HospitalInspections.org

Based on observation and interview, the facility failed to maintain the means of egress to be 1) accessible at all times, and 2) properly labeled.

Findings include:

On 10/28/19:
1) On the lower level (basement), near the dietary department, the facility had cross-corridor smoke barrier doors for the east, north-south corridor that the facility had lock during the evening hours when one walks southward, per the Facility Director. The egress going both north and south for this set of cross-corridor smoke barrier doors was mark as egress pathways. By locking these corridor doors the facility created a artificial dead of approximately 61 feet. The vending machines are located on this level and available to the public in the evening hours. Other egress pathways are available at this level that past through staff areas.

2) On the lower level at the southeast exterior exit door was labeled to press on the door' panic hardware for 15 seconds. The door was mislabeled because the door release upon activation of the door's panic hardware. A notice alarm also activated with pressure to the panic hardware for approximately 15 seconds. The labeling confused the exit.

On 10/29/19:
3) At the west exterior exit door for the east-west surgical corridor, the facility had place black electrical tape against both the exit door and the floor, impeding the doors opening.

Section 4.6.12.3 Existing life safety features obvious to the public, if not required by the code, shall be either maintained or removed.

Section 19.2.3.4 (5) Where corridor width is at least 8 foot, projections into the required width shall be permitted for fixed furniture, provide that all of the following conditions are met:
(a)The fixed furniture is securely attached to the floor or to the wall.
(b) The fixed furniture does not reduce the clear unobstructed corridor width to less than 6 feet except as permitted in 19.2.3.4(2)
(c) The fixed furniture is located on one side of the corridor.
(d) The fixed furniture is grouped such that each grouping does not exceed an area of 50 feet square.
(e) The fixed furniture groupings addressed in 19.2.3.4(5)(d) are separated from each other by a distance of at least 10 feet.
(f) The fixed furniture is located so to not obstruct access to building service and fire protection equipment.
(g) Corridors throughout the smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4 or the fixed furniture spaces are arranged and located to allow direct supervision by the facility staff from a nurse station or similar space.
(h) The smoke compartment is protected throughout by approved, supervised automatic sprinkler system in accordance with 19.3.5.8.

Federal Register/Vol. 81, No. 86/Wednesday, May 4, 2016/Rules and Regulations/Pg. 26888.

The Department of Health and Human Services (DHHS), Centers for Medicare and Medicaid Services (CMS), published Medicare and Medicaid Programs; Fire Safety Requirements for Certain Health Care Facilities; Final Rule, May 4, 2016. In the Final Rule, CMS adopted the 2010 ADA Standards for Accessible Design, published by the Department of Justice, on September 15, 2010. In adopting the ADA Standards, CMS restricted protrusions from walls to a 4" limit for wall-mounted protruding objects and a 4½" limit for handrails. The ADA Standard is the most stringent when compared to the National Fire Protection Association (NFPA), Life Safety Code (LSC), 2012

Americans with Disabilities Act (ADA)
Section 307.1 General - Protruding objects shall comply with 307.
Section 307.2 Protrusion Limits. Objects with leading edges more than 27 inches and not more than 80 inches above the finished floor or ground shall protrude 4 inches maximum horizontally onto the circulation path.
Exception: Handrails shall be permitted to protrude 4-1/2 inches maximum.


Based on observation and measurement, the facility failed to maintain the corridor widths and keep unobstructed the egress corridors.

Findings include:

On 10//28/19:
1) The lower level (basement), near the dietary department, the facility stored a bed reducing the corridor width from 107 inches to 68 inches. The bed was in the same location on 10/29/19.
2) On grade level floor, the corridor that connects the sleeping compartments and the surgical and business area, there were three beds stored reducing and obstructing the corridor width from approximately 108 inches to approximately 69 inches.

On 10/29/19:
3) On the corridor that connects the sleeping compartments and the surgical and business area, there were three beds stored reducing and obstructing the corridor width from approximately 108 inches and to approximately 69 inches. These three beds remained in this location during the fire drill and the facility added a fourth bed during the drill (formerly stored by patient room #122, see next).
4) The 4th bed described above in item #3 was stored near patient room #122 the morning prior to the fire drill and had reduced and obstructed the corridor from 95 inches to 52 inches.
5) The east-west surgical corridor, the facility had stored a anesthesia and hyperthermia cart reducing and obstructing the 8 foot corridor by approximately 20 inches with each cart located across from operating room #2.
6) The east-west surgical corridor, the facility had stored two wire carts of surgical supplies reducing and obstructing the 8 foot corridor by 24 inches with each wire cart located by the office/supply room.
7) On the lower level (basement) outside of the maintenance shop, the corridor was reduced/obstructed from 110 inches to 92 inches due to a wire cart.
8) On the lower level (basement) in the southwest smoke compartment (generally staff area and emergency exiting for the public) the facility had pallets of various products on both sides of the egress corridors.
9) On the lower level (basement) in the southeast smoke compartment (generally staff area and emergency exiting for the public) the facility had a pallet of soda and multiple large housekeeping carts on one side of the egress corridors and three large housekeeping carts on the other side of the egress corridors.

