HospitalInspections.org

Based on documentation review and interview, the facility failed to have the diesel fuel tested annually for quality. This deficient practice increased the potential that the generator would fail to run during loss of power. The facility has the capacity for 19 beds with a census of 2 on the day of survey.

Findings are:
Documentation review on 8-18-20 at 9:40 am of the provided emergency generator maintenance log revealed the documentation failed to exhibit all required information for weekly testing in accordance with National Fire Protection Association Pamphlet 110:
1. No documentation that the diesel fuel for the generator was tested for quality.

During an interview on 8-18-20 at 9:40 am, Administration Staff A confirmed that the facility failed to test the fuel for the generator and were not aware of the requirement

NFPA Standard:
NFPA 110, 2010, 8.3.8
A fuel quality test shall be performed at least annually using tests approved by ASTM standards.

Based on observation and interview, the facility failed to provide a self-closing device on the door separating construction from the occupied area. The facility use wood on the door openings to separate the corridor from construction and failed to assure the construction was smoke tight from the occupied area. The facility failed to assure building construction plans were approved by the State Fire Marshal office. This deficient practice would allow fire, gasses and smoke to migrate between the areas. The facility has the capacity for 19 beds with a census of 2 on the day of survey.

Findings are:
Observations on 8-18-20 at 12:44 pm revealed:
1. The door separating the construction area failed to provide a self-closing device and failed to be secured.
2. "Plywood" was used to cover unsealed door openings into the construction area.
3. The area above the ceiling tile within the construction area failed to be separated from the occupied areas.
4. The facility failed to submit plans for review to the authority having jurisdiction.

During an interview on 8-18-20 at 12:44 pm, Administration Staff A confirmed the lack of a self-closing device, wood separating the openings, failure of separation from occupied areas and the lack of submission of plans. Administration Staff A stated, "The facility was doing the work, not a contractor."

Based on observation and interview, the facility failed to maintain the fire rated doors in the two-hour fire barrier that separated the Hospital (health-care) from the Clinic (business). This deficient practice would allow fire, smoke and gases to migrate throughout both occupancies. The facility has the capacity for 19 beds with a census of 2 on the day of survey.

Findings are:
Observations on 8-18-20 at 1:32 pm revealed:
1. The south 1 ½-hour fire rated door separating the Clinic from the Hospital, failed to close and latch within the doorframe.

During an interview on 08-18-20 at 1:32 pm, Administration Staff A confirmed the fire rated door separating the occupancies failed to latch within the doorframe, stated it was air pressure.

Based on observation and interview, the facility used wood trusses on the exterior of the building for a roof, which covered the oxygen cylinders, which failed to provide sprinkler protection. This deficient practice would increase the potential for a fire to spread. The facility has the capacity for 19 beds with a census of 2 on the day of survey.

Findings are:
Observation on 8-18-20 at 1:58 pm revealed, an approximate 8-foot wide by 18-foot long wood truss roof covering the oxygen cylinders and no sprinkler protection provided.

During an interview on 8-18-20 at 1:58 pm, Administration Staff confirmed the wooden roof.

Based on observation and interview, the facility allowed the use of "EXIT" signage for the door leading into the Garage, and failed to assure that keys were provided for all locked doors. These deficient practices allow occupants to exit through a hazard area and delays the investigation of an emergency. The facility has the capacity for 19 beds with a census of 2 on the day of survey.

Findings are:
Observation on 8-18-20 at 12:40 pm and 1:32 pm revealed:
1. Numerous locked doors to unoccupied rooms throughout the facility.
2. Two paper "Exit" signs on the walls, with arrows directing occupants into the Garage to exit.

During an interview on 8-18-20 at 12:40 pm and 1:32 pm, Administration Staff A confirmed the paper exit signs on the walls and removed them; also stated that keys were not provided to the night shift staff to various rooms throughout the facility that were locked.

Based on observation and interview, the facility failed to maintain corridors free of obstructions.
This deficient practice would cause confusion, which would delay egress during an emergency. The facility has the capacity for 19 beds with a census of 2 on the day of survey.

