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Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not sealing holes and gaps in ceilings and/or walls or by not ensuring that ceilings have full integrity and/or proper flame spread ratings.

The findings include:

During the validation survey on November 4, 2015 with the Plant Operations Manager, it was observed between 9:00 am and 1:00 pm that:

1.) There was an open ceiling tile and other gaps in the ceiling of the sleep lab equipment storage room on the 2nd floor.

2.) The 2nd floor electrical room/telecommunications room had unsealed gaps and penetrations.

These penetrations and/or deficient ceiling tiles could have the possibility of affecting patients and staff of the facility and could allow smoke or flames to travel above the ceiling or from one section of the building to another in the event of an emergency.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not having all doors protecting corridor openings ready to close without impediments.

The findings include:

During the validation survey on November 4, 2015 with the Plant Operations Manager, it was observed between 9:00 am and 1:00 pm that:

1.) The corridor doors to patient rooms #211 and #256 were impeded from closing by metal hangers that rubbed between the top of the door and the door frame.

2.) The sliding glass doors in ICU rooms #203 and #204 failed to close tightly and left a gap between the door and frame.

This deficiency was verified by the Plant Operations Manager and acknowledged by administrative staff during the exit conference.

These impediments could prevent the doors from being quickly and easily closed and latched in the event of an emergency and could effect the patients of the listed rooms and patients in the same corridors.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not having the required emergency lighting operating properly.

The findings include:

During the validation survey on November 4, 2015 with the Plant Operations Manager, it was observed between 9:00 am and 1:00 pm that:

1.) One wall-mounted emergency light failed to operate when tested - it was located in exam room #9 in the emergency department.

2.) One lamp in the double-lamp emergency fixture in the generator room failed to illuminate when tested.

This deficiency was verified by the Plant Operations Manager and acknowledged by administrative staff during the exit conference.

The failure of the emergency lighting in these areas has the potential to promote harm to occupants of the facility in the event of a fire, power failure, or other type of emergency.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not having the building fire alarm system maintained in accordance with NFPA 70 and NFPA 72.

The findings include:

During the validation survey on November 4, 2015 with the Plant Operations Manager, it was observed between 9:00 am and 1:00 pm that there was no evidence that periodic sensitivity testing of smoke detectors had been conducted.

Actual NFPA Standard: NFPA 101, 9.6.1.4. A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, the National Electrical Code and NFPA 72, the National Fire Alarm Code.

Actual NFPA Standard: NFPA 72, 7-3.2.1*. Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the 2nd required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4% obscuration light gray smoke) the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or areas where nuisance alarms show an increase over the previous year, calibration tests shall be performed.

To ensure that a smoke detector is within its listed and marked sensitivity range, it shall be tested using any one of the following methods:

1.) calibrated test method;
2.) manufacturer's calibrated sensitivity test instrument;
3.) listed control equipment arranged for the purpose;
4.) smoke detector/control control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed range;
5.) other calibrated sensitivity test methods approved by the authority having jurisdiction.

Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.

Exception #1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated or they shall be replaced.

Exception #2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.

NOTE - The detector sensitivity shall not be tested or measured using any device that administers unmeasured concentrations of smoke or other aerosol into the detector.

This deficiency was verified by the Plant Operations Manager and acknowledged by administrative staff during the exit conference.

Failure of all or a portion of the alarm system could result in a delayed notification, and/or delayed evacuation, and has the potential to promote harm to the residents and staff in the event of a fire or other emergency.

Based on observation of the physical environment and a review of records, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining the sprinkler system in a reliable operating condition.

