to:

a) maintain egress doors with only one releasing operation in accordance with NFPA 101, 2012 Edition, Sections 7.2.1.5., 10.2.;
b) properly post mandatory signs regarding the function of the delayed egress on the exit doors as required by the code in accordance with NFPA 101, 2012 Edition, Sections 19.2.2.2.4 and 7.2.1.6.

Findings include:

1. During an observation on 08/22/2023 at 3:51 p.m., the acute care soiled utility room was inspected. Both doors leading to the room were equipped with deadbolt locks which required more than one motion to open the doors. The room had the capacity to hold three or more people.

2. During an observation on 08/22/2023 at 6:23 a.m., the emergency room exam room #3 was observed. The door leading to the room was equipped with a deadbolt lock which required more than one motion to open the door. The room had the capacity to hold three or more people.

3. During an observation on 08/22/2023 at 6:39 a.m., the Urgent Care entry doors were observed. The doors were equipped with a delayed egress function, but no delayed egress signage was present.

4. During an observation on 08/22/2023 at 6:45 a.m., the basement clininc HR double doors were observed. The doors were equipped with deadbolt locks.

5. During an observation on 08/22/2023 at 7:45 a.m., the old surgery across from the kitchen corridor doors were observed. The doors were equipped with tumbler locks.



6. During an observation on 08/22/2023 at 7:40 a.m., the women's bathroom was inspected. The door leading to the room was equipped with a deadbolt lock which required more than one motion to open the door. The room had the capacity to hold three or more people.

Based on observation, the facility failed to ensure corridor doors with automatic self-closing devices were maintained in accordance with NFPA 101-2012, Section 19.2.2.2.7 and section 19.2.2.2.8.

Findings include:

1. During an observation on 08/21/2023 at 2:51 p.m., the mechanical room door was exercised. The door would not close and latch under the power of the self-closer.

2. During an observation on 08/21/2023 at 3:43 p.m., the acute care soiled utility room door was exercised. The door would not close and latch under the power of the self-closer.

3. During an observation on 08/21/2023 at 3:44 p.m., the acute care electrical room door was exercised. The door would not close and latch under the power of the self-closer.

4. During an observation on 08/21/2023 at 3:49 p.m., the acute care housekeeping closet door was exercised. The door would not open a full 90 degrees, as a large shelving unit was found to be stored behind the door.

5. During an observation on 08/21/2023 at 3:54 p.m., the acute care staff bathroom door was exercised. The door would not close and latch under the power of the self-closer.

6. During an observation on 08/22/2023 at 6:04 a.m., the clean CSR room door was exercised. The door would not close and latch under the power of the self-closer.

7. During an observation on 08/22/2023 at 6:15 a.m., the recovery patient bath door was exercised. The door would not close and latch under the power of the self-closer.

8. During an observation on 08/22/2023 at 6:17 a.m., the recovery entrance door was observed. The door would not close and latch under the power of the self-closer, as it was observed being held open with a rubber wedge.

9. During an observation on 08/22/2023 at 6:25 a.m., the triage back door was exercised. The door would not close and latch under the power of the self-closer.

10. During an observation on 08/22/2023 at 6:48 a.m., the Urgent Care bathroom door was exercised. The door would not close and latch under the power of the self-closer.

11. During an observation on 08/22/2023 at 7:47 a.m., the basement ladies lounge door was exercised. The door would not close and latch under the power of the self-closer.

12. During an observation on 08/22/2023 at 7:57 a.m., the back kitchen loading dock door was exercised. The door would not close and latch under the power of the self-closer.

13. During an observation on 08/22/2023 at 8:01 a.m., the kitchen janitor closet door was exercised. The door would not close and latch under the power of the self-closer.

14. During an observation on 08/22/2023 at 8:06 a.m., the cafeteria door was exercised. The door would not close and latch under the power of the self-closer.

Based on observation, the facility failed to ensure latching fire/smoke barrier doors were maintained per NFPA 101-2012, Section 19.3.7.8. and 4.2.3, and 4.6.12.