Findings are:
Observation on 8-18-20 at 12:31 pm and 12:57 pm revealed:
1. Table and chairs obstructing the egress path in Behavioral Health area.
2. A cloth drop cloth attached to the ceiling in the Independent Living corridor, which obstructed the path of egress.

During an interview on 8-18-20 at 12:57 pm, Administration Staff confirmed the obstruction in the corridors and stated, "The facility didn't want anyone going past the cloth."

Based on observation and interview, the facility failed to assure the Service corridor exit doors functioned as designed. This deficient practice would cause confusion and delay egress during an emergency. The facility has the capacity for 19 beds with a census of 2 on the day of survey.

Findings are:
Observation on 8-18-20 at 2:07 pm revealed:
1. Double exit doors in the Service corridor were equipped with delayed egress signage, the delayed function failed to operate.
2. The magnetically locked exit doors in the Service corridor were programmed with a code, which failed to be posted.

During an interview on 8-18-20 at 2:07 pm, Administration Staff A confirmed the exit doors in the Service corridor failed to operate as designed.

Based on observation, documentation review and interview, the facility failed to assure that the monthly and yearly emergency light testing was documented. This deficient practice has the potential for emergency lights in the facility not operating during an emergency. The facility has the capacity for 19 beds with a census of 2 on the day of survey.

Findings are:
Documentation review on 8-18-20 at 11:29 am revealed, the facility failed to provide documentation for the monthly test and annual 1 ½ hour battery test for the battery operated emergency lights in the facility.

During an interview on 8-18-20 at 11:29 am, Administration Staff A confirmed the lack of testing documentation.

Observations on 8-18-20 at 1:29 pm revealed, when the lights in the exit corridor in the south patient care were turned off, no lighting was provided at the end of the hall near the exit door.

During an interview on 8-18-20 at 1:29 pm, Administration A confirmed the lights in the exit corridor failed to operate.

Based on observation and interview, the facility failed to provide exit signage to assure two means of egress were available. This deficient practice would delay egress. The facility has the capacity for 19 beds with a census of 2 on the day of survey.

Findings are:
Observation on 8-18-20 at 1:47 pm and 2:09 pm revealed:
1. While standing in the corridor looking east toward the Cafeteria, no exit sign was provided.
2. While standing in the Service Hall looking west, no exit sign was provided.

During an interview on 8-18-20 at 1:47 pm and 2:09 pm, Administration Staff A confirmed the lack of exit signs.

Based on observation and interview, the facility failed to assure the doors to hazardous areas would close and latch within the doorframe, failed to assure doors were equipped with self-closing devices and that hazard rooms were smoke tight. These deficient practices would allow fire, smoke and gases to migrate into the exit corridors. The facility has the capacity for 19 beds with a census of 2 on the day of survey.

Findings are:
Observation on 8-18-20 between 12:17 pm and 2:14 pm revealed:
1. Receiving Room door 8-N failed to provide a self-closing device.
2. Central Supply Room door 10-N failed to provide a self-closing device.
3. Oxygen Storage Room door was propped open with a rubber door chock.
4. Storage Room door behind the old Nurse Station failed to provide a self-closing device.
5. The Custodian door in the southwest hall failed to provide a self-closing device.
6. IT storage room door failed to provide a self-closing device.
7. Room 21-N used for storage failed to provide a self-closing device on the door.
8. Room 23-N door next to room 25-N used for storage failed to provide a self-closing device.
9. Room 24-N used for storage failed to provide a self-closing device on the door.
10. Patient Equipment Storage Room door in the IL corridor next to the restroom, failed to provide a self-closing device.
11. Housekeeping door next to Room 17-N equipped with a self-closing device failed to latch within the doorframe.
12. The undercut for the Break Room door was greater than 1 inch.
13. The door to the Garage was equipped with a metal kick down.
14. Sterile Processing door was equipped with a self-closing device which failed to latch within the doorframe.
15. Business/Record Storage Room door failed to provide a self-closing device.
16. The double doors to Clean Laundry failed to be smoke tight when the manual latch on the south door was not engaged.
17. The south door to Clean Laundry failed to provide a self-closing device.
18. The door to Soiled Laundry equipped with a self-closing device failed to latch within the doorframe.