The findings include:

During the validation survey on November 4, 2015 with the Plant Operations Manager, it was observed between 9:00 am and 1:00 pm that:

1.) Numerous pendant sprinkler heads were loaded with lint and/or dirt, especially those located near ceiling vents;

2.) Four side-wall sprinkler heads at the loading dock were severely corroded and one escutcheon was pulling away from the wall

3.) All pendant sprinkler heads in the main entrance canopy were severely corroded;

4.) One sprinkler head in the ultra-sound equipment room was missing an escutcheon;

5.) One sprinkler head in the entry corridor to the main fire alarm control panel room was missing an escutcheon;

6.) One pendant sprinkler head in the operating suite "clean side" records room had paint on its deflector;

7.) There was no evidence that a five-year internal obstruction investigation of the sprinkler piping system had been completed.

(Loaded heads - including, but not limited to, the 2nd floor storage room; operating room storage area; three heads in the operating suite soiled side)

This deficiency was verified by the Plant Operations Manager and acknowledged by administrative staff during the exit conference.

These items could lead to improper operation of the sprinkler system in the event of a fire and could effect patients, visitors, and staff.

Based on observation of the physical environment, it was determined that the facility staff failed to insure that all of the portable fire extinguishers in the facility are tested and maintained as required by NFPA 10, 21.3.5.2.

The findings include:

During the validation survey on November 4, 2015 with the Plant Operations Manager, it was observed between 9:00 am and 1:00 pm that two portable ABC fire extinguishers in server/tele-communication rooms were sitting on the floors unprotected and not properly mounted on hangers.

This deficiency was verified by the Plant Operations Manager and acknowledged by administrative staff during the exit conference.

This could result in accidental discharge, damage to the unit, or failure to operate in the event of an emergency.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by failing to address the following miscellaneous safety issues:

The findings include:

During the validation survey on November 4, 2015 with the Plant Operations Manager, it was observed between 9:00 am and 1:00 pm that:

1.) An acetylene torch set (one B size gas tank and one MC size oxygen tank) was located inside the building in the boiler room; they were removed during the survey at the direction of the surveyor;

2.) Three "H" size CO2 tanks in the kitchen were secured by a chain - one end of the chain was improperly secured to a small copper water line and not to a proper mounting.

This deficiency was verified by the Plant Operations Manager and acknowledged by administrative staff during the exit conference.

Pressurized flammable gases shall not be stored inside a health care occupancy. Storage of these vessels inside the facility could lead to fire or explosion effecting all patients, visitors, and staff. Unsecured pressurized tanks of non-flammable gases could lead to damage or personal injury in the event of a fall.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining the generator fuel tank with proper placarding.

The findings include:

During the validation survey on November 4, 2015 with the Plant Operations Manager, it was observed between 9:00 am and 1:00 pm that the diesel/fuel oil fuel tank for the exterior emergency generator had no NFPA 704 placard nor proper labeling for fuel capacity.

This deficiency was verified by the Plant Operations Manager and acknowledged by administrative staff during the exit conference.

Fuel storage tanks that are not properly placarded in accordance with NFPA 704 may cause harm to staff and residents by delaying the response actions of emergency personnel due to the lack of product identification and quantity.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by having locations where there were non-compliant electrical applications. NFPA 70, National Electrical Code

The findings include:

During the validation survey on November 4, 2015 with the Plant Operations Manager, it was observed between 9:00 am and 1:00 pm that:

1.) One power strip in the medical records suite powered a coffee maker and microwave;

2.) The surgery staff lounge had a short extension cord powering a microwave oven and a coffee maker - the cord was draped very close to a sink even though the outlet was ground fault circuit interrupter (GFCI) protected.

This deficiency was verified by the Plant Operations Manager and acknowledged by administrative staff during the exit conference.

These items could cause overheating or electrical short circuits resulting in fire. An extension cord in a wet location increases the potential for electrical shock to staff members. NFPA 70, National Electrical Code states that: 1.) extension cords shall not be used as a substitute for permanent wiring. 11.1.5; 2.) extension cords and flexible cords shall not be affixed to structures, extend through walls, ceilings or floors, or be subject to environmental or physical damage. 11.1.5.3.5. 3.) multi-plug adapters, such as multi-plug extension cords, cube adapters, strip plugs, and other devices, shall be listed and used in accordance with their listing.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not sealing holes and gaps in ceilings and/or walls or by not ensuring that ceilings have full integrity and/or proper flame spread ratings.

