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Based on record review and interview, the facility failed to maintain the written emergency preparedness plan (EPP). This was evidenced by the failure to include strategies for an identified risk. This affected all patients and could result in the facility not being prepared for a mass casualty event.

Findings:

During record review and interview with the Staff on 10/8/24, the EPP was reviewed.

At 3:12 p.m., the facilities Hazardous Risk Assessment listed mass casualty event as a top risk for the facility. The Facility's EPP failed to include strategies that addressed mass casualty events. Upon interview, Staff C acknowledged that the facility's EPP failed to include a policy and procedure that addressed mass casualty events.

Based on observation and interview, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations in the walls. This affected the Main hospital and the Emergency department, and could result in the spread of smoke in the event of a fire.

Findings:

During a tour of the facility and interview with Staff on 10/8/24, the walls and ceilings were observed.

1. At 11:06 a.m., an approximately quarter inch penetration was observed in the wall across from the lockers in the men's locker room in the Emergency Departments imaging area. Upon interview, Staff B stated that the penetration appeared to be from a wall anchor.

2. At 11:59 a.m., an approximately one foot by two-and-a-half-foot penetration was observed in the South wall in the water filler closet on the outside of the surgical wing. Upon interview, Staff B stated that it looks like the drywall was cut out to access the ventilation ducts.

Based on observation, record review and interview, the facility failed to maintain the emergency battery backup lights. This was evidenced by the failure to document annual testing. This affected the Emergency Department and the Main Hospital, and could result in a failure to provide backup lighting in the event of an emergency.

NFPA 101: Life Safety Code, 2012 Edition
19.2.9/18.2.9 Emergency Lighting.
19.2.9.1/18.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.
7.9 Emergency Lighting.
7.9.3 Periodic Testing of Emergency Lighting Equipment.
7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.
7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).
(2)* The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
(3) Functional testing shall be conducted annually for a minimum of 11/ 2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During a tour of the facility, record review and interview with Staff on 10/8/24, the emergency lighting was observed and tested.

At 2:11 p.m., the testing records for the battery backup emergency lights were requested for emergency rooms, labs, operating rooms and the outpatient medical/recover area. The facility failed to provide documentation that an annual 90 minute functional test had been conducted on the emergency battery backup lights within the last 12 months. Upon interview, Staff D acknowledged that there was no annual test record available for review.

Based on observation, record review and interview, the facility failed to maintain the battery backup exit signs. This was evidenced by the failure to document annual testing. This affected the Emergency Department and the Main Hospital, and could result in a failure of the illuminated exit signs in the event of an emergency.

NFPA 101: Life Safety Code, 2012 Edition
19.2.10/18.2.10 Marking of Means of Egress.
19.2.10.1/18.2.10.1 Means of egress shall have signs in accordance with Section 7.10, unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4.
7.10.9 Testing and Maintenance.
7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days or shall be periodically monitored in accordance with 7.9.3.1.3.
7.10.9.2 Testing. Exit signs connected to, or provided with, a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.
7.9.3 Periodic Testing of Emergency Lighting Equipment.
7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.
7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).
(2)* The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
(3) Functional testing shall be conducted annually for a minimum of 11/ 2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During a tour of the facility, record review and interview with Staff on 10/8/24, the battery backup exit signs were observed and testing and inspection records were requested.

At 2:12 p.m., the testing records for the battery backup exit signs were requested. The facility failed to provide documentation that the annual 90 minute functional test had been conducted on the exit signs within the last 12 months throughout the facility. Upon interview, Staff D acknowledged that there was no annual test record available for review.

Based on observation and interview, the facility failed to maintain the fire sprinkler system. This was evidenced by missing signage for the sprinkler valves. This affected Emergency Department, and could result in delay and confusion of identifying the fire sprinkler valves that serves the facility.

