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Based on observation and testing it was determined the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code 2000, Chapter 19, 19.3.6.3.1 " Doors protecting corridor openings in other than required enclosures of vertical openings, exit, or hazardous areas shall be substantial doors, such as those constructed of 1 3/4 in. thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke... Section 19.3.6.4

Findings Include:

On January 11 and 12, 2016, the surveyor, accompanied by the Facilities Director, Regulatory Consultant, Facilities Manager and staff observed the second floor room 2 Prep. had the door latch mechanism removed.

During the exit conference on January 12, 2016, the above findings were again
acknowledged by the COO, Assistant CNO, Associate CNO, Two Associate Administrators, Chief Medical Officer, CHRO, Facilities Director, Regulatory Consultant, Facilities Manager, and Staff.

The facility failed to protect patients from heat and smoke.

Based on observation and testing it was determined the facility did not maintain the integrity, smoke resistance, of doors in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.2.1 requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls and doors must be able to resist the passage of smoke. NFPA 80 "Fire Doors and Fire Windows" Chapter 2, Section 2-3.1.7: "The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. +/- 1/16 in for steel doors and shall not exceed 1/8 in. for wood doors...."

Findings include:

On January 11 and 12, 2016, the surveyor, accompanied by the Facilities Director, Regulatory Consultant, Facilities Manager and staff observed the following hazardous area doors:

1. Kitchen chemical room, door removed.
2. 1034 A door tested three of three times , would not positively latch.
3. Room 2189, door intentionally impeded by paper covering the latch mechanism.
4. P2224, Housekeeping room with chemicals, no door closing device.

During the exit conference on January 12, 2016, the above findings were again
acknowledged by the COO, Assistant CNO, Associate CNO, Two Associate Administrators, Chief Medical Officer, CHRO, Facilities Director, Regulatory Consultant, Facilities Manager, and Staff.

Failing to prevent heat and smoke from spreading into the exit corridor will cause harm to patients.

Based on observation, document review, and tour, the hospital failed to comply with the NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.3.5.1 requiring the hospital be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. NFPA 13 Section, 5-13.11. There was no sprinkler protecting one of the radiology rooms, which placed the patients and staff at risk if there were a fire.

NFPA 101 Life Safety Code,2000, Chapter 19, Section 19.3.5.1: " Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7."NFPA 13 Section, 5-13.11 electrical Equipment." 'Sprinkler protection shall be required in electrical equipment rooms. Hoods or shields installed to protect important electrical equipment from sprinkler discharge shall be noncombustible.'
Exception: Sprinkler shall not be required where all of the following conditions are met:
(a) The room is dedicated to electrical equipment only.
(b) Only dry-type electrical equipment is used.
(c) Equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations.
(d) No combustible storage is permitted to be stored in the room...."

Findings include:

On January 12, 2016, the surveyor, accompanied by the Facilities Director, Regulatory Consultant, Facilities Manager and staff observed the Radiology Room, room number 2168 A had no sprinkler protection, the sprinkler was removed.
The facility is approximately 500,000 square feet and the Radiology room is approximately 130 square feet. The sprinkler was installed by the close of the Life Safety survey.

During the exit conference on January 12, 2016, the above findings were again
acknowledged by the COO, Assistant CNO, Associate CNO, Two Associate Administrators, Chief Medical Officer, CHRO, Facilities Director, Regulatory Consultant, Facilities Manager, and Staff.

A fire starting in a non sprinkled area could grow rapidly and cause more sprinkler heads to fuse than necessary. Smoke produced by a fire in a non sprinkled area will cause harm to the residents/patients.

Based on observation and staff interview it was determined the facility failed to clean the kitchen exhaust hood system, filters and grease drip tray.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.3.2.6 "Cooking facilities shall be protected in accordance with 9-2.3" Section 9-2.3 "Commercial cooking equipment shall be installed in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations." Chapter 8, Section 8-3.1: " Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge...."

Findings include:

On January 12, 2016, the surveyor, accompanied by the Facilities Director, Regulatory Consultant, observed the kitchen first cook line. Four of four exhaust system hood, filters and grease drip tray area had an excessive amount of grease buildup.

During the exit conference on January 11th and 12, 2016, the above findings were again
acknowledged by the COO, Assistant CNO, Associate CNO, Two Associate Administrators, Chief Medical Officer, CHRO, Facilities Director, Regulatory Consultant, Facilities Manager, and Staff.

Failing to keep the entire kitchen exhaust hood system clean from grease will cause a fire, which could cause damage to the kitchen and will cause harm to the patients.

Based on observation and testing it was determined the facility allowed the use of a portable space heater.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.7.8: " Portable space heating shall be prohibited in all health care occupancies. Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212 Degrees F...."

Findings include:

On January 11 and 12, 2016, the surveyor, accompanied by the Facilities Director, Regulatory Consultant, observed and tested a portable space heater in room 4087. The heater did not state the device would not exceed 212 Degrees F.

During the exit conference on January 11th and 12, 2016, the above findings were again
acknowledged by the COO, Assistant CNO, Associate CNO, Two Associate Administrators, Chief Medical Officer, CHRO, Facilities Director, Regulatory Consultant, Facilities Manager, and Staff.

Allowing the use of portable space heaters, close to combustibles, will cause a fire which will cause harm to the patients.

Based on observation it was determined the facility failed to separate empty and full medical gas cylinders and provide a sign for medical gas cylinders and keep the oxygen bottles free of combustible materials.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.2.4.: "Medical gas storage and administration areas shall be protected in Accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99, Chapter 4, Section 4-3.5.2.2 (a) (2): "If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

NFPA 101 Life Safety Code 2000, or Chapter 19, Section 19.3.2.4: "Medical gas storage and administration areas shall be protected in accordance with NFPA 99 Standard for Health Care Facilities"NFPA 99, Chapter 8, Section 8-3.1.11 "Storage Requirements" Section 8-3.1.11.2: "Storage of nonflammable gases less than 3000 cubic. feet." (a) "Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. (c) "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by: (c) (2) A minimum distance of 5 ft. if the entire storage location is protected by an automatic sprinkler system...."

Findings Include:

On January 12, 2016, the surveyor, accompanied by the Facilities Director, Regulatory Consultant, Facilities Manager and staff observed the following oxygen storage areas:

1. Fifth floor room 5016 A, two full EO2 cylinders mixed with four empty EO2 cylinders in a rack marked FULL.
2. Forth floor room 4092, three full EO2 cylinders mixed with three empty EO2 cylinders in a rack marked FULL.
3. Second floor room 2016, five full EO2 cylinders mixed with one empty EO2 cylinders in a rack marked FULL.

During the exit conference on January 11th and 12, 2016, the above findings were again
acknowledged by the COO, Assistant CNO, Associate CNO, Two Associate Administrators, Chief Medical Officer, CHRO, Facilities Director, Regulatory Consultant, Facilities Manager, and Staff.

Leaking oxygen could penetrate combustible materials and create an extreme fire hazard, which could cause harm to the patients. In an emergency, patients could be harmed if an empty medical gas cylinder was mistakenly taken from the storage area.

Based on observation and interview with the laboratory staff, it was determined the facility removed the emergency shower in the laboratory, which places the employees at risk for exposure to injurious corrosive materials that were stored and utilized by the laboratory personnel.

Findings include:

NFPA 99, Health Care Facilities, Chapter 10, Section 10-6 "Emergency Shower.": "Where the eyes or body of any person can be exposed to injurious corrosive materials, suitable fixed facilities for quick drenching of flushing of the eyes and body shall be provided within the work area for immediate emergency use...."

On January 12, 2016, the surveyor, accompanied by the Facilities Director, Regulatory Consultant, Facilities Manager and staff observed the Laboratory shower had been removed. The shower was installed by the close of the Life Safety survey.

During the exit conference on January 12, 2016, the above findings were again
acknowledged by the COO, Assistant CNO, Associate CNO, Two Associate Administrators, Chief Medical Officer, CHRO, Facilities Director, Regulatory Consultant, Facilities Manager, and Staff.

Failing to provide an emergency shower with in the work place will cause harm to Staff is a spill should occur

Based on staff interview, and record review it was determined the laboratory staff did not have a working emergency procedure plan implemented to ensure Material Safety Data Sheets (MDS) were immediately available to the staff and the staff knew how and where to obtain them immediately. This has the potential risk for exposures to not be treated appropriately and timely.

NFPA 99 Health Care Facilities, 1999 Edition, Chapter 10, Section 10-2.1.3.1: "Procedures for laboratory emergencies shall be developed. Such procedures shall include alarm actuation, evacuation, and equipment shutdown procedures, and provisions for control of emergencies that could occur in the laboratory, including specific detailed plans for control operations by an emergency control group within the organization or a public fire department.

Findings Include:

On January 12, 2016, the surveyor, accompanied by the Facilities Director, Regulatory Consultant, Facilities Manager and staff requested two Material Safety Data Sheets from the Laboratory staff. The request was not completed when timed for ten minutes. The surveyor asked the staff how the employee would be treated for a Acetone exposure to the eyes and the body. The respondent did not have any urgency to explain or demonstrate the procedure as detailed in the emergency procedures of the facility.

During the exit conference on January 12, 2016, the above findings were again
acknowledged by the COO, Assistant CNO, Associate CNO, Two Associate Administrators, Chief Medical Officer, CHRO, Facilities Director, Regulatory Consultant, Facilities Manager, and Staff.

Failure to have a laboratory emergency procedures plan will cause harm to Staff and patients during a laboratory emergency.

Based on observation it was determined the facility allowed the use of a multiple outlet adapter, power strips and did not use the wall outlet receptacles for appliances.

Based on observation it was determined the facility failed to allow access to the electrical equipment/panels.

NFPA 101, Life Safety Code, 2000, Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 1999 Edition. NFPA 99, Chapter 3, Section 3-3.2.1.2: "All Patient Care Areas," Section 3-3.2.1.2 (d) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.5.1.1 "Utilities shall comply with the provisions of Section 9.1., Section 9.1.2 "Electrical wiring and equipment shall be in accordance with NFPA 70 National Electrical Code." NEC, 1999, ARTICLE 110, SECTION 110-26 Spaces About Electrical Equipment. "Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons." Table 110-26(a) Working Space Minimum of three (3) feet in all directions. ( NO STORAGE ALLOWED IN THE WORKING SPACE)

Findings include:

On January 11 and 12, 2016, the surveyor, accompanied by the Facilities Director, Regulatory Consultant, Facilities Manager and staff, observed refrigerators and microwave plugged into multi-outlet power strips and not directly plugged in to the wall outlet receptacles in the following areas:

1. Room 5125, refrigerator and microwave.
2. Room 4005, forth floor S.W. break room refrigerator.
3. Room 3018, microwave.
4. Room 3009, refrigerators and microwave.
5. Room 3004, refrigerators and microwave.
6. Room 2036, refrigerators and microwave.
7. Room 2270, three of three electrical panels blocked by a large rack.

During the exit conference on January 12, 2016, the above findings were again
acknowledged by the COO, Assistant CNO, Associate CNO, Two Associate Administrators, Chief Medical Officer, CHRO, Facilities Director, Regulatory Consultant, Facilities Manager, and Staff.

The use of multiple outlet adapters could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.

Blocking of access to electrical panels or equipment may delay personnel from controlling an emergency situation. Patients will be harmed if a fire should start because of a delay.