The findings include:

During the validation survey on November 4, 2015 with the Plant Operations Manager, it was observed between 9:00 am and 1:00 pm that:

1.) There was an open ceiling tile and other gaps in the ceiling of the sleep lab equipment storage room on the 2nd floor.

2.) The 2nd floor electrical room/telecommunications room had unsealed gaps and penetrations.

These penetrations and/or deficient ceiling tiles could have the possibility of affecting patients and staff of the facility and could allow smoke or flames to travel above the ceiling or from one section of the building to another in the event of an emergency.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not having all doors protecting corridor openings ready to close without impediments.

The findings include:

During the validation survey on November 4, 2015 with the Plant Operations Manager, it was observed between 9:00 am and 1:00 pm that:

1.) The corridor doors to patient rooms #211 and #256 were impeded from closing by metal hangers that rubbed between the top of the door and the door frame.

2.) The sliding glass doors in ICU rooms #203 and #204 failed to close tightly and left a gap between the door and frame.

This deficiency was verified by the Plant Operations Manager and acknowledged by administrative staff during the exit conference.

These impediments could prevent the doors from being quickly and easily closed and latched in the event of an emergency and could effect the patients of the listed rooms and patients in the same corridors.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not having the required emergency lighting operating properly.

The findings include:

During the validation survey on November 4, 2015 with the Plant Operations Manager, it was observed between 9:00 am and 1:00 pm that:

1.) One wall-mounted emergency light failed to operate when tested - it was located in exam room #9 in the emergency department.

2.) One lamp in the double-lamp emergency fixture in the generator room failed to illuminate when tested.

This deficiency was verified by the Plant Operations Manager and acknowledged by administrative staff during the exit conference.

The failure of the emergency lighting in these areas has the potential to promote harm to occupants of the facility in the event of a fire, power failure, or other type of emergency.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not having the building fire alarm system maintained in accordance with NFPA 70 and NFPA 72.

The findings include:

During the validation survey on November 4, 2015 with the Plant Operations Manager, it was observed between 9:00 am and 1:00 pm that there was no evidence that periodic sensitivity testing of smoke detectors had been conducted.

Actual NFPA Standard: NFPA 101, 9.6.1.4. A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, the National Electrical Code and NFPA 72, the National Fire Alarm Code.

Actual NFPA Standard: NFPA 72, 7-3.2.1*. Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the 2nd required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4% obscuration light gray smoke) the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or areas where nuisance alarms show an increase over the previous year, calibration tests shall be performed.

To ensure that a smoke detector is within its listed and marked sensitivity range, it shall be tested using any one of the following methods:

1.) calibrated test method;
2.) manufacturer's calibrated sensitivity test instrument;
3.) listed control equipment arranged for the purpose;
4.) smoke detector/control control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed range;
5.) other calibrated sensitivity test methods approved by the authority having jurisdiction.

Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.

Exception #1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated or they shall be replaced.

Exception #2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.

NOTE - The detector sensitivity shall not be tested or measured using any device that administers unmeasured concentrations of smoke or other aerosol into the detector.

This deficiency was verified by the Plant Operations Manager and acknowledged by administrative staff during the exit conference.

Failure of all or a portion of the alarm system could result in a delayed notification, and/or delayed evacuation, and has the potential to promote harm to the residents and staff in the event of a fire or other emergency.

Based on observation of the physical environment and a review of records, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining the sprinkler system in a reliable operating condition.