Findings Include:

1. During an observation on 08/21/2023 at 3:04 p.m., the 2-hour rated fire door in the business office on the second floor was exercised. The door failed to completely close and latch.

2. During an observation on 08/21/2023 at 3:06 p.m., the 2-hour rated fire doors leading to acute care from the surgery corridor were exercised. The doors failed to completely close and latch.

3. During an observation on 08/21/2023 at 3:04 p.m., the 2-hour rated fire door in the business office off the elevator leading to acute care was exercised. The door failed to completely close and latch.

4. During an observation on 08/21/2023 at 3:36 p.m., the smoke rated doors from acute care entering the ED corridor were exercised. The doors failed to completely close and latch.

5. During an observation on 08/22/2023 at 6:57 a.m., the clinic basement middle corridor doors were exercised. The doors failed to completely close and latch.

6. During an observation on 08/22/2023 at 8:38 a.m., the 2-hour rated fire doors leading to TCU were exercised. The doors failed to completely close and latch.

Based on observation, the facility failed to maintain the kitchen hood extinguishing system in accordance with NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 Edition, Sections 10.5.1, and 11.2.1

Findings include:

1. During an observation on 08/22/2023 at 8:03 a.m., the kitchen was inspected. The manual pull station to the kitchen hood extinguishing system was observed, blocked by a large cart being stored in front of it.

Based on observation, the facility failed to ensure alcohol-based hand rub (ABHR) dispensers were not mounted over ignition sources in accordance with NFPA 101, 2012 Edition, Section 19.3.2.6 (8).

Findings include:

1. During an observation on 08/21/2023 at 3:45 p.m., the acute care hallway outside patient room 109 was inspected. There was an ABHR dispenser mounted over a receptacle in the area.

2. During an observation on 08/21/2023 at 3:46 p.m., the acute care hallway outside patient room 108 was inspected. There was an ABHR dispenser mounted over a receptacle in the area.

3. During an observation on 08/21/2023 at 3:47 p.m., the acute care hallway outside patient room 107 was inspected. There was an ABHR dispenser mounted over a receptacle in the area.

Based on observation the facility failed to ensure sprinkler heads were installed clear of ceiling mounted fixtures in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.6.5.2 and Table 8.6.5.1.2.

Findings Include:

1. During an observation on 08/22/2023 at 6:47 a.m., the Urgent Care bathroom was inspected. Two sprinkler heads were observed, installed within two feet of each other.

2. During an observation on 08/22/2023 at 6:54 a.m., the IT storage room was inspected. A ceiling mounted light fixture was observed, obstructing a sprinkler head. The head was within 12 inches of the light, and the light was lower than the deflector on the sprinkler head.

3. During an observation on 08/22/2023 at 6:55 a.m., the IT room was inspected. A ceiling mounted light fixture was observed, obstructing a sprinkler head. The head was within 12 inches of the light, and the light was lower than the deflector on the sprinkler head.

Based on observation, the facility failed to:

a) maintain the monthly gauge readings on all of the sprinkler risers per NFPA 25-2011, Sections 5.2.4.1 and 5.2.4.2;
b)ensure sprinkler pipes were free of external loads in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.2.2.; and
c)ensure sprinkler systems maintained satisfactory performance with respect to activation time in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.1.1(3).

Findings include:

1. Review of inspection reports for the facility's wet sprinkler system on 08/21/2023, showed the facility lacked documentation of the monthly pressure gauge readings for the facilities wet sprinkler system.

2. During an observation on 08/21/2023 at 3:20 p.m., the IT closet was inspected. Two ceiling tiles were observed, missing from the ceiling structure within the room.

3. During an observation on 08/21/2023 at 3:41 p.m., the acute care IT room was inspected. A ceiling tile was observed, missing from the ceiling structure within the room.

