HospitalInspections.org

Based on observation and interview, the facility failed to maintain means of egress free of obstructions on the fourth floor in the Bed Tower. This deficient practice could delay evacuation of residents during an emergency. The facility has the capacity for 129 beds with a census of 60 on the day of survey.

Findings are:
Observations on 9-24-18 at 1:07 pm revealed, an unattended food cart in the corridor outside Behavioral Health Unit.

During an interview on 9-24-18 between 10:31 am and 11:47 am, Maintenance Staff A confirmed the item stored in the corridor.

NFPA Standard:
2012 NFPA 101, 19.2.1
Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11.

2012 NFPA 101, 7.1.10.1*
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on observation, interview, fire alarm test and documentation, the facility failed to assure that all staff carried keys or other reliable means to rapidly remove all occupants from the fourth floor locked unit. This deficient practice would affect all patients and occupants on the fourth floor Behavioral Health Unit.

On 9-24-18 at 4:17 pm, this deficient practice was determined to be of immediate jeopardy (IJ). The facility is licensed for 129 with a census of 60 residents.

Findings are:
Observations on 9-24-18 between 11:17 am and 4:17 pm revealed:
1. Float Staff Nurse working on the floor, failed to have keys or card to unlock the fourth floor locked exit doors on the Behavioral Health Unit.
2. Doctor in a meeting on the unit, failed to have keys or card to unlock the fourth floor locked exit doors on the Behavioral Health Unit.
3. Utilization Reviewer in a meeting on the unit, failed to have keys or card to unlock the fourth floor locked exit doors on the Behavioral Health Unit.
4. UNO Student in a meeting on the unit, failed to have keys or card to unlock the fourth floor locked exit doors on the Behavioral Health Unit.
5. UNO Student in a meeting on the unit, failed to have keys or card to unlock the fourth floor locked exit doors on the Behavioral Health Unit.

During an interview on 9-24-18 between 11:17 am and 4:17 pm, Maintenance Staff A confirmed that the all staff failed to have keys to unlock the unit exit doors.

NFPA Standard:
2012, NFPA 101, 18.2.2.2.5.1
Door-locking arrangements shall be permitted where the clinical needs of patients require specialized security measures or where patients pose a security threat, provided that staff can readily unlock doors at all times in accordance with 18.2.2.2.6.

18.2.2.2.6
Doors that are located in the means of egress and are permitted to be locked under other provisions of 18.2.2.2.5 shall comply with both of the following:
(1) Provisions shall be made for the rapid removal of occupants by means of one of the following:
(a) Remote control of locks from within the locked smoke compartment
(b) Keying of all locks to keys carried by staff at all times
(c) Other such reliable means available to the staff at all times
(2) Only one locking device shall be permitted on each door.


During a fire alarm test on 9-24-18 at 4:12 pm revealed:
1. Staff from other locations of the hospital responded to the alarm on the locked fourth floor unit, to assist in the alarm.
2. The locked exit doors failed to drop upon activation of the fire alarm.
3. Fourth floor Nursing Staff failed to assure patients were placed in their rooms during the fire alarm and appeared unsure on how to respond to the alarm.
4. Numerous staff from other areas of the building responded to the fire alarm to assist in the alarm.

During an interview on 9-24-18 at 4:10 pm, Staff R from another area of the facility failed to have key or card to exit the unit.

Documentation review on 9-24-18 at 4:45 pm revealed:
1. Fire drill policy states that staff from other areas of the hospital should respond to a fire alarm.
2. Key policy failed to state that all staff entering the locked unit are required to have a key.

During an interview on 9-24-18 at 5:20 pm with Administration Staff A and Maintenance Staff A confirmed the findings and started to put safety measures into place.

On 9-24-18 at 5:35 pm, this deficient practice was determined to be of immediate jeopardy.

On 9-24-18 at 5:35 pm, the facility immediately implemented a fire watch on the fourth floor Behavioral Health Unit and started to notify staff of the fire watch.

Due to the measures put in place, this abated the IJ.

On 9-24-18 at 9:08 pm during a phone conversation, Maintenence Staff stated that policies had been updated and a fire alarm contractor would be in the facility on 9-25-18 at 5:00 am to start modifications to the locking mechinisms on the fourth floor Behavioral Unit. An email was sent to verify the policy changes.

