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Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by failing to repair and seal wall and ceiling penetrations in the facility. This could result in the spread of fire and smoke, and affected 2 of 3 compartments.

Findings:

During a tour of the facility with staff on 5/13/2013, through 5/15/2013, the facility walls and ceilings were observed.

On 5/13/13:
1. At 12:00 p.m., there was a 1 1/2 inch penetration in the wall where the door handle hit the wall, in patient room 110.

2. At 3:25 p.m. there was a 2 inch by 3 inch penetration inside the Pharmacy wall next to the corridor door.




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3. At 11:40 a.m., there was an approximately 2 inch square unsealed penetration around a group of blue computer cables in the center of the left wall in the House Supervisor Office.

4. At 3:10 p.m., there was an approximately 2 inch circular unsealed penetration by a group of blue computer cables in the ceiling in the IT Communications Closet next to Post ICU.

5. At 3:15 p.m., there was an approximately 2 inch penetration, and an approximately 1 inch unsealed penetration, in the center of the left wall in the Post ICU Equipment Closet.

The above findings were acknowledged by staff during the survey.

Based on observation, the facility failed to maintain the corridor doors as evidenced by self-closing corridor doors that failed to latch. This could result in the spread of smoke and fire throughout the facility, and increase the risk of injury to patients, visitors and staff due to smoke and fire. This affected 1 of 3 smoke compartments.

Findings:

During the facility tour with the facility staff on 5/13/2013 through 5/15/2013, the corridor doors were observed.

On 5/13/13:
At 11:30 a.m., the self-closing corridor door in the Chapel was blocked by a chair that prevented the door from closing.

Based on observation, the facility failed to maintain the integrity of the fire rated smoke barrier walls, as evidenced by a unsealed penetration in a smoke barrier wall. This could allow the spread of smoke during a fire, and affected 2 of 3 smoke compartments.

NFPA 101, Life Safety Code (2000) Edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

8.3.6 Penetrations and Miscellaneous Openings in Floors and Smoke Barriers.
8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining
the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is
designed for the specific purpose.

Findings:

During a tour of the facility with staff on 5/13/2013 through 5/15/2013, the smoke barrier walls were observed..

On 5/13/13:

At 11:56 a.m., there was an approximately 1/4 inch penetration around a conduit in the left side of the smoke barrier wall located next to patient room 110. This was acknowledged by staff during the survey.

Based on observation, the facility failed to protect the hazardous areas as evidenced by penetrations in the wall of a hazardous area, and by failing to maintain the door to a hazardous area. This could result in the spread of smoke and fire from the hazardous area to other areas, and increase the risk of injury to patients, visitors and staff. This affected 1 of 3 smoke compartments.

Findings:

During the facility tour with the facility staff on 5/13/2013 through 5/15/2013, the hazardous areas were observed.

On 5/13/13:
1. At 11:45 a.m., there were 19 approximately 1 inch unsealed penetrations in the cinder block wall of the Electrical closet by the staff entrance to Building D. The Director of Facilities confirmed the penetrations in the Electrical closet.


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2. At 1:51 p.m., the door to the surgery suite dirty utility room was held open by a towel that was tied to the door handle, and to a hook in the wall behind the door. The door was equipped with a self-closure device. This was acknowledged by staff during the survey.

Based on observation, document review and interview, the facility failed to test all battery powered emergency lighting in the facility, and failed to provide battery powered emergency lighting in the anesthetizing locations. This was evidenced by incomplete documentation for the maintenance of the battery powered emergency lighting, and by the failure to provide battery powered emergency lighting in 2 of 2 operating rooms in the surgery suite. This could result in no lighting in the event of a power failure and emergency generator failure. This affected 3 of 3 smoke compartments.

NFPA 101, Life Safety Code 2000 Edition
19.3.2.3 Anesthetizing Locations. Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Health Care Facilities (1999) Edition
3-3.2.1.2 All Patient Care Areas
(a) Wiring, Regular Voltage.
5. Wiring in Anesthetizing Locations.
e. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

Findings:

During a tour of the facility with staff on 5/13/2013 through 5/15/2013, the emergency lighting in the anesthetizing areas were observed.

On 5/13/13:
1. At 1:40 p.m., there was no battery powered emergency lighting units in Operating Room 1 or in Operating Room 2. This was acknowledged by staff during the survey.

On 5/14/13:
2. At 8:56 a.m., during the facility tour, battery powered emergency lights were observed throughout the facility. The documentation provided for the maintenance and testing of the emergency lights was incomplete. The documentation did not include the emergency lights in the Cat Scan rooms, or the X-ray rooms. During interview, staff stated they would take an inventory and update the list.

Based on document review and interview, the facility failed to conduct 2 of 2 disaster drills within one year. This was evidenced by no documentation for 2 of 2 disaster drills. This could result in any one staff member not accomplishing all of the tasks required in the event of an emergency, and increase the risk of injury to patients, visitors and staff. This affected 3 of 3 smoke compartments.