NFPA 101: Life Safety Code, 2012 Edition
18.3.5 Extinguishment Requirements.
18.3.5.1
Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 18.3.5.5.
9.7 Automatic Sprinklers and Other Extinguishing Equipment.
9.7.1 Automatic Sprinklers.
9.7.1.1 * Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following:
(1) NFPA 13, Standard for the Installation of Sprinkler Systems

NFPA 13: Standard for the Installation of Sprinkler Systems, 2010 Edition
6.7.4 * Identification of Valves.
6.7.4.1 All control, drain, and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs.
6.7.4.2 The identification sign shall be secured with corrosion-resistant wire, chain, or other approved means.
6.7.4.3 The control valve sign shall identify the portion of the building served.

Findings:

During a tour of the facility and interview with Staff on 10/8/24, the fire sprinkler system was observed.

At 10:22 a.m., two valves were observed on the fire sprinkler drainpipe on the underside of the Main Entry Canopy outside of the Main Lobby in the Emergency Department. Both valves were missing signage that indicated their purpose. Upon interview, Staff D acknowledged that the valves were missing identification signs.

Based on observation, record review and interview, the facility failed to maintain the fire sprinkler system. This was evidenced by missing inspection records, sprinklers covered in cobwebs and obstructed sprinkler heads. This affected the Main Hospital and the Emergency Department, and could result in the malfunction of the sprinklers in the event of a fire.

NFPA 101 Life Safety Code, 2012 edition
19.3.5.1/18.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.
9.7 Automatic Sprinklers and Other Extinguishing Equipment.
9.7.1 Automatic Sprinklers.
9.7.1.1 * Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following:
(1) NFPA 13, Standard for the Installation of Sprinkler Systems
9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 13: Standard for the Installation of Sprinkler Systems, 2010 Edition
8.10.6.3 * Obstructions That Prevent Sprinkler Discharge from Reaching the Hazard.
8.10.6.3.1 Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. (457 mm) below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 8.10.6.3.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 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 (e.g., upright, pendent, or sidewall).
6.2 Inspection.
6.2.2 Gauges.
6.2.2.2 Gauges on dry, preaction, and deluge valves shall be inspected weekly to ensure that normal air and water pressure are being maintained.

Findings:

During a tour of the facility, record review and interview with Staff on 10/8/24, the automatic sprinkler system was observed.

1. At 10:25 a.m., two of four fire sprinkler heads under the ambulance canopy outside of the ambulance bay doors in the Emergency Department were observed with cobwebs covering the sensing bulbs, frames, and deflectors. Upon interview, Staff B acknowledged that the sprinklers were covered in cobwebs.

2. At 11:19 a.m., the pharmacy storage/server closet across from the pharmacy was observed. Items were stored on top of the shelving unit on the back wall of the closet at approximately 11 inches below the single sprinkler in the ceiling of the closet. Upon interview, Staff B acknowledged that the sprinkler was obstructed.

3. At 11:29 a.m., the respiratory storage closet across from the Director of Clinical Services Office was observed. A box of disposable towel was stored on the top shelf at approximately five inches below the single sprinkler in the ceiling of the closet. Upon interview, Staff D acknowledged that the sprinkler was obstructed.

4. At 4:27 p.m., the inspection and maintenance records for the dry pipe fire sprinkler system in the emergency department expansion were requested. The facility failed to provide documentation that a weekly visual inspection was being conducted on the dry pipe fire sprinkler system. Upon interview, Staff D acknowledged that there were no weekly inspection records available for review.

Based on observation and interview, the facility failed to maintain the fire extinguishers. This was evidenced by a free-standing fire extinguisher. This affected the Emergency Department, and could result in damage to the fire extinguisher and a delay in responding to a fire in the event of an emergency.

NFPA 101: Life Safety Code, 2012 Edition
18.3.5.12 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1
9.7.4.1 * Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10: Standard for Portable Fire Extinguishers, 2010 Edition
6.1.3.8 Installation Height.
6.1.3.8.3 In no case shall the clearance between the bottom of the hand portable fire extinguisher and the floor be less than 4 in. (102 mm).

