HospitalInspections.org

During the physical tour of the facility conducted on 11/06/12 between the hours of 0800 to 1600 while accompanied by the facility maintenance director we observed the following deficiencies in relation to maintaining corridor walls that resist the passage of smoke:

1. Observed penetrations above conference room doors
2. Observed penetrations above New Time Clock (Ceiling Tile Missing)
3. Observed penetrations above smoke barrier doors at North Hall
4. Observed penetrations above double doors to Emergency Room Corridor (also in corridor wall)

Corridor walls are required to resist the passage of smoke in this fully sprinklered building, failure to maintain these walls to resist the passage of smoke could place residents/staff or visitors at risk of possible harm due to the spread of smoke.

During the physical tour of this facility on 11/06/12 between the hours of 0800 to 1600 while accompanied by the facility maintenance director we observed the following deficiencies in relation to doors closing and latching as required to prevent the possible movement of smoke/fire:

1. Administration Office Door failed to latch upon closing
2. Patient Room Door #01 failed to latch upon closing
3. Pericare Linen Closet Door failed to latch upon closing
4. Janitor Room Door by Patient Room #11 failed to latch upon closing
5. Double Doors from corridor to Emergency Room failed to close and latch
6. Sub-Sterile Room Door is equipped with a roller latch (roller latches are not allowed, needs positive latch installed)
7. Door closure on Endoscopy Room has been removed

Doors are required to be properly adjusted to ensure positive latching of door to prevent the possible movement of smoke or fire, failure to ensure positive latching could place patients/staff or visitors at risk of possible harm due to the spread of smoke or fire.

During the physical tour of the facility conducted on 11/06/12 between the hours of 0800 to 1600 while accompanied by the facility maintenance director we observed the following deficiencies regarding maintaining Exit Access free of all obstructions or impediments to full instant use in the event of an emergency:

1. Observed the North Exit Door (Equipped with Exit Sign) out of the Day Room was locked and the staff that was present (NAC) indicated they did not have a key to the door but one was located at the Nurses Station (Verified)
2. Observed the Exit Egress from the Emergency Room Exit was obstructed by items in the Egress Path (Equipment/Beds left in the Egress Path)

Exits and Egress Paths are to be free and clear of any obstructions and impediments for Instant Use in the Event of an Emergency, failure to maintain the Exits and Egress Paths free and clear of any obstruction or impediment can place patients/staff or visitors at risk of possible harm due to delay in exiting the building in an emergency.

During this inspection conducted on 11/06/12 between the hours of 0800 to 1600 while accompanied by the facility maintenance director we observed the following deficiencies in regards to Emergency Illumination:

1. Emergency Illumination Device in Emergency Room #1 was not able to be tested for battery backup without taking the device apart.
2. Emergency Illumination Device in Generator Transfer Area was not able to be tested for battery backup without taking the device apart.
3. No Emergency Illumination Device was located in NEW Endoscopy Room.

Emergency Illumination Devices are required to be tested monthly for 30 seconds and annually for 90 minutes, was not able to test two of these devices without taking them apart and Rooms where patients are not capable of self preservation are required to be equipped with Emergency Illumination Devices, failure to provide and maintain these devices could place patients/staff or visitors at risk of possible harm due to insufficient illumination to exit the area.

During this inspection conducted on 11/06/12 between the hours of 0800 to 1600 while accompanied by the facility maintenance director and in conducting interviews with facility staff (Nurse/Administrator) we observed that the facility did not have a written copy of the facility's plan for protection of all persons in the event of a fire, and for their evacuation from the building when necessary. Facility staff indicated that everything is being put on their computer, however a written copy of the plan is to be available at all times at a location that is manned 24/7. Failure to have this plan readily available could place patients/staff or visitors at risk of possible harm due to the delay in implementing the facility's fire response or evacuation plans.