During an interview on 8-18-20 between 12:17 pm and 2:14 pm, Administration Staff A confirmed the hazard areas failed to provide self-closing devices, failed to latch within the doorframe, hazard doors were equipped with kick down and had an undercut greater than 1 inch.

Based on observation and interview, the facility failed to assure the newly installed stove/oven which had wheels, would be put back to it's original placement after cleaning. The facility failed to assure that the shelf on the cooking equipment under the kitchen exhaust hood fire-extinguishing system was not obstructing the extinguishing nozzles. These deficient practices would allow a fire under the hood to increase and spread outside the kitchen. The facility has the capacity for 19 beds with a census of 2 on the day of survey.

Findings are:
Observation on 8-18-20 at 1:52 pm revealed:
1. Wheeled equipment under the hood failed to provide chocks, to assure that it would be placed back in it's designed location.
2. Equipment under the hood were installed with shelves, which would cause an obstruction for the hood fire-extinguishing system.

During an interview on 8-18-20 at 1:52 pm, Kitchen staff confirmed the wheeled equipment under the hood and stated, "The stove was installed in October 2019" and came with shelf. Maintenance Staff failed to confirm if the fire-extinguishing system was designed for a shelf.

Based on observation and interview, the facility failed to assure staff sleeping rooms were provided with a system smoke detector and an audible/visual device. The lack of these devices would delay egress during a fire emergency. The facility has the capacity for 19 beds with a census of 2 on the day of survey.

Findings are:
Observations on 8-18-20 at 12:29 pm revealed, Sleeping Room 12-N failed to provide a smoke detector connected to the fire alarm system and failed to provide an audible/visual device.

During an interview on 8-18-20 at 12:29 pm, Administration Staff A confirmed the lack of a smoke detector and audible/visual device in the staff sleeping room.

Based on record review and interview, the facility failed to assure fire alarm equipment was physically identified. This deficient practice increased the potential that the fire alarm would fail to detect smoke from a fire which would affect all occupants in all smoke compartments The facility has the capacity for 19 beds with a census of 2 on the day of survey.

Findings are:
Record review on 8-18-20 between 12:33 pm to 2:47 pm revealed:
1. The facility failed to assure that fire alarm equipment throughout the facility was labeled/identified.

During an interview on 8-18-20 between 12:33 pm and 2:47 pm, Administration Staff A confirmed the devices throughout the facility were not physically labeled.

Based on observation and interview, the facility failed to assure that ceilings were free of penetrations. This deficient practice would not allow the sprinkler system to activate as it was designed and fire would spread throughout the egress corridor. The facility has the capacity for 19 beds with a census of 2 on the day of survey.

Findings are:
Observation on 8-18-20 between 11:37 am and 2:13 pm revealed:
1. Ceiling tile was out of the grid in the Utility Room in the Sleeping Hall.
2. Two ceiling tiles were out of the grid in the corridor across from the Day Room.
3. Numerous ceiling tiles were out of the grid in the corridor next to Patient Storage.
4. Ceiling tile was out of the grid in the HR Storage room.

During an interview on 8-18-20 between 11:37 am and 2:13 pm, Administration Staff A confirmed the missing ceiling tiles.

Based on record review and interview, the facility failed to provide a complete policy was in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than ten hours in any twenty-four hour period. The lack of a complete written policy and procedure would result in staff failing to implement interim safety measures in the event of an emergency. The facility has the capacity for 19 beds with a census of 2 on the day of survey.

Findings are:
Record review on 8-18-19 at 11:56 am, revealed the facility failed to assure the sprinkler fire watch included:
1. The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified.
2. All necessary tools and materials have been assembled on the impairment site.
3. Emergency impairments included on the policy.

