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Based on observation and interview, the facility failed to ensure 1 of 7 corridor doors in the ambulatory care area closed and latched into the door frame. This deficient practice could affect any patients in the ambulatory care area and the sleep center.

Findings include:

Based on observation with the Bio-Medical Engineer on 12/27/10 at 1:15 p.m., the corridor door to the clean utility room lacked a latching mechanism required to latch the door into the frame. This was acknowledged by the Bio-Medical Engineer at the time of observation.

Based on observation and interview, the facility failed to ensure 1 of 4 single fire barrier doors in the south stairway enclosure would automatically close upon activation of the fire alarm system. This deficient practice could affect all patients evacuated through the south stair way in the event of an emergency.

Findings include:

Based on an observation with the Bio-Medical Engineer on 12/27/10 at 1:39 p.m., the fourth floor south stairway fire door was propped open with a wooden door wedge. Based on an interview with the Bio-Medical Engineer at the time of observation, the door was propped open to provide additional heat to the stairway and the sprinkler piping.

Based on observation and interview, the facility failed to ensure 4 of 5 penetrations caused by the passage of wire and/or conduit through the smoke barrier wall in the basement house keeping storage room and the emergency room area were protected to maintain the smoke resistance of each smoke barrier. LSC Section 19.3.7.3 requires smoke barriers to be constructed in accordance with LSC Section 8-3. LSC Section 8.3.6.1 requires the passage of building service materials such as pipe, cable or wire to be protected so the space between the penetrating item and the smoke barrier shall be filled with a material capable of maintaining the smoke resistance of the smoke barrier or be protected by an approved device designed for the specific purpose. This deficient practice could affect all patients in the emergency room area and staff in the basement storage room.

Findings include:

Based on observations with Facilities Director and the Bio-Medical Engineer on 12/28/10 from 12:05 p.m. to 1:50 p.m., the following was noted in the smoke barrier wall at the emergency room:
a) one of one unsealed one inch penetrations around flexible conduit above the drop down ceiling in the emergency room lobby
b) two of three unsealed, one half to three fourths inch water and high voltage conduit penetrations above the drop down ceiling in the emergency room corridor
c) a four by four inch square opening where the drywall had been removed and never replaced above the drop down ceiling in the emergency room corridor
d) five of five unsealed penetrations measuring from one fourth inch to two and one half inches around plumbing lines in the smoke barrier wall of the basement housekeeping storage room.
Measurements were provided by the Bio-Medical Engineer at the time of observations.

Based on observation, interview and record review; the facility failed to ensure 1 of 2 sets of smoke barrier doors and 5 of 8 single smoke barrier doors in the emergency room area would self close and restrict the movement of smoke for at least 20 minutes. LSC 19.3.7.6 requires doors in smoke barriers shall comply with LSC Section 8.3.4. LSC 8.3.4.1 requires doors in smoke barrier shall close the opening leaving only the minimum clearance necessary for proper operation which is defined as 1/8 inch. This deficient practice could affect all patients in the emergency room.

Findings include:

Based on an observations with the Bio-Medical Engineer on 12/27/10 from 2:51 p.m. to 3:00 p.m., the following was noted regarding the smoke barrier doors of the smoke barrier wall surrounding the emergency room area:
a) the set of smoke barrier doors by Triage 3 lacked a self closing device,
b) the clean supply room door was propped open with a wooden door wedge,
c) the quiet room, ER coordinator office and the doctors sleeping room doors were propped with a kick down door stop,
d) the coat closet door lacked a self closing device.
Based of review of the building construction plans at 12:40 p.m. on 12/27/10 with the Bio-Medical Engineer, it was determined and confirmed this was the smoke barrier separation wall on the first floor. This was acknowledged by the Bio-Medical Engineer at the time of observations.

1. Based on observation and interview, the facility failed to ensure 1 of 1 maintenance repair shop corridor doors was provided with a door equipped with a self closing device causing the door to automatically close and latch into the door frame. This deficient practice was not in a patient care area but could affect any number of staff.

Findings include:

Based on observation with the Facilities Director and the Bio-Medical Engineer on 12/28/10 at 12:30 p.m., the corridor door to the maintenance repair shop did not have a self closer. This was acknowledged by the Facilities Director at the time of observation.


2. Based on observation and interview, the facility failed to ensure 2 of 2 surgery area biohazard waste rooms were provided with a door equipped with a self closing device causing the door to automatically close and latch into the door frame. This deficient practice could affect any patient in the surgery area.

