HospitalInspections.org

Based on record review and interview, the hospital failed to incorporate Emergency Preparedness Program (EP) policies and procedures for the provision of care under an 1135 waiver. This in the event of an emergency, including an emergencies requiring an evacuation as well as intake of patients from other jurisdictions, would leave caregivers without the ability to provide for the specialized medical needs of patients.

Findings include:

On 5/23/2019 at 3:00 p.m. while reviewing the facility's EP, there was no policy and procedure that specifically addressed the duties of caregivers following the issuance of an 1135 waiver by the Secretary of Health and Human Services. An interview was conducted with the Maintenance Director during the review who verified the finding.

Based on record review and interview, the hospital failed to provide as part of their Emergency Preparedness Program (EP), a method of sharing resident information and medical documentation with receiving facilities and other providers. This in the event of a transfer of residents, would leave the receiving facility and caregivers without information needed for the care and treatment of the patients.

Findings include:

On 5/23/2019 at 3:00 p.m. while reviewing the facility's EP, the plan did not include procedures for the transfer of resident medical information in the event of a resident transfer. An interview was conducted with the Maintenance Director during the review who verified the finding.

Based on record review and interview, the hospital failed to provide emergency preparedness training and testing for the calendar year. This in the event of an emergency, would leave staff unprepared putting the patients, staff and occupants of the facility at risk to the hazards of the emergency.

Findings include:

On 5/23/2019 at 3:00 p.m. while reviewing the facility Emergency Preparedness Program (EP), no records of training, testing, and annual review of the program were provided. An interview was conducted with the Maintenance Director during the review who verified the finding.

Based on record review and interview, the hospital failed to provide documentation of participation in a community based disaster drill and failed to evaluate and revise their emergency response to recent hurricane Michael pursuant to their Emergency Preparedness Program (EP).

Findings include:

On 5/23/2019 at 3:00p.m. while reviewing the Emergency Preparedness Program, no records of disaster drills were present to review. There was no after action report following the recent disaster, Hurricane Michael. There was no documentation of participation in alternative community based exercise or table top exercises. An interview was conducted with the Maintenance Director during the review who verified the finding.

Based on staff interview and observation made during the Fire & Life Safety tour of the hospital with the Maintenance Director on 5/23/2019, the hospital failed to maintain an accessible exit. This could impede or deny the exiting of occupants in an emergency and result in harm to the occupants from the dangers of an emergency situation.

The findings Include:

During the Fire & Life Safety survey of the hospital with the Maintenance Director on 5/23/2019 beginning about 10:00am, it was observed that the hospital failed to maintain the egress doors in the patient hallway. Attempts were made to open the door and the release did not work. After heavy forcing of the door it would open. The door would continue to hang every time in was closed. The Maintenance Director verified these findings at the times observed.

Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with chapter 7, unless otherwise modified by 18.2.2.2.10 thru 18.2.2.2.11, and 19.2.2.2.10 thru 19.2.2.2.11.

Exits and exit access shall be arranged to be readily accessible at all times.
NFPA 101 (2012) 18.2.1 & 19.2.1, 7.5.1.1.

Based on observation and interview made during the fire & life safety tour, with Maintenance Director the hospital failed to provide inspection, maintenance and testing of the fire sprinkler system in accordance with NFPA 25. Failure to inspect, maintain, and test system components could result in the system failing to perform as designed.

Findings include:

During the Fire Safety tour and record review of the hospital with the Maintenance Director on 5/23/2019 beginning at 10:00am, the sprinkler system was displaying a red tag dated 4/30/2019. A red tag indicates the system has a critical problem. A further review of documentation revealed the hospital had been issued a letter from the sprinkler inspection company stating the system had 5 sprinkler heads that were needing replaced. If not replaced, the system may not function in the event of a fire. The Director of Maintenance was present during the observation, and confirmed the findings. Health team leader and myself met with the Administrator notified his he would need to conduct fire watch till what time the system could be repaired.

According to NFPA 25 (2011 edition) 5.2.1.1.1; "Sprinklers shall not show signs of leakage, shall be free of corrosion, foreign materials, paint and physical damage. And shall be installed in the correct orientation." and 5.2.1.1.2; "Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage, (2) Corrosion, (3) Physical damage, (4) Loss of fluid in the glass bulb heat responsive element, (5) Loading, (6) Painting unless painted by the sprinkler manufacturer."

Based on observation and interview made during the Fire & Life Safety tour of the hospital with the Maintenance Director on 5/23/2019, the hospital failed to maintain their fire alarm system in accordance with NFPA 72. Failure to maintain initiating devices could result in a smoke detector failing to activate the alarm system resulting in the potential endangerment of the occupants of the building in the event of a fire.

Findings include:

During the Fire & Life Safety tour of the hospital with the Director of Maintenance on 5/23/2019 beginning about 10:00am, the fire alarm panel was found to be in trouble mode. After further review of documentation it was discovered the system has been in trouble since 12/2018. The system inspector had notified the hospital on 12/11/2018 in writing that the system may not operate correctly if not repaired immediately. The paper work indicated that detectors in the maintenance shop were not functioning. This condition would require fire watch till system can be repaired. The Maintenance Director verified these findings at the times observed.

There was also no record of:
1. Sensitivity test in the records provided. Sensitivity test shall be checked 1 year after installation the Sensitivity test shall be checked every alternate year thereafter NFPA 101 (2012) 18.3.4 & 19.3.4. NFPA 72 (2010 edition) 14.4.5.3.1 & 14.4.5.3.

2. Evidence of fire and smoke damper maintenance and testing in the past 6 years. According to NFPA 80 (2010 edition) 19.4.1.1; "The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years."

Based on observation and interview made during the fire & life safety tour with Maintenance Director, the hospital failed to provide inspection, maintenance and testing of the fire sprinkler system in accordance with NFPA 25. Failure to inspect, maintain, and test system components could result in the system failing to perform as designed.

Findings include:

During the Fire Safety tour and record review of the hospital with the Maintenance Director on 5/23/2019 beginning about 10:00am, The sprinkler system was displaying a red tag dated 4/30/2019. This indicates the system has a critical problem. A further review of documentation revealed the hospital had been issued a letter from the sprinkler inspection company stating the system had 5 sprinkler heads that were needing replaced. If not the system may not function in the event of a fire. The Director of Maintenance was present during the observation, and confirmed the findings. The health team leader and myself met with the Administrator and notified him he would need to conduct fire watch until the system could be repaired.

According to NFPA 25 (2011 edition) 5.2.1.1.1; "Sprinklers shall not show signs of leakage, shall be free of corrosion, foreign materials, paint and physical damage. And shall be installed in the correct orientation." and 5.2.1.1.2; "Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage, (2) Corrosion, (3) Physical damage, (4) Loss of fluid in the glass bulb heat responsive element, (5) Loading, (6) Painting unless painted by the sprinkler manufacturer."

Based on observation and interivew made during the Fire & Life Safety tour with Maintenance Director, the hospital failed to maintain fire extinguishers in accordance with NFPA 10 (for fire extinguishers) for proper signage and identification of fire extinguisher locations. This could cause a delay in locating a fire extinguisher in an emergency situation.

Findings Include:

During the Fire & Life Safety tour of the hospital with the Maintenance Director on 5/23/2019 beginning at 10:00AM, it was observed that fire extinguishers were located in flush mounted cabinets with no signage. Flush mounted cabinets must be identified with signage, which extends from the wall. The Maintenance Director verified these findings at the times observed.

NFPA 101, 19.3.5.12 and 9.7.4.1, NFPA 10.

Based on record review and interview with the Maintenance Director, the hospital failed to conduct and document the required annual Internal and External disaster drills and quarterly fire drills. These drills increase the knowledge of staff of the action to take in an emergency situation and helps prevent confusion to occupants and staff in the event of an emergency.

The findings include:

During the Fire & Life Safety record review of the hospital with the Maintenance Director on 5/23/2019 beginning about 10:00am, it was observed that the annual Internal/External disaster drills had not been done. In addition the hospital did not complete the required fire drills per year. The Maintenance Director verified these findings during the review.

Each organizational cooperation entity shall implement two or more (Internal & External) specific responses of the emergency operations plan during each year. According to CMS, drills must be separated by 4 to 7 months. Fire drills should be implemented one per shift per quarter.
F.A.C. 59A-4

Based on observation and interview with the Maintenance Director, the hospital failed to provide and maintain maintenance, inspection & testing of fire doors. This condition could allow Fire/Smoke to travel from one compartment to other compartments, thus endangering occupants of the facility.

Findings include:

During the Fire & Life Safety document review with the Maintenance Director on 5/23/2019 from 10am-5pm, it was observed that the hospital failed to provide records of fire door Maintenance, Inspection & Testing. The Maintenance Director verified these findings during the review.

Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the hospital maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.

Per NFPA 101 (2012 Edition) 19.7.6, 8.3.3.1 (LSC), NFPA 80 (2010 edition) 5.2, 5.2.3

Based on observation and interview with the Maintenance Director, the hospital failed to maintain documentation on the receptacle testing and main feeder exercise. Failure to maintain electrical devices, equipment, and wiring in accordance with the applicable standards can result in the hazards of electric shock, electrocution, energized equipment and fire resulting from electric source endangering the patients and occupants of the building.

The findings Include:

During the Fire and Life Safety document review on 5/23/2019 from about 10:00am - 5:00pm with the Maintenance Director it was found that the proper documentation for the maintenance and testing of the receptacles of main feeder breakers was not being done. The Maintenance Director verified these findings during the review.

All requirements for electrical safety shall be complied with per the NFPA 70, National Electrical Code, and NFPA 99, Health Care Facilities Code.

Based on observation and interview with the Maintenance Director, the hospital failed to maintain electrical equipment and wiring in accordance with NFPA 70 The National Electric Code (N.E.C.), and NFPA 99 Health Care Facilities Code and to provide a hospital free from electrical hazards. Failure to maintain electrical devices, equipment, and wiring in accordance with the applicable standards can result in the hazards of electric shock, electrocution, energized equipment and fire resulting from electric sources.

Findings include:

During the Fire & Life Safety tour of the hospital with the Maintenance Director on 5/23/2019 beginning about 10:00am, it was observed that there was an exhaust fan mounted in the ceiling of the biohazard room outside of radiology that was installed without conduit to protect wiring. The Maintenance Director verified these findings at the times observed.

NFPA 70 the National Electric Code (N.E.C.), and NFPA 99 Health Care Facilities Code and to provide a hospital free from electrical hazards.