During an interview on 8-18-20 at 11:56 am, Maintenance Staff A confirmed the lack of information on fire watch policy.

NFPA Standard:
NFPA 25, 2011
15.5* Preplanned Impairment Programs.
15.5.1 All preplanned impairments shall be authorized by the impairment coordinator.
15.5.2 Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented:
(1) The extent and expected duration of the impairment have been determined.
(2) The areas or buildings involved have been inspected and the increased risks determined.
(3) Recommendations have been submitted to management or the property owner or designated representative.
(4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following:
(a) Evacuation of the building or portion of the building affected by the system out of service
(b)*An approved fire watch
(c)*Establishment of a temporary water supply
(d)*Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire
(5) The fire department has been notified.
(6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified.
(7) The supervisors in the areas to be affected have been notified.
(8) A tag impairment system has been implemented. (See Section 15.3.)
(9) All necessary tools and materials have been assembled on the impairment site.

15.6 Emergency Impairments.
15.6.1 Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure.
15.6.2 When emergency impairments occur, emergency action shall be taken to minimize potential injury and damage.
15.6.3 The coordinator shall implement the steps outlined in Section 15.5.

Based on observation and interview, the facility failed to ensure that the corridor room doors would resist the passage of smoke. This deficient practice would not prevent the spread of fire and smoke within the exit corridors. The facility has the capacity for 11 beds with a census of 4 on the day of survey.

Findings are:
Observation on 8-18-20 between 1:02 pm and 2:18 pm revealed:
1. The door to Room 12 failed to latch within the doorframe.
2. Nurse station door was obstructed by a trash can.
3. Conference Room door was blocked open with a rubber door chock.
4. The west door to the OR corridor failed to latch.
5. Door 5-N failed to latch within the doorframe.

During an interview on 8-18-20 between 1:02 pm and 2:18 pm, Administration Staff A confirmed the findings.

Based on observation and interview, the facility did not ensure that fire rated corridor smoke barrier doors would resist the passage of smoke from one compartment to another. This deficient practice would not prevent the spread of fire and smoke. The facility has the capacity for 19 beds with a census of 2 on the day of survey.

Findings are:
Observation on 8-18-20 at 1:20 pm and 1:42 pm revealed:
1. The east smoke barrier door next to room 8 equipped with latching device failed to latch within the doorframe.
2. The south smoke barrier door in the Main Lobby equipped with latching device failed to latch within the doorframe.

During an interview on 8-18-20 at 1:20 pm and 1:42 pm, Administration Staff A confirmed the findings.

Based on observation and interview, the facility failed to provide protected egress corridors by using the corridor as a supply air plenum for the cooling system. This deficient practice pulled cooled air from the Conference Room to cool the corridor and adjacent occupancy, which would increase the spread smoke, fire and gasses throughout the exiting corridor. The facility has the capacity for 19 beds with a census of 2 on the day of survey.

Findings are:
Observation on 8-18-20 at 1:30 pm revealed, the facility had a portable cooling system outside of the Conference Room which provide three approximately 24 inch diameter hoses which were installed in the exterior windows in the Conference Room. The door to the Conference Room was wedged open to allow cool air into the corridor, which cooled the areas of the building that was without a cooling system.

During an interview on 8-18-20 at 1:30 pm, Administration A confirmed the corridor was being used as a plenum and stated, "The cooling system for the adjoining business occupancy and other rooms within the hospital had been out of service for over a month".

Based on documentation review and interview, the facility failed to hold fire drills and failed to conduct them at random times under varied conditions. When fire drills are held within the same time frame, they are not conducted under varied times and conditions. If facility staff are not challenged by different times and conditions, they might not respond appropriately when faced with an actual fire. The facility has the capacity for 19 beds with a census of 2 on the day of survey.

Findings are:
Fire drill documentation review on 8-18-20 at 11:35 am revealed:
1. The facility failed to conduct a 2nd shift drill during the first quarter of 2020.
2. The facility failed to conduct any drills during the second quarter of 2020.
3. The facility failed to assure that staff initiated alarms and followed procedures.