Findings include:

Based on observations with the Bio-Medical Engineer on 12/27/10 from 3:12 p.m. to 3:15 p.m., the latch on the biohazard waste room corridor door in the surgery area was taped preventing the door from latching into the frame. In addition, the corridor door to the biohazard waste/soiled linen room lacked a self closing device. These were acknowledged by the Bio-Medical Engineer at the time of observations.

Based on observation and interview, the facility failed to ensure 1 of 2 exit discharge paths from the second floor administration area was readily accessible at all times. This deficient practice could affect all staff in the administration area in the event of an emergency.

Findings include:

Based on an observation with the Bio-Medical Engineer on 12/27/10 at 1:20 p.m., the door to the rear exit discharge path of the administration area which lead into the nurses' station was obstructed by a refrigerator. This was acknowledged by the Bio-Medical Engineer at the time of observation.

Based on observation and interview, the facility failed to ensure 1 of 1 west fire door sets in the surgery area was arranged to automatically close and latch. LSC 19.2.2.5 requires horizontal exits to be in accordance with 7.2.4 and 7.2.4.3.8 requires fire doors to be self closing or automatic closing in accordance with 7.2.1.8. In addition NFPA 80, Standard for Fire Doors and Windows at 2-1.4.1 requires all closing mechanisms shall be adjusted to overcome fire resistance of the latch mechanism so that positive latching is achieved on each door operation. This deficient practice all patients in the surgery area.

Findings include:

Based on observation with the Bio-Medical Engineer on 12/27/10 at 3:15 p.m., the coordinating device on the west surgery area fire doors failed to function properly leaving a one inch gap between the frame and the doors. Additionally, when allowed to close the doors wedged together at the top and did not close and latch into the frame. Measurements were provided by the Bio-Medical Engineer at the time of observation, and it was acknowledged these were fire doors.

Based on observation and interview, the facility failed to ensure 2 of 2 emergency lights were tested monthly for 30 seconds and annually for at least a 1? hour duration. LSC 7.9.3 Periodic Testing of Emergency Lighting Equipment requires a functional test shall be conducted on every required battery powered emergency lighting system at 30 day intervals for a minimum of 30 seconds. An annual test shall be conducted on every required battery powered emergency lighting system for not less than 1 ? hour duration. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect all occupants.

Findings include:

Based on an observation with the Facilities Director and the Bio-Medical Engineer on 12/27/10 at 12:02 p.m., two battery operated emergency task lights were observed at the emergency generator. Based on an interview with the Facilities Director and the Bio-Medical Engineer at the time of observation, there were no written records of a monthly or an annual test regarding the battery operated emergency task lights available for review.

Based on record review and interview, the facility failed to include the evacuation of the smoke compartment in the written plan for the protection of 12 of 12 patients and for their evacuation in the event of an emergency. LSC 19.7.2.2 requires a written health care occupancy fire safety plan that shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to the fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
This deficient practice could affect all patients in the facility.

Findings include:

Based on a record review with the Facilities Director and the Bio-Med Engineer of the facility's written fire disaster plan titled "Evacuation of Hospital" on 12/27/10 at 10:28 a.m., the fire plan did not address the evacuation of the smoke compartment nor the preparation of floors for evacuation. This was acknowledged by the Facilities Director at the time of record review.

Based on record review and interview, the facility failed to ensure fire drills were conducted quarterly on each shift for 1 of the last 4 completed quarters. This deficient practice could affect all patients.

Findings include:

Based on review of the "Fire Drill Sign-In Sheet" with the Facilities Director and the Bio-Med Engineer on 12/27/10 at 12:02 p.m., there was no record of a first, second and third shift fire drill for the second quarter of 2010. Based on an interview with the Facilities Director and Bio-Med Engineer at the time of record review, no other documentation was available for review to verify these drills were conducted.

Based on observation and interview, the facility failed to ensure 16 of 23 smoke detectors in the various locations throughout the facility were not installed where air flow would adversely affect their operation. NFPA 72, National Fire Alarm Code, 2-3.5.1 requires in spaces served by air handling systems, detectors shall not be located where air flow prevents operation of the detectors. This deficient practice could affect the twelve patients in the north and south corridors of the medical surgery area and any number of patients throughout the facility.