Based on observation, the facility failed to ensure that the emergency lighting functioned 24 hours seven days a week.

Findings include:

The emergency generator was put under load with normal utility electrical power still available to the facility. The facility's emergency lighting circuits were then turned off to establish the emergency power fixtures (lights and exit/directional signs) throughout the building.

During one of these test, it was discovered that the emergency lighting and exit markings were not available/illuminating for the north-south corridor located between the medical records and the imaging department's east-west corridor.

Based on observation, the facility failed to ensure that egress markings were installed or maintained for proper egress within the building.

Findings include:

The below listed locations had the following egress marking issues:
1) The basement level, near the maintenance shop was a right angle in the corridor, there was a missing egress directional sign to direct persons south to the exterior exits.
2) The basement level, near the maintenance shop was a right angle in the corridor, the directional sign that instructed persons to the stairs by the elevators had a burnt-out bulb internal to the directional sign.

Based on observation and calculation, the facility failed to ensure that the alcohol-based hand rubs (ABHR) did not exceed 10 gallons per smoke compartment.

Findings include:

On 10/28/19, on the lower level (basement) within the southeast smoke compartment, the facility exceeded 10 gallons of alcohol-based hand rub (ABHR). The EVS office and the southeast mechanical room were within the same smoke compartment.

Within the Environmental Services (EVS) office the facility had:
18 containers of 1200 milliliters (40.6 fluid ounces) within a non-fire cabinet; and
26 containers of 1200 milliliters (40.6 fluid ounces) on a wire rack.

Within the southeast mechanical room the facility had:
36 (9 boxes of four containers) of 1200 milliliters (40.6 fluid ounces).

The ABHR containers outside of a cabinet was 26 from the EVS office and 36 within the southeast mechanical room totaling to 62 containers at 1200 milliliters each. The amount converts to 19.67 gallons ((62 containers x 40.6 fluid ounces) divided by 128 ounces per gallon).

Based on observation, interview and documentation review, the facility failed to maintain the fire sprinkler system.

Findings include:

At the fire sprinkler riser room at the north end of the building, the riser was equipped with a testable backflow device that had not been tested since May 2017 per that attached tag (this is an annual testing requirement by a certified backflow tester with a fire sprinkler license issued by the State Fire Marshal's office). Interview with the Facility Director revealed that there was no other documentation to indicate that the backflow device had been tested since the tag's date.

Based on observation, the facility failed to ensure that all portable fire extinguishers had been examined annually and found to be within normal functioning range.

Findings include:

On 10/28/19, in the dietary department, the K-Class portable fire extinguisher had been last tested by the facility's vendor on 02/20/18. This extinguisher was also out of the normal functioning range (green zone) and the indicator was off to the right of the green zone.

Based on observation, the facility failed to ensure that all corridor doors were free from impediments to closure and could resist the passage of smoke.

Findings include:

1) On 10/28/19, the dietary department south egress door was held open with a door chock.
2) On 10/29/19, the Human Resources office corridor door was held open with a door chock.

Based on observation and interview, the facility failed to maintain the cross-corridor smoke barrier doors to allow them to close.

Findings include:

On the grade-level at the cross-corridor smoke barrier doors located between the housing nurse station smoke compartment and the north smoke compartment that leads towards the conference room and surgical suite access, the east leaf failed to close. This door did not close on its own with the activation of the fire alarm, nor when released manually. This leaf was open approximately three inches.

The Facility Director indicated that this leaf had to be manually closed due to a air pressure gradient difference between the two smoke compartments' air handling equipment.

National Fire Protection Association (NFPA) 70, National Electric Code, 2011 Edition

CLEARANCES

Article 110 - Requirements for Electrical Installations
110.26 Spaces About Electrical Equipment. Access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operations and maintenance of such equipment.
(A) Working Space. Working space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of 110.26 (A)(1), (A)(2), and (A)(3) or as required or permitted elsewhere in this Code.