Observations on 9-25-18 at 8:40 am during a fire alarm test, the locking devices on the exit doors on the fourth floor Behavioral Units unlocked during the test.

Based on observation and interview, the facility failed to assure that rooms where procedures were conducted had emergency lighting. This deficient practice could delay evacuation of residents during an emergency. The facility has the capacity for 129 beds with a census of 60 on the day of survey.

Findings are:
Observations on 9-26-18 between 11:24 am and 2:34 pm revealed:
1. Cistosuite procedure room failed to provide emergency lighting.
2. Cathlab 1 and 2 failed to provide emergency lighting.

During an interview on 9-26-18 between 11:24 am and 2:34 pm, Maintenance Staff E confirmed the lack of emergency lighting.

Based on observation and interview the facility failed to maintain the fire resistance rating of the Bed Tower's Center exiting stairway by allowing a new penetration through the stairway that did not directly serve that stairway. This deficient practice would allow fire, smoke, and gasses to spread into the stairway. The facility is licensed for 129 with a census of 60 on the day of survey.

Findings are:
Observations on 9-24-18 at 1:45 pm revealed, a newly installed insulated pipe penetration just above the exit door through the center stairway of the bed tower on the ground level.

During an interview on 9-24-18 at 1:45 pm, Maintenance C confirmed the findings.

A. Based on observation and interview, the facility failed to assure the door to a hazardous area would close and latch within the doorframe. These deficient practices would allow fire, smoke and gasses to migrate into the exit corridor on 3rd and 4th floors in Bed Tower and 2nd floor West Campus. The facility has the capacity for 129 beds with a census of 60 on the day of survey.

Findings are:
Observation on 9-24-18 between 12:42 pm and 1:48 pm in the Bed Tower revealed:
1. The gap between the 1 ½ hour rated doors 482B at the lower portion was not smoke tight.
2. The IT room door in 4th floor Staff Locker room failed to latch.
3. The Electrical room door in the 4th floor Staff Locker room failed to close; the door drug on the carpet.
4. The door between Exercise room and the Gym with a self-closure was equipped with a metal kick down on the lower portion of the door.
5. Soiled linen door 3A222 failed to latch within the doorframe.

During an interview on 9-24-18 between 12:42 pm and 1:48 pm, Maintenance Staff A confirmed the findings.

Observation on 9-25-18 between 1:46 pm and 3:28 pm in the 2nd floor West Campus Building revealed:

6. 1-hour fire rated door W2074, Education Office equipped with a self-closing device failed to latch and had two unsealed penetrations.
7. Room W2566 "old peds" used for storage, the door failed to provide latching device and closure.
8. Room W2578 "old peds" used for storage, the door failed to provide latching device and closure.
9. Room W2060, Nursing Student Locker room door equipped with a self-closure, failed to close and latch within the doorframe.
10. Room 2608 storage room, which was an old shower room door was equipped with louvers.
11. Room 2030 door equipped with a self-closure failed to latch within the doorframe.

During an interview on 9-25-18 between 1:46 pm and 3:28 pm, Maintenance Staff C confirmed the findings.

Observation on 9-26-18 at 1:56 pm and 2:88 pm in the OR Area West Campus Building revealed:
12. Storage Room B double doors failed to be smoke tight.
13. W1070 OR Housekeeping door equipped with a self-closure failed to latch within the doorframe.

During an interview on 9-26-18 at 1:56 pm and 2:88 pm, Maintenance Staff A confirmed the findings.


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B. Based on observation and interview, the facility failed to maintain the 1-hour separation of hazardous areas of the second floor of the Bed Tower. This deficient practice would allow smoke and fire to migrate out of the hazardous room. The facility has the capacity for 129 beds with a census of 60 on the day of survey.

Findings are:
Observation on 9-24-18 at 2:17 pm revealed an unsealed penetration of a ¾ inch conduit going through the 1 hour rated fire wall in the electrical room next to room 221.