Findings include:

Based on observations with the Bio-Medical Engineer on 12/27/10 from 10:40 a.m. to 2:34 p.m., the following smoke detectors were located within three feet of an supply air duct fan:
a) one of one in the Financial Service corridor
b) one of three in the Administration area corridor
c) two of three in the second floor lobby
d) four of eight in the rehabilitation gym
e) two of two in both ICU rooms
f) two of two in the north and south Medical surgical corridors
h) four of four in the emergency room area
These were acknowledged by the Bio-Medical Engineer at the time of observations.

Based on observation and interview, the facility failed to ensure 1 of 2 Rehabilitation gym fire extinguishers was provided maintenance when the gauge on the fire extinguisher indicated it needed recharging. NFPA 10, Standard for Portable Fire Extinguishers, in Section 4-4.1 requires fire extinguishers to be subjected to maintenance no more than one year apart or when specifically indicated by inspection. This deficient practice could affect all residents in the Rehabilitation gym in the event of an emergency.

Findings include:

Based on an observation with the Bio-Medical Engineer on 12/27/10 at 1:32 p.m., the gauge on the portable fire extinguisher located near the staff restroom in the Rehabilitation gym indicated the extinguisher needed to be recharged. This was acknowledged by the Bio-Medical Engineer at the time of observation.

Based on interview and record review, the facility failed to ensure an undetermined number of dampers were inspected and provided necessary maintenance at least every six years in accordance with NFPA 90A. LSC 9.2.1 requires air conditioning, heating, ventilating ductwork and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. NFPA 90A, 1999 Edition, 3.4.7, Maintenance, requires at least every 6 years, fusible links shall be removed; all dampers shall be operated to verify they fully close; the latch, if provided, shall be checked, and moving parts shall be lubricated as necessary. This deficient practice affects all patients, staff and visitors.

Findings include:

During record review and interview with the Facilities Director and the Bio-Medical Engineer on 12/27/10 at 12:30 p.m., there were fire/smoke dampers throughout the facility but the exact number of fire/smoke dampers was unknown and they could not provide documentation of the last inspection.

Based on observation and interview, the facility failed to ensure 1 of 1 deep fat fryers was installed correctly. NFPA 96, 9-1.2.3 requires deep fat fryers be installed at least 16 inches from the surface flames of adjacent cooking equipment, or have a protective shielding constructed of steel or tempered glass measuring at least eight inches in height between the two appliances. This deficient practice could affect all kitchen staff and patients in the cafeteria in the event of an emergency.

Findings include:

Based on an observation with the Facilities Director and the Bio-Medical Engineer on 12/28/10 at 11:20 a.m., the deep fat fryer was located inches from the gas burners on the commercial cooking stove and did not have a protective shielding measuring at least eight inches in height between the two appliances. This was acknowledged by the Facilities Director and the Bio-Medical Engineer at the time of observation.

1. Based on observation, record review and interview: the facility failed to ensure 1 of 1 emergency generators was equipped with a remote manual stop. LSC 7.9.2.3 requires emergency generators providing power to emergency lighting systems shall be installed, tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110, 1999 edition, 3-5.5.6 requires Level I 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. NFPA 37, Standard for the Installation and Use of Stationary Combustion Engines and Gas Turbines, 1998 Edition, at 8-2.2(c) requires engines of 100 horsepower or more have provision for the shutting down the engine at the engine and from a remote location. This deficient practice could affect all occupants.

Findings include:

Based on observation with the Facilities Director and the Bio-Medical Engineer on 12/28/10 at 12:25 p.m., the only shut off device was located on the emergency generator panel of the emergency generator located in the basement. Based on review of the "Emergency Generator Log Sheet" with the Facilities Director and the Clinical Biomedical Engineer, there was no documentation available which indicated the amount of horsepower the generator provided. Based on a telephone interview on 1/3/11 at 9:40 a.m. with the Bio-Medical Engineer, the emergency generator was 700 horsepower.


2. Based on record review and interview, the facility failed to maintain a complete written record of monthly generator load testing for 1 of 12 months. Chapter 3-4.4.1.1 of NFPA 99 requires monthly testing of the generator serving the emergency electrical system to be in accordance with NFPA 110, the Standard for Emergency and Standby Powers Systems, chapter 6-4.2. Chapter 6-4.2 of NFPA 110 requires generator sets in Level 1 and Level 2 service to be exercised under operating conditions or not less than 30 percent of the EPS nameplate rating, whichever is greater, at least monthly, for a minimum of 30 minutes. Chapter 3-5.4.2 of NFPA 99 requires a written record of inspection, performance, exercising period, and repairs for the generator to be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice could affect all patients.