(1) Depth of Working Space. The depth of the working space in the direction of live parts shall not be less than that specified in Table 110.26 (A)(1) unless the requirements of 110.26 (A)(1)(a), (A)(1)(b), or (A)(1)(c) are met. Distances shall be measured from the exposed live parts or from the enclosure or opening if the live parts are enclosed. (Nominal Voltage to Ground of 0 -150 = 3 feet).

COVERS

Article 314 - Outlet, Device, Pull, and Junction Boxes; Conduit bodies; Fittings; and Handhole Enclosures
314.25 Covers and Canopies. In completed installations, each box shall have a cover, faceplate, lampholder, or luminaire canopy, except where the installation complies with 410.24(B).
314.28(c) Pull and Junction Boxes and Conduit Bodies.
(c) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where used, metal covers shall comply with the grounding requirements of 250.110.

Article 400 - Flexible Cords and Cables
400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
1) As a substitute for the 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
Exception to 4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B)
5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings
6) Where installed in raceways, except as otherwise permitted in the Code
7) Where subject to physical damage

PANELBOARD LABELING

Article 408.4 - Field Identification Required
A) Circuit Director of Circuit Identification. Every circuit and circuit modification shall be legibly identified as to its clear, evident, and specific purpose or use. The identification shall include an approved degree of detail that allows each circuit to be distinguished from all others. Spare positions that contain unused overcurrent devices or switches shall be described accordingly. The identification shall be included in a circuit directory that is located on the face or inside of the panel door in the case of a panelboard and at each switch or circuit breaker in a switchboard or switchgear. No circuit shall be described in a manner that depends on transient conditions of occupancy.

GROUND-FAULT CIRCUIT INTERRUPTER (GFCI)

Article 422.51 Cord-and-plug connected vending machines manufaturered or remanufactured on or after January 1, 2005, shall include a ground-fault circuit interrupter as an integral part of the attachment plug or be located within 300 mm (12 inches) of the attachment plug. Older vending machines manufactured or remanufactured prior to January 1, 2005, shall be connected to a GFCI-protected outlet.

BRANCH CIRCUIT, FEEDER, AND SERVICE CALCULATIONS

NFPA 70, Section 220-10 Computation of Branch Circuit Loads. Branch circuit loads shall be computed as shown in 220.12, 220.14 and 220.16.
220.12 Lighting Loads for Specified Occupancies.
220.14 Other Loads - All Occupancies.
220.16 Loads for Additions to Existing Installations.

BRANCH CIRCUIT LOADS (CAPACITY)

Article 210.23 Permissible loads. In no case should the load exceed branch circuit ampere rating. An individual branch circuit shall be permitted to supply two or more outlets or receptacles shall supply the load specified according to its size as specified in 210.23(A) through 210.23(D) and as summarized in 210.24 and Table 210.24.

ELECTRICAL CODE PURPOSE
Article 90.1(B) Adequacy. This Code contains provisions that are considered necessary for safety. Compliance therewith and proper maintenance results in an installation that is essentially free from hazard but not necessarily efficient, convenient or adequate for good service or future expansion of electrical use.
Informational Note: Hazards often occur because of overloading of wiring systems by methods usage not in conformity with this Code. This occurs because initial wiring did not provide for increases in the use of electricity. An initial adequate installation and reasonable provisions for system changes provide for future increases in the use of electricity.


Based on observation, the facility failed to ensure that the facility had installed and/or maintained, the electrical system within the building per NFPA 70, National Electrical Code.

Findings include:

The below listed locations had the following electrical concerns on 10/29/19:

1) Within the electrical room next to the conference room on the grade-level:
a) there was stored 16 boxes of electrical parts within three feet of electrical panel CBLZ
b) there was a trash container within three feet of electrical panel L2.
c) there was a ladder and step ladder in front of and within three feet of electrical panel EQL1.

2) In the remote physical therapy rehabilitation location there were items directly in front of the electrical panels in both the northwest and the northeast rooms with electrical panels.

3) The following locations were using relocatable power taps (RPT) as permanent wiring:
a) In the Admitting area, a RPT was being used as permanent wiring for a refrigerator and two coffee makers.
b) In the Human Resources office, a RPT was being used as permanent wiring for an espresso machine.
c) In the emergency department staff break area, a RPT was being used as permanent wiring for ice machine.

4) In the lobby area the facility had two vending machines. The facility did not have evidence that these machines were equipped with ground-fault circuit interrupters (GFCI) either internally within the machines or external of the machines.

19.7.1 Evacuation and Relocation Plan and Fire Drills

19.7.1.1 The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of a fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary.

19.7.1.2. All employees shall be periodically instructed and kept informed with respect to their duties under the plan required by 19.7.1.1.