During this inspection conducted on 11/06/12 between the hours of 0800 to 1600 while accompanied by the facility maintenance director we observed an area that was lacking the required sprinkler protection as required by NFPA 13:

1. Observed area located off the Electrical Room that was not equipped with a sprinkler heard that would provide protection for this area. It appeared that this area had been modified and a wall put in place blocking the existing sprinkler heard on the other side of the wall.

Failure to provide the area protection with a fire sprinkler system could place the patients/staff or visitors at risk of possible harm due to the inability of the fire sprinkler system to perform and protect as required.

During this inspection and documentation review conducted on 11/06/12 between the hours of 0800 to 1600 we observed that the facility was not conducting the Quarterly Testing of the Fire Sprinkler System. Facility was not able to provide documentation to show that the Quarterly Testing of the Sprinkler System was being conducted and the facility maintenance director also indicated that it was not being done. Facility will need to schedule this testing for the 1st Quarter of 2013 as the Fire Sprinkler System was Annually Tested on 11/01/12 which would suffice for the 4th Quarter Testing of 2012. Facility will also need to maintain this Testing Documentation for review. Failure to conduct the testing as required could place patients/staff or visitors at risk of possible harm due to the inability of the Fire Sprinkler System to perform as required.

During this inspection conducted on 11/06/12 between the hours of 0800 to 1600 while accompanied by the facility maintenance director we observed the following deficiencies in regards to the proper use of multi-plug power strips:

1. Observed in the Employee Break Room that electrical devices (Water Cooler and other unapproved devices) were plugged into a multi-plug power strip with flexible cord
2. Observed Piggybacked Multi-plug Power Strips in the Electrical Equipment Room.

Only Computer Equipment (Per C.M.S. interpretation of the Electrical Code) are allowed to be plugged into multi-plug power strips, other electrical items are to be plugged directly into an approved electrical outlet. Multi-plug Power Strips are not allowed to be plugged into another power strip but must be plugged directly into an approved electrical outlet. Failure to ensure proper use of these devices could place patients/staff or visitors at risk of possible harm due to fire from these devices overheating.

During the physical tour of the facility conducted on 11/06/12 between the hours of 0800 to 1600 while accompanied by the facility maintenance director we observed the following deficiencies in relation to maintaining corridor walls that resist the passage of smoke:

1. Observed penetrations above conference room doors
2. Observed penetrations above New Time Clock (Ceiling Tile Missing)
3. Observed penetrations above smoke barrier doors at North Hall
4. Observed penetrations above double doors to Emergency Room Corridor (also in corridor wall)

Corridor walls are required to resist the passage of smoke in this fully sprinklered building, failure to maintain these walls to resist the passage of smoke could place residents/staff or visitors at risk of possible harm due to the spread of smoke.

During the physical tour of this facility on 11/06/12 between the hours of 0800 to 1600 while accompanied by the facility maintenance director we observed the following deficiencies in relation to doors closing and latching as required to prevent the possible movement of smoke/fire:

1. Administration Office Door failed to latch upon closing
2. Patient Room Door #01 failed to latch upon closing
3. Pericare Linen Closet Door failed to latch upon closing
4. Janitor Room Door by Patient Room #11 failed to latch upon closing
5. Double Doors from corridor to Emergency Room failed to close and latch
6. Sub-Sterile Room Door is equipped with a roller latch (roller latches are not allowed, needs positive latch installed)
7. Door closure on Endoscopy Room has been removed

Doors are required to be properly adjusted to ensure positive latching of door to prevent the possible movement of smoke or fire, failure to ensure positive latching could place patients/staff or visitors at risk of possible harm due to the spread of smoke or fire.