4. During an observation on 08/22/2023 at 6:50 a.m., the clinic basement storage room was observed. Four areas were observed, where cords were connected to the sprinkler pipe within the room.

5. During an observation on 08/22/2023 at 6:52 a.m., the paint room was inspected. A cord was observed, attached to the sprinkler pipe within the room.

6. During an observation on 08/22/2023 at 7:21 a.m., air handler room #2 was inspected. A black cord was observed, zip tied to the wet sprinkler pipe within the room.

7. During an observation on 08/22/2023 at 7:39 a.m., the basement IT closet was inspected. A ceiling tile was observed, missing from the ceiling structure within the room.

8. During an observation on 08/22/2023 at 8:08 a.m., the kitchen janitor closet was inspected. Storage was observed, within 18 inches of the sprinkler head within the room.

9. During an observation on 08/22/2023 at 8:08 a.m., the dietary supply store room was inspected. One of the sprinkler heads within the room was observed to be missing its escutcheon ring.

10. During an observation on 08/22/2023 at 8:09 a.m., the IT phone room was inspected. Two ceiling tiles were observed, missing from the ceiling structure within the room.

Based on observation, the facility failed to maintain access to portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.3.1.

Findings include:

1. During an observation on 08/22/2023 at 7:03 a.m., the radiology exam room #2 was inspected. There was a portable extinguisher in the room which was blocked from access by three sharps disposal containers being stored in front of it.

2. During an observation on 08/22/2023 at 7:30 a.m., the physical therapy room was inspected. There was a portable fire extinguisher in the room which was blocked from access by a trash receptacle being stored in front of it.

Based on observation, the facility failed to ensure fire/smoke barrier doors located in the fire/smoke partitions were maintained per NFPA 101-2012, Section 8.4.3.4 and NFPA 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition, Section 6.3.1.7.1, and NFPA 101-2012, Section 19.3.7.8.

Findings include:

1. During an observation on 08/22/2023 at 8:18 a.m., the behavioral health entry 45-minute fire/smoke doors were inspected. The doors were not tight enough when closed. The gap between the doors was at least 1/2" wide. Doors cannot have a gap of more than 1/8" when closed.

Based on observation, the facility failed to utilize portable space heaters in a health care occupancy in accordance with NFPA 101, 2012 Edition, Section 19.7.8.

Findings Include:

1. During an observation on 08/21/2023 at 3:38 p.m., the acute care nursing station was inspected. There was a portable space heater plugged into the wall within the area.

2. During an observation on 08/21/2023 at 3:40 p.m., the social services office was inspected. There was a portable space heater plugged into the wall and being used.

Actual NFPA Standard: NFPA 101 Life Safety Code (2012)
19.7.8 Portable Space-Heating Devices. Portable space-heating devices shall be prohibited in all health care occupancies, unless both of the following criteria are met:
(1) Such devices are used only in non-sleeping staff and employee areas.
(2) The heating elements of such devices do not exceed 212°F (100°C).

Based on record review and observation, the facility failed to meet acceptable standards in the performance of medical gas systems verification/inspection per NFPA 99, 2012 code.

Findings include:

1. Record review of the facilities Medical Gas Piping and Vacuum Systems Annual Preventative Maintenance Verification for Health Care Facilities, dated 05/16/2023, showed:

a) The newly remodeled ICU is not monitored by an area alarm.

b) All of the older style Puritan Bennet area alarms are very quiet and may not meet the 80 db @ 3' requirement. The alarm monitoring the LDR cannot be heard from the area being served.

c) The line pressure gauge for the X-Ray room 2 and CT scan is located upstream of the zone valves.

d) The Anesthesia room in the new surgery center contains medical gases, but no zone valve was identified for the area.

e) The Old Surgery Trauma Zone Valve is labeled "Not In Use", but an oxygen outlet is still being fed with oxygen from an unknown source.

f) There is a line pressure sensor and a line pressure gauge located immediately after the medical air and medical vacuum source valve, but they are not connected with DISS connectors.