The findings include:

During the validation survey on November 4, 2015 with the Plant Operations Manager, it was observed between 9:00 am and 1:00 pm that:

1.) Numerous pendant sprinkler heads were loaded with lint and/or dirt, especially those located near ceiling vents;

2.) Four side-wall sprinkler heads at the loading dock were severely corroded and one escutcheon was pulling away from the wall

3.) All pendant sprinkler heads in the main entrance canopy were severely corroded;

4.) One sprinkler head in the ultra-sound equipment room was missing an escutcheon;

5.) One sprinkler head in the entry corridor to the main fire alarm control panel room was missing an escutcheon;

6.) One pendant sprinkler head in the operating suite "clean side" records room had paint on its deflector;

7.) There was no evidence that a five-year internal obstruction investigation of the sprinkler piping system had been completed.

(Loaded heads - including, but not limited to, the 2nd floor storage room; operating room storage area; three heads in the operating suite soiled side)

This deficiency was verified by the Plant Operations Manager and acknowledged by administrative staff during the exit conference.

These items could lead to improper operation of the sprinkler system in the event of a fire and could effect patients, visitors, and staff.

Based on observation of the physical environment, it was determined that the facility staff failed to insure that all of the portable fire extinguishers in the facility are tested and maintained as required by NFPA 10, 21.3.5.2.

The findings include:

During the validation survey on November 4, 2015 with the Plant Operations Manager, it was observed between 9:00 am and 1:00 pm that two portable ABC fire extinguishers in server/tele-communication rooms were sitting on the floors unprotected and not properly mounted on hangers.

This deficiency was verified by the Plant Operations Manager and acknowledged by administrative staff during the exit conference.

This could result in accidental discharge, damage to the unit, or failure to operate in the event of an emergency.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by failing to address the following miscellaneous safety issues:

The findings include:

During the validation survey on November 4, 2015 with the Plant Operations Manager, it was observed between 9:00 am and 1:00 pm that:

1.) An acetylene torch set (one B size gas tank and one MC size oxygen tank) was located inside the building in the boiler room; they were removed during the survey at the direction of the surveyor;

2.) Three "H" size CO2 tanks in the kitchen were secured by a chain - one end of the chain was improperly secured to a small copper water line and not to a proper mounting.

This deficiency was verified by the Plant Operations Manager and acknowledged by administrative staff during the exit conference.

Pressurized flammable gases shall not be stored inside a health care occupancy. Storage of these vessels inside the facility could lead to fire or explosion effecting all patients, visitors, and staff. Unsecured pressurized tanks of non-flammable gases could lead to damage or personal injury in the event of a fall.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining the generator fuel tank with proper placarding.

The findings include:

During the validation survey on November 4, 2015 with the Plant Operations Manager, it was observed between 9:00 am and 1:00 pm that the diesel/fuel oil fuel tank for the exterior emergency generator had no NFPA 704 placard nor proper labeling for fuel capacity.

This deficiency was verified by the Plant Operations Manager and acknowledged by administrative staff during the exit conference.

Fuel storage tanks that are not properly placarded in accordance with NFPA 704 may cause harm to staff and residents by delaying the response actions of emergency personnel due to the lack of product identification and quantity.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by having locations where there were non-compliant electrical applications. NFPA 70, National Electrical Code

The findings include:

During the validation survey on November 4, 2015 with the Plant Operations Manager, it was observed between 9:00 am and 1:00 pm that:

1.) One power strip in the medical records suite powered a coffee maker and microwave;

2.) The surgery staff lounge had a short extension cord powering a microwave oven and a coffee maker - the cord was draped very close to a sink even though the outlet was ground fault circuit interrupter (GFCI) protected.

This deficiency was verified by the Plant Operations Manager and acknowledged by administrative staff during the exit conference.

These items could cause overheating or electrical short circuits resulting in fire. An extension cord in a wet location increases the potential for electrical shock to staff members. NFPA 70, National Electrical Code states that: 1.) extension cords shall not be used as a substitute for permanent wiring. 11.1.5; 2.) extension cords and flexible cords shall not be affixed to structures, extend through walls, ceilings or floors, or be subject to environmental or physical damage. 11.1.5.3.5. 3.) multi-plug adapters, such as multi-plug extension cords, cube adapters, strip plugs, and other devices, shall be listed and used in accordance with their listing.