Findings include:

Based on review of the generator log "Emergency Generator Log Sheet" with the Facilities Director and the Bio-Medical Engineer on 12/27/10 at 11:39 p.m., there was no documentation available for a generator load test for the month of September, 2010. This was acknowledged by the Facilities Director and the Bio-Medical Engineer at the time of record review.

1. Based on observation and interview, the facility failed to ensure 2 of 2 flexible cords were not used as a substitute for fixed wiring. NFPA 70, National Electrical Code, 1999 Edition, Article 400-8 requires, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice could was not in a resident care area but could affect any number of staff.

Findings include:

Based on observations with the Facilities Director and the Bio-Medical Engineer on 12/28/10 at 12:10 p.m., heavy duty extension cords were plugged in and providing power to two fans in the sub-basement tunnel. Based on interview at the time of observation, the fans were needed continuously to cool two separate pieces of equipment .

2. Based on observation and interview, the facility failed to ensure 1 of 1 wet locations was provided with ground fault circuit interrupter (GFCI) protection against electric shock. NFPA 70, Article 517, Health Care Facilities, defines wet locations as areas subjected to wet conditions. These include standing fluids on the floor or drenching of the work area, either of which condition is intimate to the patient or staff. NFPA 70, 517-20 Wet Locations, requires all receptacles and fixed equipment within the area of the wet location to have GFCI protection. Moisture can reduce the contact resistance of the body, and electrical insulation is more subject to failure. This deficient practice could affect any staff using the sink in the basement central sterilization room in the event of an electrical short.

Findings include:

Based on an observation with the Facilities Director and the Bio-Medical Engineer on 12/29/10 at 11:40 a.m., the basement central sterilization room had two electrical receptacles on the wall within three feet of the four compartment sink which were not provided with GFCI protection to prevent electric shock. Based on observation of the breaker box and interview with the Bio-Medical Engineer at the time of observation, he confirmed the receptacles were not on a GFCI breaker.

Based on observation and interview, the facility failed to ensure 1 of 7 corridor doors in the ambulatory care area closed and latched into the door frame. This deficient practice could affect any patients in the ambulatory care area and the sleep center.

Findings include:

Based on observation with the Bio-Medical Engineer on 12/27/10 at 1:15 p.m., the corridor door to the clean utility room lacked a latching mechanism required to latch the door into the frame. This was acknowledged by the Bio-Medical Engineer at the time of observation.

Based on observation and interview, the facility failed to ensure 1 of 4 single fire barrier doors in the south stairway enclosure would automatically close upon activation of the fire alarm system. This deficient practice could affect all patients evacuated through the south stair way in the event of an emergency.

Findings include:

Based on an observation with the Bio-Medical Engineer on 12/27/10 at 1:39 p.m., the fourth floor south stairway fire door was propped open with a wooden door wedge. Based on an interview with the Bio-Medical Engineer at the time of observation, the door was propped open to provide additional heat to the stairway and the sprinkler piping.

Based on observation and interview, the facility failed to ensure 4 of 5 penetrations caused by the passage of wire and/or conduit through the smoke barrier wall in the basement house keeping storage room and the emergency room area were protected to maintain the smoke resistance of each smoke barrier. LSC Section 19.3.7.3 requires smoke barriers to be constructed in accordance with LSC Section 8-3. LSC Section 8.3.6.1 requires the passage of building service materials such as pipe, cable or wire to be protected so the space between the penetrating item and the smoke barrier shall be filled with a material capable of maintaining the smoke resistance of the smoke barrier or be protected by an approved device designed for the specific purpose. This deficient practice could affect all patients in the emergency room area and staff in the basement storage room.

Findings include:

Based on observations with Facilities Director and the Bio-Medical Engineer on 12/28/10 from 12:05 p.m. to 1:50 p.m., the following was noted in the smoke barrier wall at the emergency room:
a) one of one unsealed one inch penetrations around flexible conduit above the drop down ceiling in the emergency room lobby
b) two of three unsealed, one half to three fourths inch water and high voltage conduit penetrations above the drop down ceiling in the emergency room corridor
c) a four by four inch square opening where the drywall had been removed and never replaced above the drop down ceiling in the emergency room corridor
d) five of five unsealed penetrations measuring from one fourth inch to two and one half inches around plumbing lines in the smoke barrier wall of the basement housekeeping storage room.
Measurements were provided by the Bio-Medical Engineer at the time of observations.