g) The Medical Air intake is not located above the roof line, and is not screened for protection.

h) Unable to identify the location of the Medical Surgical Vacuum exhaust to identify if it meets NFPA 99 Standards.

i) The Source Valve for the bulk oxygen is not labeled properly.

j) The green LED bulb that indicates the Medical Air Compressor is activated is burnt out for the left on/off switch facing the unit.

k) The carbon monoxide monitor would only reach 10 PPM CO when 20 PPM CO was input. Attempted CO calibration. Calibration failed.

l) The maintenance office was moved from its previous location that contained the master alarm panel. The old maintenance office has become the computer lab and does not have any type of monitoring for the medical gas alarms. The master alarm panel should be moved to the new maintenance office.

Based on observations, the facility failed to maintain electrical rooms with sufficient working space around electrical panels in accordance with NFPA 70 National Electric Code, 2011 Edition, Article 110-26 (E) (1) (a) through (E) (1) (d).

Findings include:

1. During an observation on 08/22/2023 at 7:04 a.m., the radiology exam room #2 was inspected. The electrical panel in the room was blocked from easy access by various items being stored in front of it.

2. During an observation on 08/22/2023 at 8:18 a.m., the behavioral health housekeeping closet was inspected. A large dental chair was observed, being stored in front of the electrical panel within the room.

Based on observation and record review, the facility failed to maintain documentation of inspections on all Patient-Care Related Electrical Equipment (PCREE).

Findings include:

1. Observations and record review during the building inspection and tour on 08/21/23-08/22/2023 revealed the facility provided electric beds for 23 of its residents in the extended care portion of the building and for 23 patients in the CAH. Further observation revealed the beds did not have any sort of tag or label indicating when the beds had been last electrically tested and when they were due for re-testing.