Observation on 9-25-18 between 10:07 am and 10:54 am revealed:
1. An unsealed penetration around a ¾ inch conduit in the 1 hour rated wall above the ceiling tile of the oxygen storage room across from room 226. Maintenance staff sealed around the penetration at the time of observation.
2. An unsealed penetration around a ¾ inch conduit in the 1 hour rated wall above the ceiling tile across from LDR4 above door 3B-275-2. Maintenance staff sealed around the penetration at the time of observation.

During interviews conducted on 9-24-18 at 2:17 pm, Maintenance staff B confirmed the findings.

During interviews conducted on 9-25-18 between 10:07 am and 10:54 am, Maintenance staff C confirmed the findings.


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C. Based on observation and interview, the facility failed to maintain the 1-hour separation of hazardous areas of the first floor and fourth floor of the Bed Tower, and the West Campus. This deficient practice would allow smoke and fire to migrate out of the hazardous room. The facility is licensed for 129 with a census of 60 on the day of survey.

Findings are:
Observations on 9-24-18 between 2:22 pm and 2:28 pm revealed:
1. 3 unsealed penetrations around flex-conduit in the wall above ceiling tile of the in-patient dialysis pump room.
2. Unsealed penetration around the supply airline in the wall above ceiling tile of the soiled linen utility room.

Observations on 9-25-18 between 9:38 am and 2:49 pm revealed:
1. An unsealed penetration in the wall above ceiling tile of the oxygen storage room across from room 121.
2. An unsealed penetration around conduit in wall above the ceiling tile on the corridor side of the west storage room on fourth floor by west fire alarm strobe.
3. Unsealed penetrations around 3 pipes in wall above ceiling tile of the chiller room above the chemical testing sink.

During interviews on 9-24-18 between 2:22 pm and 2:28 pm, and on 9-25-18 between 9:38 am and 2:49 pm, Maintenance E confirmed the findings.

Based on observations and interview, the facility failed to provide audible/visual fire alarm notification devices in the enclosed interior courtyard. The lack of fire alarm notification devices could cause a fire emergency to go undetected in the area of the facility because of the inability to hear and see the alarm device. The facility has the capacity for 129 beds with a census of 60 on the day of survey.

Findings are:
Observations on 9-26-18 at 11:46 am revealed, the facility failed to provide an audible/visual notification device in enclosed interior courtyard.

During an interview on 9-26-18 at 11:46 am, Maintenance Staff C and Maintenance Staff E confirmed the lack of the notification devices.

Based on observation and staff interview, the facility failed to provide complete sprinkler coverage. This deficient practice had the potential to allow a fire to potentially grow beyond the capabilities of the sprinkler system. The facility has the capacity for 129 beds with a census of 60 on the day of survey.

Findings are:
Observation on 9-25-18 at 2:15 pm revealed a clothes closet that measured 7 square feet in area that was affixed to the building in the old ICU room 1, failed to have required fire sprinkler coverage.

During an interview on 9-25-18 at 2:15 pm, Maintenance F confirmed the findings of no sprinkler protection in the closet.

A. Based on observation and interview, the facility failed to assure that fire sprinklers were not obstructed, or that anything was attached to fire sprinkler piping and allowed unsealed penetrations in the ceilings. These deficient practices would affect the operating temperature of the fire sprinklers and increased the potential that the fire sprinkler system would fail to activate as designed during a fire in the Bed Tower and West Campus. The facility has the capacity for 129 beds with a census of 60 on the day of survey.

Findings are:
Observation on 9-25-18 between 9:53 am and 3:44 pm revealed:
1. A missing escutcheon for the fire sprinkler in the 3rd floor Bed Tower, Anesthesia storage room.
2. Items encroached into the required clear space for the fire sprinkler creating an obstruction in the restroom of the 2nd floor Repertory Therapy Office.
3. Ceiling tile out of the grid in Room W2009.
4. Items encroached into the required clear space for the fire sprinkler creating an obstruction in the closet of room W2038.
5. A cord attached to the sprinkler pipe in room W1692 Equipment Room behind the sterilizers holding a insulated supply air pipe.

During an interview on 9-25-18 between 9:53 am and 3:44 pm, Maintenance Staff A confirmed the findings.