Findings:

During a tour of the facility and interview with Staff on 10/8/24, the fire extinguishers were observed.

At 10:26 a.m., a red ABC fire extinguisher was observed freestanding on the ground along the South wall of the electrical room next to the ambulance bay door entrance to the Emergency Department. Upon interview, Staff D acknowledged that the fire extinguisher was free standing and not mounted on a wall in the room.

Based on observation and interview, the facility failed to maintain the corridor doors. This was evidenced by corridor doors that failed to latch. This affected the Main Hospital, and could result in the spread of fire or smoke in the event of a fire.

Findings:

During a tour of the facility and interview with Staff on 10/8/24, the corridor doors were observed.

1. At 11:21 a.m., the corridor door to the pharmacy storage/server closet across from the pharmacy failed to latch when tested. Upon interview, Staff A stated that the door was scheduled to be replaced.

2. At 12:05 p.m., the corridor door to the shower room next to Patient Room 107 failed to latch when tested. Upon interview, Staff D acknowledged that the door failed to latch.

Based on record review and interview, the facility failed to maintain the integrity of the heating, ventilation, and air-conditioning (HVAC) system. This was evidenced by the failure to identify the location of the fire/smoke dampers throughout the facility. This affected the Emergency Department and the Main Hospital, and could result in the spread of smoke in the event of a fire.

NFPA 101: Life Safety Code, 2012 Edition
19.5.2/18.5.2 Heating, Ventilating, and Air-Conditioning.
19.5.2.1/18.5.2.1 Heating, ventilating, and air-conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer ' s specifications, unless otherwise modified by 19.5.2.2.
9.2 Heating, Ventilating, and Air-Conditioning.
9.2.1 Air-Conditioning, Heating, Ventilating Ductwork, and Related Equipment.
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, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 90A: Standard for the Installation of Air-Conditioning and Ventilating Systems, 2012 Edition
5.4.8 Maintenance.
5.4.8.1 Fire dampers and ceiling dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.

NFPA 80: Standard for Fire Doors and Other Opening Protectives, 2010 Edition
19.3.4 Documentation.
All inspections and testing shall be documented, indicating the location of the fire damper, date(s) of inspection, name of inspector, and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected.
19.4 * Periodic Inspection and Testing.
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.

Findings:

During record review and interview with Staff on 10/8/24, the fire dampers inspection records were reviewed.

At 1:51 p.m., a document titled, "SNF Fire Damper Inspection Fall River Campus" was reviewed. The inspection report dated 11/14/23 indicated the facility had 41 fire dampers. The document listed the damper numbers (1 through 41), damper passed or failed, a functional inspections, and the cleanliness inspection. At the bottom of the second page, under the comment section, it stated that the fusible links for dampers 5, 12, 23, 27, and 35 were replaced at time of inspection. The document failed to include the locations of each dampers. Upon interview, Staff D acknowledged that the damper location was not included in the documentation.

Based on observation and interview, the facility failed to maintain the vacuum and piped medical gas systems. This was evidenced by an obstructed and silenced medical gas master alarm panel. This affected the emergency department and could result in delayed access to the panel in the event of an emergency.

NFPA 99: Health Care Facilities Code, 2012 Edition
5.1.9.2 * Master Alarms. A master alarm system shall be provided to monitor the operation and condition of the source of supply, the reserve source (if any), and the pressure in the main lines of each medical gas and vacuum piping system.
5.1.9.2.1 The master alarm system shall consist of two or more alarm panels located in at least two separate locations, as follows:
(2) In order to ensure continuous surveillance of the medical gas and vacuum systems while the facility is in operation, the second master alarm panel shall be located in an area of continuous observation (e.g., the telephone switchboard, security office, or other continuously staffed location).

Findings:

During a tour of the facility and interview with Staff on 10/8/24, the gas and vacuum piped medical gas system was observed.

1. At 10:52 a.m., the Total Alert master alarm panel for the Emergency Department expansion was observed. The mute button indicated the audible panel alarm was silenced. Upon interview, Staff A stated that a sensor had gone bad in the system and required replacement. The part was ordered, and their vendor was waiting for it so they could schedule the replacement.

2. At 10:54 a.m., the Total Alert master alarm panel for the Emergency Department expansion was observed. A printer and a 50-gallon wheeled document shredding container were observed obstructing access to the panel located at the Nurse Station in the Emergency Department. Upon interview, Staff A and Staff B acknowledged that the panel was obstructed.

Based on observation, record review and interview, the facility failed to maintain the isolated power system equipment. This was evidenced by the failure to provide testing documentation. This affected the Main Hospital, and could result in the malfunction of the line isolation monitoring equipment.

NFPA 99: Health Care Facilities Code, 2012 Edition
6.3.2.6.3.6 A reliable test switch shall be mounted on the line isolation monitor to test its capability to operate (i.e., cause the alarms to operate and the meter to indicate in the "alarm on" zone). This switch shall transfer the grounding connection of the line isolation monitor from the reference grounding point to a test impedance arrangement connected across the isolated line; the test impedance(s) shall be of the appropriate magnitude to produce a meter reading corresponding to the rated total hazard current at the nominal line voltage, or to a lesser alarm hazard current if the line isolation monitor is so rated. The operation of this switch shall break the grounding connection of the line isolation monitor to the reference grounding point before transferring this grounding connector to the test impedance(s), so that making this test will not add to the hazard of a system in actual use; nor will the test include the effect of the line-to-ground stray impedance of the system. The test switch shall be of a self-restoring type.

Findings:

During a tour of the facility, record review and interview with Staff on 10/8/24, the operating rooms were observed.

At 2:04 p.m., The facility was observed with two line isolation monitor (LIM) units outside of each Operating Rooms. Both LIM units were equipped with a test switch that activates both visual and audible alarms when tested. The inspection and testing records for the LIM units for both Operating Rooms were requested. The facility failed to provide testing records for the LIM system in the operating rooms. Upon interview, Staff B and Staff D stated they were not aware of the requirement.

Based on observation and interview, the facility failed to maintain the electrical equipment. This was evidenced by the use of extension cords and suspended power strips. This affected the Main Hospital and could result in an increased risk of fire.

NFPA 101 Life Safety Code, 2012 Edition
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.
9.1 Utilities.
9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70 National Electrical Code, 2011 Edition
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
(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 this Code
(7) Where subject to physical damage
400.10 Pull at Joints and Terminals. Flexible cords and cables shall be connected to devices and to fittings so that tension is not transmitted to joints or terminals. Exception: Listed portable single-pole devices that are intended to accommodate such tension at their terminals shall be permitted to be used with single-conductor flexible cable.

Findings:

During a tour of the facility and interview with Staff on 10/8/24, the electrical equipment was observed.

1. At 11:09 a.m., a white power strip was observed suspended approximately four inches above the floor under the Patient Access Manager's desk in the Patient Finance and Registration Office. The Power Strip was powering computer and phone equipment. Upon interview, Staff B acknowledged the suspended power strip.

2. At 11:12 a.m., a white power strip was observed suspended approximately eight inches above the floor, near a small black refrigerator in the Lab office. The power strip was powering the refrigerator and a coffee pot. Upon interview, Staff B acknowledged the suspended power strip.

3. At 11:27 a.m., an extension cord was observed powering a microwave behind the Medical Staff Services desk in the Quality Office. Upon interview, Staff A acknowledged the extension cord.

4. At 12:10 p.m., a white power strip was observed suspended approximately four inches above the floor, under the Nurses Workstation at Nurse Station 1. The power strip was powering computer and phone equipment. Upon interview, Staff B acknowledged the suspended power strip.