Actual NFPA Standard: NFPA 99, Health Care Facilities Code (2012)
3.3.137 Patient-Care-Related Electrical Equipment.
Electrical equipment appliance that is intended to be used for diagnostic, therapeutic, or monitoring purposes in a patient care vicinity.
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.
10.3.4 Leakage Current - Fixed Equipment.
10.3.4.1 Permanently wired appliances in the patient care vicinity shall be tested prior to installation while the equipment is temporarily insulated from ground.
10.3.4.2 The leakage current flowing through the ground conductor of the power supply connection to ground of permanently wired appliances installed in general or critical care areas
shall not exceed 10.0 mA (ac or dc) with all grounds lifted.
10.3.5 Touch Current - Portable Equipment.
10.3.5.1* Touch Current Limits. The touch current for cord connected equipment shall not exceed 100 ?A with the ground wire intact (if a ground wire is provided) with normal polarity and shall not exceed 500 ?A with the ground wire disconnected.
10.3.5.2 If multiple devices are connected together and one power cord supplies power, the leakage current shall be measured as an assembly.
10.3.5.3 When multiple devices are connected together and more than one power cord supplies power, the devices shall be separated into groups according to their power supply cord, and the leakage current shall be measured independently for each group as an assembly.
10.3.5.4 Touch Leakage Test Procedure. Measurements shall be made using the circuit, as illustrated in Figure 10.3.5.4, with the appliance ground broken in two modes of appliance operation as follows:
(1) Power plug connected normally with the appliance on
(2) Power plug connected normally with the appliance off (if equipped with an on/off switch)
10.3.5.4.1 If the appliance has fixed redundant grounding (e.g., permanently fastened to the grounding system), the touch leakage current test shall be conducted with the redundant
grounding intact.
10.3.5.4.2 Test shall be made with Switch A in Figure 10.3.5.4 closed.
10.3.6* Lead Leakage Current Tests and Limits - Portable Equipment.
10.3.6.1 The leakage current between all patient leads connected together and ground shall be measured with the power plug connected normally and the device on.
10.3.6.2 An acceptable test configuration shall be as illustrated in Figure 10.3.5.4.
10.3.6.3 The leakage current shall not exceed 100 ?A for ground wire closed and 500 ?A ac for ground wire open.
10.5.2.1 Testing Intervals.
10.5.2.1.1 The facility shall establish policies and protocols for the type of test and intervals of testing for patient care-related electrical equipment.
10.5.2.1.2 All patient care-related electrical equipment used in patient care rooms shall be tested in accordance with 10.3.5.4 or 10.3.6 before being put into service for the first time and after any repair or modification that might have compromised electrical safety.
10.5.2.5* System Demonstration. Any system consisting of several electric appliances shall be demonstrated to comply with this code as a complete system.
10.5.3 Servicing and Maintenance of Equipment.
10.5.3.1 The manufacturer of the appliance shall furnish documents containing at least a technical description, instructions for use, and a means of contacting the manufacturer.
10.5.3.1.1 The documents specified in 10.5.3.1 shall include the following, where applicable:
(1) Illustrations that show the location of controls
(2) Explanation of the function of each control
(3) Illustrations of proper connection to the patient or other equipment, or both
(4) Step-by-step procedures for testing and proper use of the appliance
(5) Safety considerations in use and servicing of the appliance
(6) Precautions to be taken if the appliance is used on a patient simultaneously with other electric appliances
(7) Schematics, wiring diagrams, mechanical layouts, parts
lists, and other pertinent data for the appliance
(8) Instructions for cleaning, disinfection, or sterilization
(9) Utility supply requirements (electrical, gas, ventilation, heating, cooling, and so forth)
(10) Explanation of figures, symbols, and abbreviations on
the appliance
(11) Technical performance specifications
(12) Instructions for unpacking, inspection, installation, adjustment,
and alignment
(13) Preventive and corrective maintenance and repair
procedures
10.5.3.1.2 Service manuals, instructions, and procedures provided by the manufacturer shall be considered in the development of a program for maintenance of equipment.
10.5.6 Record Keeping - Patient Care Appliances.
10.5.6.1 Instruction Manuals.
10.5.6.1.1 A permanent file of instruction and maintenance manuals shall be maintained and be accessible.
10.5.6.1.2 The file of manuals shall be in the custody of the engineering group responsible for the maintenance of the appliance.
10.5.6.1.3 Duplicate instruction and maintenance manuals shall be available to the user.
10.5.6.1.4 Any safety labels and condensed operating instructions on an appliance shall be maintained in legible condition.
10.5.6.2* Documentation.
10.5.6.2.1 A record shall be maintained of the tests required by this chapter and associated repairs or modifications.
10.5.6.2.2 At a minimum, the record shall contain all of the following:
(1) Date
(2) Unique identification of the equipment tested
(3) Indication of which items have met or have failed to meet the performance requirements of 10.5.6.2
10.5.6.3 Test Logs. A log of test results and repairs shall be maintained and kept for a period of time in accordance with a health care facility's record retention policy.
10.5.8 Qualification and Training of Personnel.
10.5.8.1* Personnel concerned for the application or maintenance of electric appliances shall be trained on the risks associated with their use.
10.5.8.1.1 The health care facilities shall provide programs of continuing education for its personnel.
10.5.8.1.2 Continuing education programs shall include periodic review of manufacturers' safety guidelines and usage requirements for electrosurgical units and similar appliances.
10.5.8.2 Personnel involved in the use of energy-delivering devices including, but not limited to, electrosurgical, surgical laser, and fiberoptic devices shall receive periodic training in fire suppression.
10.5.8.3 Equipment shall be serviced by qualified personnel only.

Based on observation the facility failed to maintain gas cylinders per NFPA 99-2012, Section 11.6.2.3.

Findings Include:

1. During an observation on 08/22/2023 at 8:04 a.m., the kitchen was inspected. There were two free-standing carbon dioxide tanks sitting on the floor within the room.

2. During an observation on 08/22/2023 at 8:48 a.m., the oxygen storage room in was inspected. There was an E-sized oxygen tank free-standing within the room.