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B. Based on observation and interview, the facility allowed foreign materials to accumulate on fire sprinklers in the Bed Tower kitchen walk-in cooler. This deficient practice could prevent the fire sprinklers to operate as designed. The facility is licensed for 129 with a census of 60 on the day of survey.

Findings are:

Observations on 9-24-18 at 1:13 pm revealed, two fire sprinklers nearest to the cooling fans in the walk-in cooler covered with foreign material, dirt and dust, on the bulb and deflector.

During an interview on 9-24-18 at 1:13 pm, Maintenance C confirmed the findings.


38543

C. Based on observation and staff interview, the facility failed to maintain the required minimum clearance around a fire sprinkler deflector. The deficient practice could prevent the fire sprinkler from activation in the case of fire and could obstruct the spray pattern of the sprinkler resulting in inefficient coverage and failure to extinguish a fire. The facility has the capacity for 129 beds with a census of 60 on the day of survey.

Findings are:
Observations on 9-25-18 between 3:13 pm and 3:32 pm revealed:
1. A box that was stored on a shelf in the Pharmacy break room closet measured 14 inches below the sprinkler deflector, encroaching into the required minimum 18 clearance from obstructions to the sprinkler deflector. Maintenance Staff B removed the box from the shelf at the time of observation.
2. A Styrofoam cooler stored on a shelf in the Pharmacy storage room measured 13 inches below the sprinkler deflector, encroaching into the required minimum 18 clearance from obstruction to the sprinkler deflector. Maintenance Staff B removed the Styrofoam cooler from the shelf at the time of observation.

During interviews on 9-25-18 between 3:13 pm and 3:32 pm, Maintenance Staff B and Maintenance Staff F confirmed the findings.


39858

D. Based on observation and interview, the facility allowed dust and dirt to accumulate on fire sprinklers in multiple rooms of the Emergency Department. This deficient practice would cause failure of the fire sprinklers to operate as designed. The facility is licensed for 129 with a census of 60 on the day of survey.

Findings are:
Observations on 9-26-18, between 9:55 am and 10:13 am revealed:
1. Dust and dirt accumulation on the fire sprinkler in the ER Trauma room.
2. Corrosion on the fire sprinkler inside of the south doors of the ER area.
3. Dirt and dust accumulation on the fire sprinkler in the ER 8 patient restroom.
4. A missing escutcheon, dirt and dust accumulation and duct tape on the fire sprinkler in ER room 10.
5. Dirt and dust accumulation on fire sprinkler in ER room 1.

During interviews on 9-26-18 between 9:55 am and 10:13 am, Maintenance E confirmed the findings.

Based on record review and interview, the facility failed to assure that a complete policy was in place regarding the procedures to be taken in the event that the fire sprinkler system is out of service for more than ten hours in any twenty-four hour period. The lack of a complete written policy and procedure would result in staff failing to implement interim safety measures in the event of an emergency. The facility has the capacity for 129 beds with a census of 60 on the day of survey.

Findings are:
Record review on 9-26-18 at 3:22 pm, of the fire watch procedures revealed:
1. The policy failed to list emergency impairments would include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping and equipment failure.
2. The facility failed to have a list of contact information including property owner or designee, insurance company, fire department, authorities having jurisdiction (HHSS, SFM, Norfolk Fire), monitoring company, fire alarm company and sprinkler company.

During an interview on 9-26-18 at 3:22 pm, Maintenance Staff A confirmed the lack of specific items in the fire watch policy.

NFPA Standard:
NFPA 25, 2011,15.5 Preplanned Impairment Programs.
15.5.1 All preplanned impairments shall be authorized by the impairment coordinator.
15.5.2 Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented:
(1) The extent and expected duration of the impairment have been determined.
(2) The areas or buildings involved have been inspected and the increased risks determined.
(3) Recommendations have been submitted to management or the property owner or designated representative.
(4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following:
(a) Evacuation of the building or portion of the building affected by the system out of service
(b)*An approved fire watch
(c)*Establishment of a temporary water supply
(d)*Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire
(5) The fire department has been notified.
(6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified.
(7) The supervisors in the areas to be affected have been notified.
(8) A tag impairment system has been implemented. (See Section 15.3.)
(9) All necessary tools and materials have been assembled on the impairment site.

