HospitalInspections.org

Facility has an appoved waiver until November 11, 2013


27394



27395

Facility has an appoved waiver until November 11, 2013


19980

27394





13879


Based on observation and interview the facility failed to provide documentation for the brushes installed on the 90 minute fire doors in the third floor corridor. This deficient practice may prevent smoke and fire to spread to other smoke compartments on the third floor. The facility census was 74 patients.

Findings are:
Observations on 9-24-13 at 12:12 pm revealed, facility had installed brushes on the fire rated doors on the third floor.

During an interview on 9-24-13 at 1:38 pm, Safety E failed to provide documentation for the brushes and stated that it was unknown if the brushes were rated for the doors.

27394



04583


Facility has an appoved waiver until November 11, 2013


19980

19980



04583


Facility has an appoved waiver until November 11, 2013

Facility has an appoved waiver until November 11, 2013


27395

27395



04583


Facility has an appoved waiver until November 11, 2013


19980

20404





04583


Based on observation and interview the facility failed to have the emergency generator installed in accordance with NFPA 110 by not having a remote shutdown for the emergency generator other than on the generator itself. This deficient practice has the potential to effect all residents, staff and visitors of the facility in the event of an emergency condition.
Findings are:
1. Observation on September 23, 2013 at 11:54am revealed that the emergency shutdown switch for the emergency generator was located in the same room as the generator and would not allow for safe shutdown of the emergency generator in the case of fire or other emergency involving the generator itself. The switch had been installed on the interior wall by the exit door. This observation was confirmed in an interview with Facilities C at the above listed date and time.

NFPA 110, 2002ed. 5.6.5.6 All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building.





13879


Based on observation, record review and staff interview, the facility failed to install a line isolation monitor or ground-fault circuit interrupter outlets in the Operating Rooms in accordance with NFPA 99. The facility failed to provide documentation that no wet procedures are preformed in the facility. This condition had the potential to allow a patient to receive electrical shock during a surgery. The facility census was 74.

Findings are:
Observations during the initial facility tour on 5/6/13, from 3:16 pm to 4:45 pm revealed GFCI outlets, GFCI breakers or line isolation monitors failed to be installed in all Operating Room and the C-Section Room.

Record review on 9-23-13 revealed no written specifics of which type of procedures would normally take place in the operating rooms to determine if any special protection against electric shock had to be provided if wet procedures are likely to be performed or not.

During an interview on 9-23-13 at 12:45 pm, Safety A verified that GFCI outlets, GFCI Breakers or line isolation monitoring failed to be installed and that a policy of normally conducted procedures with what, if any, special protection needed did not exist.

Actual NFPA Standard:
NFPA 99, 3-3.2.1.2 All Patient Care Areas.
(f) Wet Locations.
1. * Wet location patient care areas shall be provided with special protection against electric shock. This special protection shall be provided by a power distribution system that inherently limits the possible ground-fault current due to a first fault to a low value, without interrupting the power supply; or by a power distribution system in which the power supply is interrupted if the ground-fault current does, in fact, exceed a value of 6 mA.
2. The use of an isolated power system (IPS) shall be permitted as a protective means capable of limiting ground fault current without power interruption. When installed, such a power system shall conform to the requirements of 3-3.2.2.
3. Where power interruption under first fault condition (line-to-ground fault) is tolerable, the use of a ground-fault circuit interrupter (GFCI) shall be permitted as the protective means that monitors the actual ground fault current and interrupts the power when that current exceeds 6 mA.

Facility has an appoved waiver until November 11, 2013


20404

27394



19980



04583

Facility has an appoved waiver until November 11, 2013