Findings:

During document review and interview with facility staff on 5/13/2013, through 5/15/2013, the disaster drills were requested, and staff was interviewed.

On 5/13/13:
1. At 10:45 a.m., the documentation for the disaster drills was requested from the facility.

On 5/15/13:
2. At 9:15 a.m., the Director of Facilities stated that the facility participated in the statewide disaster drill in October 2012, but no documentation was provided for review.

Based on record review, the facility failed to hold fire drills at unexpected times under varying conditions as evidenced by fire drills that were held around the same time of day. This could result in any one staff member not accomplishing all of the tasks required in the event of an emergency, and increase the risk of injury to patients, visitors and staff. This affected 3 of 3 smoke compartments.

Findings:

During the facility tour with the facility staff on 5/13/2013 through 5/15/2013, the fire drills were reviewed.

On 5/14/13:

At 9:15 a.m., the fire drills showed a pattern of being conducted around the same time of day. The fire drills were for two twelve hour shifts, from 7:00 a.m., to 7:00 p.m., and from 7:00 p.m., to 7:00 a.m.

The six fire drills for the second shift were held between 7:00 p.m., and 7:30 p.m. The dates were: 5/18/2013 at 7:20 p.m.; 3/1/2013, at 7:30 p.m.; 1/18/2013 at 7:00 p.m.; 11/6/2012 at 7:00 p.m.; 9/5/2012 at 7:30 p.m.; and 7/17/2012 at 7:30 p.m. There were no drills conducted between the hours of 7:30 p.m., and 9:30 a.m. The Director of Facilities confirmed that this information was correct.

Based on observation, record review and interview, the facility failed to maintain their fire alarm system in accordance with NFPA 101. This was evidenced by the overhead public address speakers for the fire alarm system that were not audible in all occupied spaces. This could result in delayed response to a fire, and increase the risk of injury to patients, visitors and staff. This affected 3 of 3 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code.
9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.
9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.
9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.
9.6.3.9 Audible alarm notification appliances shall produce signals that are distinctive from audible signals used for other purposes in the same building.

Findings:

During observation, fire alarm testing and interview with the facility staff on 5/13/2013 through 5/15/2013, the fire alarm system was observed, and staff was interviewed.

On 5/14/13:
1. At 10:30 a.m., the overhead speakers for the public address system could not be heard in the Med Surge area. The Director of Facilities stated that there was a dead area in the speaker system, and the facility was working to resolve the problem. The fire alarm system devices were audible.

On 5/15/13:
2. At 10:30 a.m., the fire drill records provided the following on the evaluation notes for these fire drills:
4/10/13: "Code Red called out properly-West Hallway speaker and ER not working."
12/11/12: "Speakers in West Hallway not audible/functional. Could not hear PA System."
11/6/12: "Hallway West Building C and Building B, Speakers were hard to hear."

Based on document review and interview, the facility failed to maintain the smoke detectors, as evidenced by failing to provide written documentation for smoke detector sensitivity testing. This could result in the smoke detectors not functioning as designed in the event of a fire, which may delay notification to facility staff of a fire. This failure affected 3 of 3 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
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, National Electrical Code, and
NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72, National Fire Alarm Code, 1999 edition
7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. after the second required calibration test, if sensitivity tests indicated that the detector has remained within its listed and marked sensitivity range (or 4% obscuration light gray smoke, if not marked), 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 in areas where nuisance show any increase over the previous year, calibration tests shall be performed.

To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any 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 unit arrangement where by the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity 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.

Findings:

During document review and interview with staff on 5/13/2013 through 5/15/2013, the documentation for smoke detector sensitivity testing was requested.

On 5/14/13:
1. At 3:52 p.m., the facility failed to provide documentation for smoke detector sensitivity testing. During interview, facility staff stated they would contact the vendor, and request the report for smoke detector sensitivity testing.

On 5/15/13:
2. At 9:22 a.m., the facility staff stated there was no documentation for smoke detector sensitivity testing.

Based on observation, document review and interview, the facility failed to maintain the integrity of the automatic sprinkler system. This was evidenced by failing to correct deficiencies noted on the five year certification report, failing to provide 2 of 4 quarterly test reports for the Inspector's Test Valve, and by missing sprinkler escutcheon rings. This failure could result in the automatic sprinkler system not functioning as designed in the event of a fire, and affected 3 of 3 smoke compartments.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water Based Fire Protection Systems (1998) Edition
2-2.1 Sprinklers.
2-2.1.1* Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any
sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
Exception No. 1:* Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

2-3 Testing
2-3.3 Alarm Devices. Water flow alarm devices including, but not limited to, mechanical water motor gongs, van-type water flow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

Findings:

During a tour of the facility with staff on 5/13/2013 through 5/15/2013, the automatic sprinkler system was observed.