During an interview on 8-18-20 at 11:35 am, Administration Staff A confirmed the lack of fire drills.

Based on record review and interview, the facility failed to have a preventative maintenance plan in place to inspect and test all fire doors annually throughout the facility. This deficient practice would allow the spread of fire through faulty fire doors that would otherwise contain a fire. The facility has the capacity for 19 beds with a census of 2 on the day of survey.

Findings are:
Record review on 8-18-20 at 11:23 am revealed, the facility failed to inspect all fire rated doors throughout the facility.

During an interview on 8-18-20 at 11:23 am, Administration Staff A confirmed that the facility was unaware of the door inspection requirements.

Based on observation and interview, the facility failed to install ground fault protected outlet (GFCI) at the sink location in patient rooms. This deficient practice would increase the probability of the electrical equipment to cause an electrical shock or fire, which has the potential to spread outside the room. The facility has the capacity for 19 beds with a census of 2 on the day of survey.

Findings are:
Observations on 8-18-20 at 1:33 pm revealed, the light fixtures above the sink in Patient Rooms 1-8 provided an electrical outlet, which failed to be GFCI protected.

During an interview on 8-18-20 at 1:33 pm, Maintenance Staff A confirmed the outlets failed to be GFCI and tested the outlet to verify the function.

NFPA Standard:
2011 NFPA 70, 210-8(b)
Ground-Fault Circuit-Interrupter Protection for Personnel Other than Dwelling Units
All 125-volt, single-phase, 15- and 20-ampere receptacles installed in the locations specified below shall have ground-fault circuit-interrupter protection for personnel.
1. Bathrooms
2. Rooftops
Exception: Receptacles that are not readily accessible and are supplied from a dedicated branch circuit for electric snow-melting or deicing equipment shall be permitted to be installed in accordance with the applicable provisions of Article 426.

Based on documentation review and interview, the facility failed to have the diesel fuel tested annually for quality. This deficient practices increased the potential that the generator would fail to run during loss of power. The facility has the capacity for 19 beds with a census of 2 on the day of survey.

Findings are:
Documentation review on 8-18-20 at 9:40 am of the provided emergency generator maintenance log revealed the documentation failed to exhibit all required information for weekly testing in accordance with National Fire Protection Association Pamphlet 110:
1. No documentation that the diesel fuel for the generator was tested for quality.

During an interview on 8-18-20 at 9:40 am, Administration Staff A confirmed that the facility failed to test the fuel for the generator and were not aware of the requirement

NFPA Standard:
NFPA 110, 2010, 8.3.8
A fuel quality test shall be performed at least annually using tests approved by ASTM standards.

Based on observation and interview, the facility failed to prohibit the use of extension cords as a substitute for adequate wiring. This deficient practice would create electrical injury and increase a fire hazard. The facility has the capacity for 19 beds with a census of 2 on the day of survey.

Findings are:
Observation on 8-18-20 at 12:16 pm and 2:09 pm revealed:
1. An extension cord in the Huddle Room for the fig tree lights.
2. Extension cord in the southwest Staff Sleeping Room.
3. Two extension cords in the Clean Laundry Room for a fan and sewing machine.

During an interview on 8-18-20 at 12:16 pm and 10:09 pm, and Administration Staff A confirmed the use of extension cords.

Based on observation and interview, the facility failed to secure an oxygen cylinder, which would increase the possibility of injury to anyone in the path of the cylinder if the cylinder were to fall over, break the stem, and become a projectile. The facility has the capacity for 19 beds with a census of 2 on the day of survey.

Findings are:
Observation on 8-18-20 between 12:10 pm and 2:05 pm revealed:
1. An unrestrained oxygen cylinder in the Administration Staff A office.
2. Three unrestrained oxygen cylinders in the oxygen storage room across from room 14.
3. Three unrestrained large oxygen cylinders in the secured exterior oxygen storage area.

During an interview on 8-18-20 between 12:10 pm and 2:05 pm, Administration Staff A confirmed the unrestrained oxygen cylinder.