During the physical tour of the facility conducted on 11/06/12 between the hours of 0800 to 1600 while accompanied by the facility maintenance director we observed the following deficiencies regarding maintaining Exit Access free of all obstructions or impediments to full instant use in the event of an emergency:

1. Observed the North Exit Door (Equipped with Exit Sign) out of the Day Room was locked and the staff that was present (NAC) indicated they did not have a key to the door but one was located at the Nurses Station (Verified)
2. Observed the Exit Egress from the Emergency Room Exit was obstructed by items in the Egress Path (Equipment/Beds left in the Egress Path)

Exits and Egress Paths are to be free and clear of any obstructions and impediments for Instant Use in the Event of an Emergency, failure to maintain the Exits and Egress Paths free and clear of any obstruction or impediment can place patients/staff or visitors at risk of possible harm due to delay in exiting the building in an emergency.

During this inspection conducted on 11/06/12 between the hours of 0800 to 1600 while accompanied by the facility maintenance director we observed the following deficiencies in regards to Emergency Illumination:

1. Emergency Illumination Device in Emergency Room #1 was not able to be tested for battery backup without taking the device apart.
2. Emergency Illumination Device in Generator Transfer Area was not able to be tested for battery backup without taking the device apart.
3. No Emergency Illumination Device was located in NEW Endoscopy Room.

Emergency Illumination Devices are required to be tested monthly for 30 seconds and annually for 90 minutes, was not able to test two of these devices without taking them apart and Rooms where patients are not capable of self preservation are required to be equipped with Emergency Illumination Devices, failure to provide and maintain these devices could place patients/staff or visitors at risk of possible harm due to insufficient illumination to exit the area.

During this inspection conducted on 11/06/12 between the hours of 0800 to 1600 while accompanied by the facility maintenance director and in conducting interviews with facility staff (Nurse/Administrator) we observed that the facility did not have a written copy of the facility's plan for protection of all persons in the event of a fire, and for their evacuation from the building when necessary. Facility staff indicated that everything is being put on their computer, however a written copy of the plan is to be available at all times at a location that is manned 24/7. Failure to have this plan readily available could place patients/staff or visitors at risk of possible harm due to the delay in implementing the facility's fire response or evacuation plans.

During this inspection conducted on 11/06/12 between the hours of 0800 to 1600 while accompanied by the facility maintenance director we observed an area that was lacking the required sprinkler protection as required by NFPA 13:

1. Observed area located off the Electrical Room that was not equipped with a sprinkler heard that would provide protection for this area. It appeared that this area had been modified and a wall put in place blocking the existing sprinkler heard on the other side of the wall.

Failure to provide the area protection with a fire sprinkler system could place the patients/staff or visitors at risk of possible harm due to the inability of the fire sprinkler system to perform and protect as required.

During this inspection and documentation review conducted on 11/06/12 between the hours of 0800 to 1600 we observed that the facility was not conducting the Quarterly Testing of the Fire Sprinkler System. Facility was not able to provide documentation to show that the Quarterly Testing of the Sprinkler System was being conducted and the facility maintenance director also indicated that it was not being done. Facility will need to schedule this testing for the 1st Quarter of 2013 as the Fire Sprinkler System was Annually Tested on 11/01/12 which would suffice for the 4th Quarter Testing of 2012. Facility will also need to maintain this Testing Documentation for review. Failure to conduct the testing as required could place patients/staff or visitors at risk of possible harm due to the inability of the Fire Sprinkler System to perform as required.

During this inspection conducted on 11/06/12 between the hours of 0800 to 1600 while accompanied by the facility maintenance director we observed the following deficiencies in regards to the proper use of multi-plug power strips:

1. Observed in the Employee Break Room that electrical devices (Water Cooler and other unapproved devices) were plugged into a multi-plug power strip with flexible cord
2. Observed Piggybacked Multi-plug Power Strips in the Electrical Equipment Room.

Only Computer Equipment (Per C.M.S. interpretation of the Electrical Code) are allowed to be plugged into multi-plug power strips, other electrical items are to be plugged directly into an approved electrical outlet. Multi-plug Power Strips are not allowed to be plugged into another power strip but must be plugged directly into an approved electrical outlet. Failure to ensure proper use of these devices could place patients/staff or visitors at risk of possible harm due to fire from these devices overheating.