On 5/13/13:
1. At 12:24 p.m., the sprinkler escutcheon ring was missing in the social services office.

On 5/14/13:
2. At 9:41 a.m., during document review staff provided a five year certification report from an outside vendor dated 11/26/12. The report noted deficiencies, and staff was asked for documentation for the corrections of the noted deficiencies in the report. Staff stated there was no documentation for the corrections, and did not know if any of the deficiencies had been corrected.

3. At 11:50 a.m., there were two 3 inch penetrations in the ceiling that exposed the automatic sprinkler pipes in the Doctor's Lounge. The sprinkler escutcheon rings were missing. This deficiency was noted on the five year discrepancy report, and acknowledged by staff during the survey and document review.

4. At 11:52 a.m., there were two 3 inch penetrations in the ceiling that exposed the automatic sprinkler pipes in the doctors on-call sleeping room, and a 2 inch penetration next to one of the sprinklers. The sprinkler escutcheon rings were missing. This deficiency was noted on the five year discrepancy report, and was acknowledged by staff during the survey.

5. At 11:57 a.m., in the Materials Management Department there were approximately 28 sprinkler escutcheon rings missing. This deficiency was noted on the five year discrepancy report, and acknowledged by staff during survey.

6. At 2:14 p.m., during the testing of the automatic sprinkler system the panel addressed the Inspector's Test Valve (ITV) as water flow boiler room. The ITV was located outside of the Emergency lobby, and not in the boiler room. This deficiency was noted on the five year certification discrepancy report, and was acknowledged by staff during the survey.

On 5/15/13:
7. At 9:52 a.m., during the main drain water flow test the 6 inch bell located outside of the boiler room failed to activate an alarm. This deficiency was noted on the five year certification discrepancy report, and was acknowledged by staff during the survey.





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Based on observation and record review, the facility failed to maintain the portable fire extinguishers. This was evidenced by obstructed access to portable fire extinguishers, by portable fire extinguishers that were past their annual inspection dates, and by incomplete monthly inspection dates. This could result in delayed response to a fire, and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected 2 of 3 smoke compartments and the CT Trailer.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition
1-6.6 Fire extinguishers shall not be obstructed or obscured from view.
4-3.1 Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire Extinguishers shall be inspected at more frequent intervals when circumstances require.
4-3.2* Procedures. Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) *Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or " hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

Findings:

During the facility tour with the facility staff on 5/13/2013 through 5/15/13, the portable fire extinguishers were observed, and records were reviewed.

On 5/13/13:
1. At 11:59 a.m., the K-fire extinguisher was blocked by a chair in the dish washer area of the Cafeteria.

2. At 2:50 p.m., the fire extinguisher was blocked by a cart that contained a drink container and a box of drinks, in the Dietary Department.

On 5/14/13:
3. At 8:30 a.m., there were 2 of 2 fire extinguishers that were past the annual inspection date of 4/13/12, and had incomplete monthly inspections, in the CT Trailer.



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On 5/13/13:
4. At 12:09 p.m., the ABC fire extinguisher located in dietary was obstructed by food carts and a coffee machine that was place in front of the fire extinguisher. This was acknowledged by staff during the survey.

Based on observation, the facility failed to maintain its exit corridors free of obstructions or impediments, as evidenced by 1 of 2 exit corridors in the surgery suite that were impeded by medical equipment and a chair. This failure could result in the delay of evacuating patients in the event of a fire or other emergency, and affected 1 of 3 smoke compartments.

Findings:

During a tour of the facility with staff on 5/13/2013 through 5/15/2013, the exit corridors and path of travel were observed.

On 5/13/13:

At 1:48 p.m., the east emergency exit path of travel in the surgery suite was obstructed by two tourniquet machines, a chair and two monitors that were left unattended in the exit corridor. This was acknowledged by staff during the survey.

Based on observation, the facility failed to maintain the compressed gas cylinders as evidenced by gas cylinders that were not stored individually secured. This could result in an increased risk of fire, and increase the risk of injury to patients, visitors and staff due to smoke and fire. This affected 1 of 3 smoke compartments.

NFPA 101, 2000 Edition
19.3.2.4
Medical Gas.
Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, 1999 Edition
1-2 Application
Chapters 12 through 18 specify the conditions under which the requirements of Chapters 3 through 11 shall apply in Chapters 12 through 18.

12-3.8 Gas System Requirements
12-3.8.1 Patient
Equipment shall conform to the patient equipment requirements in Chapter 8, " Gas Equipment " .

Gas Equipment
8-3-1.11.1 Storage Requirements
8-3.1.11.2 Storage for nonflammable gases less than 3000 ft.3 (85 m3).
(h) Cylinder or container restraint shall meet 4-3.5.2.1 (b) 27

4-3.5.2.1 Gases in Cylinders and Liquefied Gases in Containers- Level 1
(b) Special Precautions- Oxygen Cylinders and Manifolds.
Great care shall be exercised in handling oxygen to prevent contact of oxygen under pressure with oils, greases, organic lubricants, rubber, or other materials of an organic nature. The following regulations, based on those of the CGA Pamphlet G-4, Oxygen, shall be observed:
27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.


Findings:

During the facility tour with the facility staff on 5/13/2013 through 5/15/2013, the facility compressed gas cylinder storage areas were observed.

On 5/13/13:
1. At 12:05 p.m., there were 4 carbon dioxide tanks loosely secured with one chain, and not individually secured under the dishwasher sink in the Cafeteria. The Director of Facilities confirmed the 4 carbon dioxide tanks were loosely secured with one chain, and were not individually secured under the dishwasher sink in the Cafeteria.

2. At 1:45 p.m., there were 4 E oxygen cylinders secured with one chain and not individually secured in the outside Medical Gas Storage. The Director of Facilities confirmed the 4 E oxygen cylinders secured with one chain, and were not individually secured in the outside Medical Gas Storage.

Based on document review and interview, the facility failed to maintain the piped in medical gas system in reliable working condition, as evidenced by the failure to repair discrepancies that were noted on the annual inspection report. This could result in failure of the medical gas system, and affected 3 of 3 smoke compartments.

NFPA 101, 2000 Edition
19.3.2.4
Medical Gas.
Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, 1999 Edition
1-2 Application
Chapters 12 through 18 specify the conditions under which the requirements of Chapters 3 through 11 shall apply in Chapters 12 through 18.

12-3.4 Gas and Vacuum System Requirements
12-3.4 If installed, patient gas systems shall conform to Level 1 gas systems of Chapter 4.

Findings:

During document review and interview with staff on 5/12/2013 through 5/15/2013, the annual medical gas report was reviewed.

On 5/14/13:
1. At 10:22 a.m., the facility provided the current annual medical gas report dated 2/14/13. The report noted the following discrepancies:
(14) Outlets need repairs, (2) Oxygen Latch Buttons, (2) Vacuum Latch Buttons, (1) N20 Hose Coupler, (1) O2 Modernization outlet Kit, (7) Shutoff Valve Labels and (1) Alarm Panel Light Bulb.

2. At 3:26 p.m., during interview, staff stated the repairs had not been completed and provided a quote that had not been approved or signed by the facility.

Based on document review and interview, the facility failed to ensure the emergency generator was exercised under load for at least 30 minutes per month. This was evidenced by failing to exercise the emergency generator under load for a minimum of 30 minutes per month for 2 of 12 months. This could result in potential failure of the emergency generator, and affected 3 of 3 smoke compartments.

NFPA 101 Life Safety Code, 2000 edition
4.6.12 Maintenance and Testing

4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.


Findings:

During document review with staff on 5/13/2013 through 5/15/2013, the emergency generator logs were reviewed.

On 5/13/13:
At 4:00 p.m., the generator logs provided by staff documented the emergency generator was exercised under load for 25 minutes on 2/13/13, and 12/13/12. During interview, staff stated there was no additional documentation for review, and stated they did not know why the generator was exercised under load for only 25 minutes.

Based on observation, the facility failed to maintain its electrical equipment and wiring in accordance with NFPA 70. This was evidenced by high wattage electrical appliances plugged into surge protectors and not directly into an electrical outlet, by multi-outlet adapters that were suspended above the floor, by multi-outlet adapters attached to walls and cabinets, and by the use of surge protectors as a substitute for fixed wiring. This could result in an electrical fire, and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected 2 of 3 smoke compartments.

NFPA 70, National Electrical Code?, 1999 Edition
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent.
A. Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified.

400-8 Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for a fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this code

Findings:

During the facility tour with the facility staff on 5/13/2013 through 5/15/2013, the electrical wiring and connections were observed.

On 5/13/13:
1. At 1:40 p.m., there was a refrigerator plugged into a surge protector that was attached to a cabinet, and was not plugged directly into the electrical outlet, in the Front Admitting Office.

2. At 2:45 p.m., there was a refrigerator, a television and a microwave plugged into a surge protector which was dangling over the refrigerator, in the Physician's Lounge.

3. At 2:55 p.m., there was a refrigerator, a microwave and a coffee maker plugged into a surge protector attached to the wall, and not plugged directly into the electrical outlet, in the ICU Storage.

4. At 3:00 p.m., there was a refrigerator plugged into a surge protector and not directly into the electrical outlet in ICU, at the entrance to Post OP.



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On 5/13/13:
5. At 11:38 a.m., there was a microwave plugged into an extension cord and not directly into the wall receptacle, in the nurse's lounge room.

6. At 12:04 p.m., there was a refrigerator plugged into a power strip and not directly into the wall receptacle. in the Manager's office.

Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by failing to repair and seal wall and ceiling penetrations in the facility. This could result in the spread of fire and smoke, and affected 2 of 3 compartments.

Findings:

During a tour of the facility with staff on 5/13/2013, through 5/15/2013, the facility walls and ceilings were observed.

On 5/13/13:
1. At 12:00 p.m., there was a 1 1/2 inch penetration in the wall where the door handle hit the wall, in patient room 110.

2. At 3:25 p.m. there was a 2 inch by 3 inch penetration inside the Pharmacy wall next to the corridor door.




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3. At 11:40 a.m., there was an approximately 2 inch square unsealed penetration around a group of blue computer cables in the center of the left wall in the House Supervisor Office.

4. At 3:10 p.m., there was an approximately 2 inch circular unsealed penetration by a group of blue computer cables in the ceiling in the IT Communications Closet next to Post ICU.

5. At 3:15 p.m., there was an approximately 2 inch penetration, and an approximately 1 inch unsealed penetration, in the center of the left wall in the Post ICU Equipment Closet.

The above findings were acknowledged by staff during the survey.

Based on observation, the facility failed to maintain the corridor doors as evidenced by self-closing corridor doors that failed to latch. This could result in the spread of smoke and fire throughout the facility, and increase the risk of injury to patients, visitors and staff due to smoke and fire. This affected 1 of 3 smoke compartments.

Findings:

During the facility tour with the facility staff on 5/13/2013 through 5/15/2013, the corridor doors were observed.

On 5/13/13:
At 11:30 a.m., the self-closing corridor door in the Chapel was blocked by a chair that prevented the door from closing.

Based on observation, the facility failed to maintain the integrity of the fire rated smoke barrier walls, as evidenced by a unsealed penetration in a smoke barrier wall. This could allow the spread of smoke during a fire, and affected 2 of 3 smoke compartments.

NFPA 101, Life Safety Code (2000) Edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

8.3.6 Penetrations and Miscellaneous Openings in Floors and Smoke Barriers.
8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining
the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is
designed for the specific purpose.

Findings:

During a tour of the facility with staff on 5/13/2013 through 5/15/2013, the smoke barrier walls were observed..

On 5/13/13:

At 11:56 a.m., there was an approximately 1/4 inch penetration around a conduit in the left side of the smoke barrier wall located next to patient room 110. This was acknowledged by staff during the survey.

Based on observation, the facility failed to protect the hazardous areas as evidenced by penetrations in the wall of a hazardous area, and by failing to maintain the door to a hazardous area. This could result in the spread of smoke and fire from the hazardous area to other areas, and increase the risk of injury to patients, visitors and staff. This affected 1 of 3 smoke compartments.

Findings:

During the facility tour with the facility staff on 5/13/2013 through 5/15/2013, the hazardous areas were observed.

On 5/13/13:
1. At 11:45 a.m., there were 19 approximately 1 inch unsealed penetrations in the cinder block wall of the Electrical closet by the staff entrance to Building D. The Director of Facilities confirmed the penetrations in the Electrical closet.


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2. At 1:51 p.m., the door to the surgery suite dirty utility room was held open by a towel that was tied to the door handle, and to a hook in the wall behind the door. The door was equipped with a self-closure device. This was acknowledged by staff during the survey.

Based on observation, document review and interview, the facility failed to test all battery powered emergency lighting in the facility, and failed to provide battery powered emergency lighting in the anesthetizing locations. This was evidenced by incomplete documentation for the maintenance of the battery powered emergency lighting, and by the failure to provide battery powered emergency lighting in 2 of 2 operating rooms in the surgery suite. This could result in no lighting in the event of a power failure and emergency generator failure. This affected 3 of 3 smoke compartments.

NFPA 101, Life Safety Code 2000 Edition
19.3.2.3 Anesthetizing Locations. Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Health Care Facilities (1999) Edition
3-3.2.1.2 All Patient Care Areas
(a) Wiring, Regular Voltage.
5. Wiring in Anesthetizing Locations.
e. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

Findings:

During a tour of the facility with staff on 5/13/2013 through 5/15/2013, the emergency lighting in the anesthetizing areas were observed.

On 5/13/13:
1. At 1:40 p.m., there was no battery powered emergency lighting units in Operating Room 1 or in Operating Room 2. This was acknowledged by staff during the survey.

On 5/14/13:
2. At 8:56 a.m., during the facility tour, battery powered emergency lights were observed throughout the facility. The documentation provided for the maintenance and testing of the emergency lights was incomplete. The documentation did not include the emergency lights in the Cat Scan rooms, or the X-ray rooms. During interview, staff stated they would take an inventory and update the list.

Based on document review and interview, the facility failed to conduct 2 of 2 disaster drills within one year. This was evidenced by no documentation for 2 of 2 disaster drills. This could result in any one staff member not accomplishing all of the tasks required in the event of an emergency, and increase the risk of injury to patients, visitors and staff. This affected 3 of 3 smoke compartments.