19.7.1.3. A copy of the plan required by 19.7.1.1 shall be readily available at all times in the telephone operator's location or at the security center.

19.7.1.4. Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions.

19.7.1.6. Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

19.7.1.7. When drills are conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

19.7.1.8. Employees of health care occupancies shall be instructed in life safety procedures and devices.

19.7.2. Procedure in Case of Fire

19.7.2.1. Protection of Patients

19.2.1.1. For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel.

19.2.1.2. The basic response required of all staff shall include the following:
(1) Removal of all occupants directly involved with the fire emergency
(2) Transmission of an appropriate fire alarm signal to warn other building occupants and summon staff
(3) Confinement of the effects of the fire by closing doors to isolate the fire area
(4) Relocation of patients as detailed in the health care occupancy's fire safety plan

19.7.2.2. A written health care occupancy fire safety plan shall provide for all of the following:
(1) Use of alarms
(2) Transmission of alarms to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolate of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire

19.7.2.3. Staff Response

19.7.2.3.1. All health care occupancy personnel shall be instructed in the use of and response to fire alarms.

19.7.2.3.2. All health care occupancy personnel shall be instructed in the use of the code phrase to ensure transmission of an alarm under any of the following conditions:
(1) When the individual who discovers the fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system

19.7.2.3.3. Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.

19.7.3. Maintenance of Means of Egress

19.7.3.1. Proper maintenance shall be provided to ensure the dependability of the the method of evacuation selected.

19.7.3.2. Health care occupancies that find it necessary to lock means of egress doors shall, at all times, maintain an adequate staff qualified to release locks and direct occupants from the immediate danger area to a place of safety in case of fire or other emergency.


Based on observation, interview and document review, the facility failed to 1) establish that all fire drills had been conducted one drill per shift per quarter; and 2) ensure its staff was familiar with fire drill procedures.

Findings include:

1) On 10/28/19, document review revealed no evidence that the facility conducted the required quarterly fire drills for each shift over the past twelve months. There were no fire drill reports available for the first quarter of 2019 for the swing shift (4:00 PM - 12:00 AM) and the night shift (12:00 AM - 8:00 AM).

2) On 10/28/19, interview with two maintenance staff revealed that they did not know where the smoke compartments existed within the building.

On 10/29/19, prior to activating the fire alarm:
- an interview with a new nursing staff member (at the facility since 04/2019) about the facility's fire safety plan and the nursing staff member was uncertain of the rescue and alarm portion of the plan. This staff member was then prompted to examine the backside of identification badge for the R.A.C.E. acronym (rescue, alarm containment, extinguish) as part of their fire safety plan.
- a second interview with a respiratory therapist (at the facility for three years) revealed that the respiratory therapist was familiar with the facility's fire safety plan, knew where the smoke compartments were located and where the manual pull stations were located and knew how to operate these device (in test mode).

Based on document review and interview, the facility failed to maintain the piped-in medical gas systems.

Findings include:

Review of the facility's 07/11/19 medical gas report revealed that there were 15 items identified needing repair for the vacuum and medical gas systems, such as:
a) medical air compressor and carbon monoxide monitoring (two items);
b) vacuum pump (four items);
c) gas manifold (two items);
d) master alarm panels #1 and #2 (five items); and
e) zone valve boxes MV#2 and MV#3 (two items).

Interview with the Facility Director revealed that there was no subsequent documentation to establish that the above listed items had been repaired.

Based on interview and document review, the facility failed to establish that the line isolation monitors within the operating rooms had been tested.

Findings include:

The facility did not have documentation to establish that the line isolation monitors (LIM) within the operating rooms had been tested at intervals of less than or equal to 1 month. Interview with the Facility Director indicated that there was no documentation to demonstrate that the LIM were being tested.

Based on document review and interview, the facility failed to establish that it had conducted all of the weekly emergency generator inspections over the past twelve months.

Findings include:

The facility did not have evidence of the following weekly emergency generator inspections:
- 07/14/19
- 07/29/19
- 08/03/19
- 09/08/19
- 09/15/19
and
- 10/13/19.

Based on observation, the facilty failed to ensure that relocatable power taps (RPT) within the building conformed to the allowable standards.

Findings include:

1) On 10/28/19, within the doctor's sleeping area the facility had a domestic, non Underwriters Laboratories (UL) 1363 standard RPT (non patient care area standard).
2) On 10/29/19, within the post-anesthesia care unit (PACU) on the south wall, the facility had a black colored, non UL 1363A or UL 60601-1 standard RPT (patient care area standard).