15.6 Emergency Impairments.
15.6.1 Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure.
15.6.2 When emergency impairments occur, emergency action shall be taken to minimize potential injury and damage.
15.6.3 The coordinator shall implement the steps outlined in Section 15.5.

Based on observation and staff interview, the facility failed to install portable fire extinguishers so the top of the extinguisher was not more than five feet above the finished floor. This condition could prevent staff from accessing a fire extinguisher during a fire, which would allow a fire to increase in size. The facility has the capacity for 129 beds with a census of 60 on the day of survey.

Findings are:
Observation on 9-25-18 at 2:15 pm revealed, the fire extinguisher installed in the IT room next to the old ICU measured 71 1/8 inches to the top of the handle.

During an interview on 9-25-18 at 2:15 pm, Maintenance Staff F confirmed the measurement.

A. Based on observation and interview, the facility allowed the use of unapproved devices to hold a corridor door in the open position and failed to ensure that the corridor room doors would resist the passage of smoke. This deficient practice would not prevent the spread of fire and smoke within the exit corridors, on the 4th floor Bed Tower and 2nd floor West Campus. The facility has the capacity for 129 beds with a census of 60 on the day of survey.

Findings are:
Observation on 9-24-18 at 1:32 pm on 4th floor Bed Tower revealed:
1. The Behavioral Health Director's office door was obstructed with a book.
2. The Behavioral Health Social Worker's office door was obstructed with a ceramic gnome.
3. The Behavioral Health Nurse Manager's office door was obstructed with a chair.

During an interview on 9-24-18 at 1:32 pm, Maintenance Staff A confirmed the doors were obstructed from closing.

Observation on 9-25-18 at 2:13 pm on 2nd floor West Campus revealed:
4. "Old Peds" Patient room doors W2572, W2569, W2566 W2563 were equipped with a metal kick down on the lower portion of the door.

During an interview on 9-25-18 at 2:13 pm, Maintenance Staff C confirmed the metal kick downs on the corridor doors.

NFPA Standard:
2012 NFPA 101, 19.3.6.3.10*
Doors shall not be held open by devices other than those that release when the door is pushed or pulled.
2012 NFPA 101, A.19.3.6.3.10 Doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.


38543

B. Based on observation and interview the facility failed to maintain corridor doors to resist the passage of smoke. This deficient practice would allow smoke and fire gases to migrate throughout the smoke compartment. The facility has the capacity for 129 beds with a census of 60 on the day of survey.

Findings are:
Observations on 9-24-18 between 12:41 pm and 1:31 pm revealed:
1. Patient room door 235 failed to latch and seal within the door frame.
2. Patient room door 232 failed to latch and seal within the door frame.
3. Patient room door 208 failed to latch and seal within the door frame.
4. Patient room door 209 failed to latch and seal within the door frame.

During interviews on 9-24-18 between 12:41 pm and 1:31 pm, Maintenance B confirmed the findings.


39858

C. Based on observation and interview the facility failed to maintain corridor doors to resist the passage of smoke. This deficient practice would allow smoke and fire gases to migrate throughout the smoke compartment. The facility is licensed for 129 with a census of 60 on the day of survey.

Findings are:
Observations on 9-24-18 between 12:32pm and 12:52 pm revealed:
1. The door of patient room 109 failed to latch.
2. The door of room 111 was warped and had an excessive gap at the top.
3. The oxygen storage room door (1B-234) had an excessive gap

During interviews on 9-24-18 between 12:32pm and 12:52 pm, Maintenance E confirmed the findings.

Based on observation and interview, the facility failed to maintain the smoke separation between smoke compartments of the first floor of the Bed Tower section of the building. This deficient practice would allow smoke and gases to migrate between all three smoke compartments. The facility is licensed for 129 with a census of 60 on the day of survey.

Findings are:
Observations on 9-24-18 between 2:19 pm and 2:31 pm revealed:
1. An unsealed penetration of the wall above the ceiling tile over door number 1A-591, the west smoke compartment doors from the center elevator.
2. An unsealed penetration around a data conduit above the ceiling tile over the smoke compartment door across from room 101

During interviews on 9-24-18 between 2:19 pm and 2:31 pm, Maintenance E confirmed the findings.