Findings:

During document review and interview with facility staff on 5/13/2013, through 5/15/2013, the disaster drills were requested, and staff was interviewed.

On 5/13/13:
1. At 10:45 a.m., the documentation for the disaster drills was requested from the facility.

On 5/15/13:
2. At 9:15 a.m., the Director of Facilities stated that the facility participated in the statewide disaster drill in October 2012, but no documentation was provided for review.

Based on record review, the facility failed to hold fire drills at unexpected times under varying conditions as evidenced by fire drills that were held around the same time of day. This could result in any one staff member not accomplishing all of the tasks required in the event of an emergency, and increase the risk of injury to patients, visitors and staff. This affected 3 of 3 smoke compartments.

Findings:

During the facility tour with the facility staff on 5/13/2013 through 5/15/2013, the fire drills were reviewed.

On 5/14/13:

At 9:15 a.m., the fire drills showed a pattern of being conducted around the same time of day. The fire drills were for two twelve hour shifts, from 7:00 a.m., to 7:00 p.m., and from 7:00 p.m., to 7:00 a.m.

The six fire drills for the second shift were held between 7:00 p.m., and 7:30 p.m. The dates were: 5/18/2013 at 7:20 p.m.; 3/1/2013, at 7:30 p.m.; 1/18/2013 at 7:00 p.m.; 11/6/2012 at 7:00 p.m.; 9/5/2012 at 7:30 p.m.; and 7/17/2012 at 7:30 p.m. There were no drills conducted between the hours of 7:30 p.m., and 9:30 a.m. The Director of Facilities confirmed that this information was correct.

Based on observation, record review and interview, the facility failed to maintain their fire alarm system in accordance with NFPA 101. This was evidenced by the overhead public address speakers for the fire alarm system that were not audible in all occupied spaces. This could result in delayed response to a fire, and increase the risk of injury to patients, visitors and staff. This affected 3 of 3 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code.
9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.
9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.
9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.
9.6.3.9 Audible alarm notification appliances shall produce signals that are distinctive from audible signals used for other purposes in the same building.

Findings:

During observation, fire alarm testing and interview with the facility staff on 5/13/2013 through 5/15/2013, the fire alarm system was observed, and staff was interviewed.

On 5/14/13:
1. At 10:30 a.m., the overhead speakers for the public address system could not be heard in the Med Surge area. The Director of Facilities stated that there was a dead area in the speaker system, and the facility was working to resolve the problem. The fire alarm system devices were audible.

On 5/15/13:
2. At 10:30 a.m., the fire drill records provided the following on the evaluation notes for these fire drills:
4/10/13: "Code Red called out properly-West Hallway speaker and ER not working."
12/11/12: "Speakers in West Hallway not audible/functional. Could not hear PA System."
11/6/12: "Hallway West Building C and Building B, Speakers were hard to hear."

Based on document review and interview, the facility failed to maintain the smoke detectors, as evidenced by failing to provide written documentation for smoke detector sensitivity testing. This could result in the smoke detectors not functioning as designed in the event of a fire, which may delay notification to facility staff of a fire. This failure affected 3 of 3 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
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, National Electrical Code, and
NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72, National Fire Alarm Code, 1999 edition
7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. after the second required calibration test, if sensitivity tests indicated that the detector has remained within its listed and marked sensitivity range (or 4% obscuration light gray smoke, if not marked), 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 in areas where nuisance show any increase over the previous year, calibration tests shall be performed.

To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any 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 unit arrangement where by the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity 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.

Findings:

During document review and interview with staff on 5/13/2013 through 5/15/2013, the documentation for smoke detector sensitivity testing was requested.

On 5/14/13:
1. At 3:52 p.m., the facility failed to provide documentation for smoke detector sensitivity testing. During interview, facility staff stated they would contact the vendor, and request the report for smoke detector sensitivity testing.

On 5/15/13:
2. At 9:22 a.m., the facility staff stated there was no documentation for smoke detector sensitivity testing.

Based on observation, document review and interview, the facility failed to maintain the integrity of the automatic sprinkler system. This was evidenced by failing to correct deficiencies noted on the five year certification report, failing to provide 2 of 4 quarterly test reports for the Inspector's Test Valve, and by missing sprinkler escutcheon rings. This failure could result in the automatic sprinkler system not functioning as designed in the event of a fire, and affected 3 of 3 smoke compartments.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water Based Fire Protection Systems (1998) Edition
2-2.1 Sprinklers.
2-2.1.1* Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any
sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
Exception No. 1:* Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

2-3 Testing
2-3.3 Alarm Devices. Water flow alarm devices including, but not limited to, mechanical water motor gongs, van-type water flow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

Findings:

During a tour of the facility with staff on 5/13/2013 through 5/15/2013, the automatic sprinkler system was observed.