Based on observation, interview and record review; the facility failed to ensure 1 of 2 sets of smoke barrier doors and 5 of 8 single smoke barrier doors in the emergency room area would self close and restrict the movement of smoke for at least 20 minutes. LSC 19.3.7.6 requires doors in smoke barriers shall comply with LSC Section 8.3.4. LSC 8.3.4.1 requires doors in smoke barrier shall close the opening leaving only the minimum clearance necessary for proper operation which is defined as 1/8 inch. This deficient practice could affect all patients in the emergency room.

Findings include:

Based on an observations with the Bio-Medical Engineer on 12/27/10 from 2:51 p.m. to 3:00 p.m., the following was noted regarding the smoke barrier doors of the smoke barrier wall surrounding the emergency room area:
a) the set of smoke barrier doors by Triage 3 lacked a self closing device,
b) the clean supply room door was propped open with a wooden door wedge,
c) the quiet room, ER coordinator office and the doctors sleeping room doors were propped with a kick down door stop,
d) the coat closet door lacked a self closing device.
Based of review of the building construction plans at 12:40 p.m. on 12/27/10 with the Bio-Medical Engineer, it was determined and confirmed this was the smoke barrier separation wall on the first floor. This was acknowledged by the Bio-Medical Engineer at the time of observations.

1. Based on observation and interview, the facility failed to ensure 1 of 1 maintenance repair shop corridor doors was provided with a door equipped with a self closing device causing the door to automatically close and latch into the door frame. This deficient practice was not in a patient care area but could affect any number of staff.

Findings include:

Based on observation with the Facilities Director and the Bio-Medical Engineer on 12/28/10 at 12:30 p.m., the corridor door to the maintenance repair shop did not have a self closer. This was acknowledged by the Facilities Director at the time of observation.


2. Based on observation and interview, the facility failed to ensure 2 of 2 surgery area biohazard waste rooms were provided with a door equipped with a self closing device causing the door to automatically close and latch into the door frame. This deficient practice could affect any patient in the surgery area.

Findings include:

Based on observations with the Bio-Medical Engineer on 12/27/10 from 3:12 p.m. to 3:15 p.m., the latch on the biohazard waste room corridor door in the surgery area was taped preventing the door from latching into the frame. In addition, the corridor door to the biohazard waste/soiled linen room lacked a self closing device. These were acknowledged by the Bio-Medical Engineer at the time of observations.

Based on observation and interview, the facility failed to ensure 1 of 2 exit discharge paths from the second floor administration area was readily accessible at all times. This deficient practice could affect all staff in the administration area in the event of an emergency.

Findings include:

Based on an observation with the Bio-Medical Engineer on 12/27/10 at 1:20 p.m., the door to the rear exit discharge path of the administration area which lead into the nurses' station was obstructed by a refrigerator. This was acknowledged by the Bio-Medical Engineer at the time of observation.

Based on observation and interview, the facility failed to ensure 1 of 1 west fire door sets in the surgery area was arranged to automatically close and latch. LSC 19.2.2.5 requires horizontal exits to be in accordance with 7.2.4 and 7.2.4.3.8 requires fire doors to be self closing or automatic closing in accordance with 7.2.1.8. In addition NFPA 80, Standard for Fire Doors and Windows at 2-1.4.1 requires all closing mechanisms shall be adjusted to overcome fire resistance of the latch mechanism so that positive latching is achieved on each door operation. This deficient practice all patients in the surgery area.

Findings include:

Based on observation with the Bio-Medical Engineer on 12/27/10 at 3:15 p.m., the coordinating device on the west surgery area fire doors failed to function properly leaving a one inch gap between the frame and the doors. Additionally, when allowed to close the doors wedged together at the top and did not close and latch into the frame. Measurements were provided by the Bio-Medical Engineer at the time of observation, and it was acknowledged these were fire doors.

Based on observation and interview, the facility failed to ensure 2 of 2 emergency lights were tested monthly for 30 seconds and annually for at least a 1? hour duration. LSC 7.9.3 Periodic Testing of Emergency Lighting Equipment requires a functional test shall be conducted on every required battery powered emergency lighting system at 30 day intervals for a minimum of 30 seconds. An annual test shall be conducted on every required battery powered emergency lighting system for not less than 1 ? hour duration. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect all occupants.

Findings include:

Based on an observation with the Facilities Director and the Bio-Medical Engineer on 12/27/10 at 12:02 p.m., two battery operated emergency task lights were observed at the emergency generator. Based on an interview with the Facilities Director and the Bio-Medical Engineer at the time of observation, there were no written records of a monthly or an annual test regarding the battery operated emergency task lights available for review.

Based on record review and interview, the facility failed to include the evacuation of the smoke compartment in the written plan for the protection of 12 of 12 patients and for their evacuation in the event of an emergency. LSC 19.7.2.2 requires a written health care occupancy fire safety plan that shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to the fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
This deficient practice could affect all patients in the facility.

Findings include:

Based on a record review with the Facilities Director and the Bio-Med Engineer of the facility's written fire disaster plan titled "Evacuation of Hospital" on 12/27/10 at 10:28 a.m., the fire plan did not address the evacuation of the smoke compartment nor the preparation of floors for evacuation. This was acknowledged by the Facilities Director at the time of record review.

Based on record review and interview, the facility failed to ensure fire drills were conducted quarterly on each shift for 1 of the last 4 completed quarters. This deficient practice could affect all patients.

Findings include:

Based on review of the "Fire Drill Sign-In Sheet" with the Facilities Director and the Bio-Med Engineer on 12/27/10 at 12:02 p.m., there was no record of a first, second and third shift fire drill for the second quarter of 2010. Based on an interview with the Facilities Director and Bio-Med Engineer at the time of record review, no other documentation was available for review to verify these drills were conducted.

Based on observation and interview, the facility failed to ensure 16 of 23 smoke detectors in the various locations throughout the facility were not installed where air flow would adversely affect their operation. NFPA 72, National Fire Alarm Code, 2-3.5.1 requires in spaces served by air handling systems, detectors shall not be located where air flow prevents operation of the detectors. This deficient practice could affect the twelve patients in the north and south corridors of the medical surgery area and any number of patients throughout the facility.

Findings include:

Based on observations with the Bio-Medical Engineer on 12/27/10 from 10:40 a.m. to 2:34 p.m., the following smoke detectors were located within three feet of an supply air duct fan:
a) one of one in the Financial Service corridor
b) one of three in the Administration area corridor
c) two of three in the second floor lobby
d) four of eight in the rehabilitation gym
e) two of two in both ICU rooms
f) two of two in the north and south Medical surgical corridors
h) four of four in the emergency room area
These were acknowledged by the Bio-Medical Engineer at the time of observations.

Based on observation and interview, the facility failed to ensure 1 of 2 Rehabilitation gym fire extinguishers was provided maintenance when the gauge on the fire extinguisher indicated it needed recharging. NFPA 10, Standard for Portable Fire Extinguishers, in Section 4-4.1 requires fire extinguishers to be subjected to maintenance no more than one year apart or when specifically indicated by inspection. This deficient practice could affect all residents in the Rehabilitation gym in the event of an emergency.

Findings include:

Based on an observation with the Bio-Medical Engineer on 12/27/10 at 1:32 p.m., the gauge on the portable fire extinguisher located near the staff restroom in the Rehabilitation gym indicated the extinguisher needed to be recharged. This was acknowledged by the Bio-Medical Engineer at the time of observation.

Based on interview and record review, the facility failed to ensure an undetermined number of dampers were inspected and provided necessary maintenance at least every six years in accordance with NFPA 90A. LSC 9.2.1 requires air conditioning, heating, ventilating ductwork and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. NFPA 90A, 1999 Edition, 3.4.7, Maintenance, requires at least every 6 years, fusible links shall be removed; all dampers shall be operated to verify they fully close; the latch, if provided, shall be checked, and moving parts shall be lubricated as necessary. This deficient practice affects all patients, staff and visitors.

Findings include:

During record review and interview with the Facilities Director and the Bio-Medical Engineer on 12/27/10 at 12:30 p.m., there were fire/smoke dampers throughout the facility but the exact number of fire/smoke dampers was unknown and they could not provide documentation of the last inspection.

Based on observation and interview, the facility failed to ensure 1 of 1 deep fat fryers was installed correctly. NFPA 96, 9-1.2.3 requires deep fat fryers be installed at least 16 inches from the surface flames of adjacent cooking equipment, or have a protective shielding constructed of steel or tempered glass measuring at least eight inches in height between the two appliances. This deficient practice could affect all kitchen staff and patients in the cafeteria in the event of an emergency.

Findings include:

Based on an observation with the Facilities Director and the Bio-Medical Engineer on 12/28/10 at 11:20 a.m., the deep fat fryer was located inches from the gas burners on the commercial cooking stove and did not have a protective shielding measuring at least eight inches in height between the two appliances. This was acknowledged by the Facilities Director and the Bio-Medical Engineer at the time of observation.

1. Based on observation, record review and interview: the facility failed to ensure 1 of 1 emergency generators was equipped with a remote manual stop. LSC 7.9.2.3 requires emergency generators providing power to emergency lighting systems shall be installed, tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110, 1999 edition, 3-5.5.6 requires Level I 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. NFPA 37, Standard for the Installation and Use of Stationary Combustion Engines and Gas Turbines, 1998 Edition, at 8-2.2(c) requires engines of 100 horsepower or more have provision for the shutting down the engine at the engine and from a remote location. This deficient practice could affect all occupants.

Findings include:

Based on observation with the Facilities Director and the Bio-Medical Engineer on 12/28/10 at 12:25 p.m., the only shut off device was located on the emergency generator panel of the emergency generator located in the basement. Based on review of the "Emergency Generator Log Sheet" with the Facilities Director and the Clinical Biomedical Engineer, there was no documentation available which indicated the amount of horsepower the generator provided. Based on a telephone interview on 1/3/11 at 9:40 a.m. with the Bio-Medical Engineer, the emergency generator was 700 horsepower.


2. Based on record review and interview, the facility failed to maintain a complete written record of monthly generator load testing for 1 of 12 months. Chapter 3-4.4.1.1 of NFPA 99 requires monthly testing of the generator serving the emergency electrical system to be in accordance with NFPA 110, the Standard for Emergency and Standby Powers Systems, chapter 6-4.2. Chapter 6-4.2 of NFPA 110 requires generator sets in Level 1 and Level 2 service to be exercised under operating conditions or not less than 30 percent of the EPS nameplate rating, whichever is greater, at least monthly, for a minimum of 30 minutes. Chapter 3-5.4.2 of NFPA 99 requires a written record of inspection, performance, exercising period, and repairs for the generator to be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice could affect all patients.

Findings include:

Based on review of the generator log "Emergency Generator Log Sheet" with the Facilities Director and the Bio-Medical Engineer on 12/27/10 at 11:39 p.m., there was no documentation available for a generator load test for the month of September, 2010. This was acknowledged by the Facilities Director and the Bio-Medical Engineer at the time of record review.

1. Based on observation and interview, the facility failed to ensure 2 of 2 flexible cords were not used as a substitute for fixed wiring. NFPA 70, National Electrical Code, 1999 Edition, Article 400-8 requires, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice could was not in a resident care area but could affect any number of staff.

Findings include:

Based on observations with the Facilities Director and the Bio-Medical Engineer on 12/28/10 at 12:10 p.m., heavy duty extension cords were plugged in and providing power to two fans in the sub-basement tunnel. Based on interview at the time of observation, the fans were needed continuously to cool two separate pieces of equipment .

2. Based on observation and interview, the facility failed to ensure 1 of 1 wet locations was provided with ground fault circuit interrupter (GFCI) protection against electric shock. NFPA 70, Article 517, Health Care Facilities, defines wet locations as areas subjected to wet conditions. These include standing fluids on the floor or drenching of the work area, either of which condition is intimate to the patient or staff. NFPA 70, 517-20 Wet Locations, requires all receptacles and fixed equipment within the area of the wet location to have GFCI protection. Moisture can reduce the contact resistance of the body, and electrical insulation is more subject to failure. This deficient practice could affect any staff using the sink in the basement central sterilization room in the event of an electrical short.

Findings include:

Based on an observation with the Facilities Director and the Bio-Medical Engineer on 12/29/10 at 11:40 a.m., the basement central sterilization room had two electrical receptacles on the wall within three feet of the four compartment sink which were not provided with GFCI protection to prevent electric shock. Based on observation of the breaker box and interview with the Bio-Medical Engineer at the time of observation, he confirmed the receptacles were not on a GFCI breaker.