Based on observation and interview, the facility did not ensure that fire rated corridor separation doors would resist the passage of smoke from one compartment to another. This deficient practice would not prevent the spread of fire and smoke on the fourth floor in the Bed Tower and second floor West Campus. The facility has the capacity for 129 beds with a census of 60 on the day of survey.

Findings are:
Observation on 9-24-18 at 1:26 pm revealed, the gap between doors 403 failed to be smoke tight.

During interview on 9-24-18 at 1:26 pm, Maintenance Staff A confirmed the findings

Observation on 9-25-18 at 2:06 pm revealed, East door W2585 equipped with latching device failed to be smoke tight.

During an interview on 9-25-18 at 2:06 pm, Maintenance Staff A confirmed the findings.

Based on observation and interview, the facility allowed storage to obstruct access to the electrical disconnects boxes. This deficient practice could cause a delay and injury when turning off the power during an electrical issue emergency on the 2nd floor West Campus. The facility has the capacity for 129 beds with a census of 60 on the day of survey.

Findings are:
Observations on 9-25-18 at 1:57 pm revealed, items stored in front of three electrical panel boxes in the 2nd floor Missouri Room.

During an interview on 9-25-18 at 11: 1:27 pm, Maintenance Staff C confirmed the items stored in front of the electrical panel boxes.

NFPA Standard:
2011 NFPA 70, 110.26
Sufficient access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment.

Based on interview and record review, the facility failed to provide a complete fire evacuation plan. This deficient practice would delay evacuation and affected all occupants in all smoke compartments and floors. The facility has the capacity for 129 beds with a census of 60 on the day of survey.

Findings are:
Record review on 9-26-18, at 3:40 pm revealed:
1. The fire evacuation plan failed to include that evacuation shall not pass the smoke compartment or room where the fire originates.
2. The fire evacuation plan failed to include the removal of occupants above and below the area of fire origin.

During an interview on 9-26-18 at 3:40 pm, Maintenance Staff A confirmed the lack of specific evacuation.

Based on observation and interview, the facility allowed the use of portable electric space heaters on 4th floor on the Bed Tower and failed to provide documentation the heating element of the device did not exceed 212 degrees Fahrenheit. This deficient practice would increase the probability of a fire. The facility has the capacity for 129 beds with a census of 60 on the day of survey.

Findings are:
Observations on 9-24-18 at 12:57 pm revealed, a portable heating device sitting on a cardboard box under a desk in the IT area.

During an interview on 9-24-18 at 12:57 pm, Maintenance Staff A stated that the facility did not have the manufactures specification for the heaters and could not confirm the heating element of the device did not exceed 212 degrees Fahrenheit and that the heater was brought into the facility by staff.

NFPA Standard:
2012 NFPA 101, 19.7.8
Portable space heating devices shall be prohibited in all health care occupancies, unless both of the following criteria are met:
(1) Such devices are used only in nonsleeping staff and employee areas.
(2) The heating elements of such devices do not exceed 212°F (100°C).

A. Based on observation and interview, the facility failed to assure that electrical junction boxes were covered. This deficient practice increased the potential for electrical fire on 2nd floor in West Campus. The facility has the capacity for 129 beds with a census of 65 on the day of survey.

Findings are:
Observations on 9-25-18 at 2:27 pm revealed, an open electrical junction box in Mechanical Room W2MECH09, south of the light fixture.

During an interview on 9-25-18 at 2:27 pm, Maintenance Staff A confirmed the open junction box.


39858

B. Based on observation and interview, the facility failed to maintain the electrical system. This deficient practice has the capability of causing and electrical shock or fire. The facility is licensed for 129 with a census of 60 on the day of survey.

Findings are:
Observation on 9-24-18, at 2:31 revealed, a missing cover on an electrical junction box, with un-capped wires, above the ceiling tile by the door across from room 101 on the first floor of the Bell Tower.

During an interview on 9-24-18 at 2:31, Maintenance E confirmed the findings.

A. Based on observation and interview, the facility failed to prohibit the use of extension cords and power strips as a substitute for adequate wiring. This deficient practice would create electrical injury and increase the probability of a fire on 3rd and 4th floors in Bed Tower and 1st, 2nd floors in West Campus. The facility has the capacity for 129 beds with a census of 60 on the day of survey.