On 5/13/13:
1. At 12:24 p.m., the sprinkler escutcheon ring was missing in the social services office.

On 5/14/13:
2. At 9:41 a.m., during document review staff provided a five year certification report from an outside vendor dated 11/26/12. The report noted deficiencies, and staff was asked for documentation for the corrections of the noted deficiencies in the report. Staff stated there was no documentation for the corrections, and did not know if any of the deficiencies had been corrected.

3. At 11:50 a.m., there were two 3 inch penetrations in the ceiling that exposed the automatic sprinkler pipes in the Doctor's Lounge. The sprinkler escutcheon rings were missing. This deficiency was noted on the five year discrepancy report, and acknowledged by staff during the survey and document review.

4. At 11:52 a.m., there were two 3 inch penetrations in the ceiling that exposed the automatic sprinkler pipes in the doctors on-call sleeping room, and a 2 inch penetration next to one of the sprinklers. The sprinkler escutcheon rings were missing. This deficiency was noted on the five year discrepancy report, and was acknowledged by staff during the survey.

5. At 11:57 a.m., in the Materials Management Department there were approximately 28 sprinkler escutcheon rings missing. This deficiency was noted on the five year discrepancy report, and acknowledged by staff during survey.

6. At 2:14 p.m., during the testing of the automatic sprinkler system the panel addressed the Inspector's Test Valve (ITV) as water flow boiler room. The ITV was located outside of the Emergency lobby, and not in the boiler room. This deficiency was noted on the five year certification discrepancy report, and was acknowledged by staff during the survey.

On 5/15/13:
7. At 9:52 a.m., during the main drain water flow test the 6 inch bell located outside of the boiler room failed to activate an alarm. This deficiency was noted on the five year certification discrepancy report, and was acknowledged by staff during the survey.





27272

Based on observation and record review, the facility failed to maintain the portable fire extinguishers. This was evidenced by obstructed access to portable fire extinguishers, by portable fire extinguishers that were past their annual inspection dates, and by incomplete monthly inspection dates. This could result in delayed response to a fire, and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected 2 of 3 smoke compartments and the CT Trailer.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition
1-6.6 Fire extinguishers shall not be obstructed or obscured from view.
4-3.1 Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire Extinguishers shall be inspected at more frequent intervals when circumstances require.
4-3.2* Procedures. Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) *Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or " hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

Findings:

During the facility tour with the facility staff on 5/13/2013 through 5/15/13, the portable fire extinguishers were observed, and records were reviewed.

On 5/13/13:
1. At 11:59 a.m., the K-fire extinguisher was blocked by a chair in the dish washer area of the Cafeteria.

2. At 2:50 p.m., the fire extinguisher was blocked by a cart that contained a drink container and a box of drinks, in the Dietary Department.

On 5/14/13:
3. At 8:30 a.m., there were 2 of 2 fire extinguishers that were past the annual inspection date of 4/13/12, and had incomplete monthly inspections, in the CT Trailer.



21101

On 5/13/13:
4. At 12:09 p.m., the ABC fire extinguisher located in dietary was obstructed by food carts and a coffee machine that was place in front of the fire extinguisher. This was acknowledged by staff during the survey.

Based on observation, the facility failed to maintain its exit corridors free of obstructions or impediments, as evidenced by 1 of 2 exit corridors in the surgery suite that were impeded by medical equipment and a chair. This failure could result in the delay of evacuating patients in the event of a fire or other emergency, and affected 1 of 3 smoke compartments.

Findings:

During a tour of the facility with staff on 5/13/2013 through 5/15/2013, the exit corridors and path of travel were observed.

On 5/13/13:

At 1:48 p.m., the east emergency exit path of travel in the surgery suite was obstructed by two tourniquet machines, a chair and two monitors that were left unattended in the exit corridor. This was acknowledged by staff during the survey.

Based on observation, the facility failed to maintain the compressed gas cylinders as evidenced by gas cylinders that were not stored individually secured. This could result in an increased risk of fire, and increase the risk of injury to patients, visitors and staff due to smoke and fire. This affected 1 of 3 smoke compartments.

NFPA 101, 2000 Edition
19.3.2.4
Medical Gas.
Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, 1999 Edition
1-2 Application
Chapters 12 through 18 specify the conditions under which the requirements of Chapters 3 through 11 shall apply in Chapters 12 through 18.

12-3.8 Gas System Requirements
12-3.8.1 Patient
Equipment shall conform to the patient equipment requirements in Chapter 8, " Gas Equipment " .

Gas Equipment
8-3-1.11.1 Storage Requirements
8-3.1.11.2 Storage for nonflammable gases less than 3000 ft.3 (85 m3).
(h) Cylinder or container restraint shall meet 4-3.5.2.1 (b) 27

4-3.5.2.1 Gases in Cylinders and Liquefied Gases in Containers- Level 1
(b) Special Precautions- Oxygen Cylinders and Manifolds.
Great care shall be exercised in handling oxygen to prevent contact of oxygen under pressure with oils, greases, organic lubricants, rubber, or other materials of an organic nature. The following regulations, based on those of the CGA Pamphlet G-4, Oxygen, shall be observed:
27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.


Findings:

During the facility tour with the facility staff on 5/13/2013 through 5/15/2013, the facility compressed gas cylinder storage areas were observed.

On 5/13/13:
1. At 12:05 p.m., there were 4 carbon dioxide tanks loosely secured with one chain, and not individually secured under the dishwasher sink in the Cafeteria. The Director of Facilities confirmed the 4 carbon dioxide tanks were loosely secured with one chain, and were not individually secured under the dishwasher sink in the Cafeteria.

2. At 1:45 p.m., there were 4 E oxygen cylinders secured with one chain and not individually secured in the outside Medical Gas Storage. The Director of Facilities confirmed the 4 E oxygen cylinders secured with one chain, and were not individually secured in the outside Medical Gas Storage.

Based on document review and interview, the facility failed to maintain the piped in medical gas system in reliable working condition, as evidenced by the failure to repair discrepancies that were noted on the annual inspection report. This could result in failure of the medical gas system, and affected 3 of 3 smoke compartments.

NFPA 101, 2000 Edition
19.3.2.4
Medical Gas.
Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, 1999 Edition
1-2 Application
Chapters 12 through 18 specify the conditions under which the requirements of Chapters 3 through 11 shall apply in Chapters 12 through 18.

12-3.4 Gas and Vacuum System Requirements
12-3.4 If installed, patient gas systems shall conform to Level 1 gas systems of Chapter 4.

Findings:

During document review and interview with staff on 5/12/2013 through 5/15/2013, the annual medical gas report was reviewed.

On 5/14/13:
1. At 10:22 a.m., the facility provided the current annual medical gas report dated 2/14/13. The report noted the following discrepancies:
(14) Outlets need repairs, (2) Oxygen Latch Buttons, (2) Vacuum Latch Buttons, (1) N20 Hose Coupler, (1) O2 Modernization outlet Kit, (7) Shutoff Valve Labels and (1) Alarm Panel Light Bulb.

2. At 3:26 p.m., during interview, staff stated the repairs had not been completed and provided a quote that had not been approved or signed by the facility.

Based on document review and interview, the facility failed to ensure the emergency generator was exercised under load for at least 30 minutes per month. This was evidenced by failing to exercise the emergency generator under load for a minimum of 30 minutes per month for 2 of 12 months. This could result in potential failure of the emergency generator, and affected 3 of 3 smoke compartments.

NFPA 101 Life Safety Code, 2000 edition
4.6.12 Maintenance and Testing

4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.


Findings:

During document review with staff on 5/13/2013 through 5/15/2013, the emergency generator logs were reviewed.

On 5/13/13:
At 4:00 p.m., the generator logs provided by staff documented the emergency generator was exercised under load for 25 minutes on 2/13/13, and 12/13/12. During interview, staff stated there was no additional documentation for review, and stated they did not know why the generator was exercised under load for only 25 minutes.

Based on observation, the facility failed to maintain its electrical equipment and wiring in accordance with NFPA 70. This was evidenced by high wattage electrical appliances plugged into surge protectors and not directly into an electrical outlet, by multi-outlet adapters that were suspended above the floor, by multi-outlet adapters attached to walls and cabinets, and by the use of surge protectors as a substitute for fixed wiring. This could result in an electrical fire, and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected 2 of 3 smoke compartments.

NFPA 70, National Electrical Code?, 1999 Edition
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent.
A. Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified.

400-8 Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for a fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this code

Findings:

During the facility tour with the facility staff on 5/13/2013 through 5/15/2013, the electrical wiring and connections were observed.

On 5/13/13:
1. At 1:40 p.m., there was a refrigerator plugged into a surge protector that was attached to a cabinet, and was not plugged directly into the electrical outlet, in the Front Admitting Office.

2. At 2:45 p.m., there was a refrigerator, a television and a microwave plugged into a surge protector which was dangling over the refrigerator, in the Physician's Lounge.

3. At 2:55 p.m., there was a refrigerator, a microwave and a coffee maker plugged into a surge protector attached to the wall, and not plugged directly into the electrical outlet, in the ICU Storage.

4. At 3:00 p.m., there was a refrigerator plugged into a surge protector and not directly into the electrical outlet in ICU, at the entrance to Post OP.



21101

On 5/13/13:
5. At 11:38 a.m., there was a microwave plugged into an extension cord and not directly into the wall receptacle, in the nurse's lounge room.

6. At 12:04 p.m., there was a refrigerator plugged into a power strip and not directly into the wall receptacle. in the Manager's office.