Findings are:
Observation on 9-24-18, between 12:43 pm and 2:07 pm on the 4th floor revealed:
1. A refrigerator and microwave plugged into an extension cord on the 4th floor in the construction storage area.
2. Power strips daisy chained at the Help Desk Tech southwest corner on 4th floor
3. Power strips daisy chained at the Help Desk Tech northwest corner on 4th floor
4. Power strips daisy chained at numerous IT desks on 4th floor
5. A refrigerator plugged into a power strip in Room 3A244.

During an interview on 9-24-18 between 12:43 pm and 2:07 pm, Maintenance Staff A confirmed the use of an extension cord and power strips daisy chained.

Observation on 9-25-18, between 2:28 pm and 3:17 pm on the 2nd floor West Campus Building. revealed:
6. A refrigerator plugged into a power strip in Room W2054.
7. A microwave plugged into a power strip in Room W2011.
8. A refrigerator and microwave plugged into a power strip in Quality Office.
9. Power strips daisy chained at the Quality reception desk W2026.
10. Power strips daisy chained outside Office coding W2050.
11. A refrigerator and microwave plugged into a power strip in W2030 Med. Staff Services.
12. Power strips daisy chained in W2038.

During an interview on 9-25-18, between 2:28 pm and 3:17 pm, Maintenance Staff A confirmed the use of power strips and power strips daisy chained.

Observation on 9-26-18, between 11:08 am and 2:17 pm on the 1st floor West Campus Building. revealed:
13. Extension cord and power strip used to power the Cathlab 1 operating table.
14. Power strip used to power Omni Machine in Storage Room A in the OR area.

During an interview on 9-26-18, between 11:08 am and 2:17 pm, Maintenance Staff A confirmed the extension cord and power strips.



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B. Based on observation and interview the facility failed to prohibit the use of electrical extension cords as a substitute for fixed permanent wiring, in the lower level of Bed Tower. This deficient practice could result in the failure of the electrical circuit that could result in a fire. The facility is licensed for 129 with a census of 60 on the day of survey.

Findings are:
Observations on 9-24-18 at 12:48 pm revealed, an extension cord which was attached to cable trays in the IT room next to the center elevator on the lower level of the bed tower. The cord ran through the wall to the outside of the room.

During an interview on 9-24-18 at 12:48 pm, Maintenance C confirmed the findings.

A. Based on observation and interview, the facility failed to post "Oxygen in Use, No Smoking" signs on rooms where oxygen was stored. The deficient practice would not alert persons entering the room to use extra caution with potential sources of ignition in the OR area West Campus. The facility has the capacity for 129 beds with a census of 60 on the day of survey.

Findings are:
Observation on 9-26-18 at 11:26 am revealed, no warning signage was posted on the oxygen storage room W1058.

During an Interview on 9-26-18 at 11:26 am, Maintenance Staff A confirmed that signage failed to be posted.

NFPA Standard:
2012 NFPA 101, 19.1.1.3.1
All health care facilities shall be designed, constructed, maintained, and operated to minimize the possibility of a fire emergency requiring the evacuation of occupants.

NFPA Standard:
2012 NFPA 99, 11.3.4.1
A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure.
11.3.4.2
The sign shall include the following wording as a minimum:
CAUTION:
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING




38543

B. Based on observation and interview the facility failed to provide signage on the doors of the oxygen storage rooms of the second floor of the bed tower. This deficient practice would not warn occupants of the oxidizing gas stored within the storage room. The facility has the capacity for 129 beds with a census of 60 on the day of survey.

Findings are:
Observations on 9-25-18 between 1:04 pm and 1:54 pm revealed:
1. The oxygen storage room across from patient room 226 did not have signage on the door to indicate that oxygen was stored within that room.
2. The oxygen storage room across from patient room 206 did not have signage on the door to indicate that oxygen was stored within that room.

During interviews on 9-25-18 between 1:04 pm and 1:54 pm, Maintenance B confirmed the findings.

NFPA 99
11.3.4.1 A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure.
11.3.4.2 The sign shall include the following wording as a minimum:

CAUTION:
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING