HospitalInspections.org

During the survey tour of 03/31/2015, between the hours of 1230 and 1630, while accompanied by the Maintenance Manager, through observation and staff interview, it was discovered that the facility has failed to maintain the construction requirements for the classification of construction. The facility has a Type II (III) classification by NFPA 220. This has the potential for the spread of smoke and fire into the structure in the event of a fire. These findings were acknowledged by the Maintenance Manager.

The findings include but are not limited to:

Two penetrations were discovered in the wall of the autoclave boiler room (surgery).
· Corrected during survey

Based upon a record review and staff interviews during the survey of 04/01/2015, between the hours of 1000 and 1045, while accompanied by the Plant Operator, it is discovered that the facility has failed to maintain a written plan for the protection of all residents and for their evacuation in the event of an emergency in accordance with the Life Safety Code. At a minimum a written health care occupancy fire safety plan shall provide for the following:

1. Use of Alarms
2. Transmission of alarms to fire department
3. Response to Alarms
4. Isolation of the Fire
5. Evacuation of the immediate area
6. Evacuation of smoke compartment
7. Preparation of floors and building for evacuation
8. Extinguishment of fire

This could lead to the inability of staff to safely evacuated residents and visitors in the event of an emergency. This finding was acknowledged by the Plant Operator.

The findings include but are not limited to:

1. There is no documentation of annual review of the Disaster Plan.
2. The plan exists in fragmented form in several documents, some of which are quite dated. Plan needs to be updated to incorporate all the topics necessary for all emergency responses and evacuation in a manner whereby staff can readily access this information.

Based upon a review of the facility fire drill records and staff interview with the Maintenance Manager during the record review portion of the facility survey of 03/31/2015, between the hours of 0945 and 1200, it was discovered that the facility has failed to conduct fire drills for staff. This could result in staff ' s failure to provide for the safety of patients and visitors through a failure to respond to a fire emergency in accordance with the facility ' s published fire procedures. These findings were acknowledged by the Maintenance Manager.

The findings are as follows:

1. Swing Shift - missing 2nd & 3rd Quarters 2014.
2. Night Shift - missing 3rd Quarter 2014.

Based upon staff interview, observation and record review during the survey of the facility on 03/31/2015, between the hours of 0945 and 1200, while accompanied by the Maintenance Manager, it was discovered that the facility has failed to maintain the automatic fire sprinkler system in a reliable operating condition as required by NFPA 25. This could result in a failure of the proper operation of the automatic fire sprinkler system with the potential of fire spreading unchecked, placing patients, visitors and staff at risk. This finding was acknowledged by the Maintenance Manager.

The findings include but are not limited to:

1. The AFSS is overdue for 5 year testing (last completed 05/2007).

During the survey tour of 04/01/2015, between the hours of 1030 and 1130, while accompanied by the Surgery Supervisor and the Maintenance Manager, through record review, observation and staff interview, it was discovered that the facility has failed to protect medical gas administration areas in accordance with NFPA 99. This could result in ignition of flammable gases or oxidizers, placing staff and patients at risk. These findings were acknowledged by the Surgery Supervisor and the Maintenance Manager.

The findings include but are not limited to:

1. The hospital's ORs utilizing general anesthesia routinely falls below 35%.

2. The OR written policy on humidity does not address the low end humidity level.

During the survey tour of 03/31/2015, between the hours of 1230 and 1630, while accompanied by the Maintenance Manager, through observation and staff interview, it was discovered that the facility failed to maintain their emergency generator in accordance with the requirements of National Fire Protection Association (NFPA) Standard 110. This could compromise the ability of the emergency power supply to be shut down safely in the event of a generator malfunction, placing staff at risk. These findings were acknowledged by the Maintenance Manager.

The findings are as follows:
1. Generator(s) are lacking a Remote Stop Switch (per NFPA 110 3-5.5.6)

During the survey tour of 03/31/2015, between the hours of 1230 and 1630, while accompanied by the Maintenance Manager, through observation and staff interview, it was discovered that the facility has failed to maintain the construction requirements for the classification of construction. The facility has a Type II (III) classification by NFPA 220. This has the potential for the spread of smoke and fire into the structure in the event of a fire. These findings were acknowledged by the Maintenance Manager.

The findings include but are not limited to:

Two penetrations were discovered in the wall of the autoclave boiler room (surgery).
· Corrected during survey

Based upon a record review and staff interviews during the survey of 04/01/2015, between the hours of 1000 and 1045, while accompanied by the Plant Operator, it is discovered that the facility has failed to maintain a written plan for the protection of all residents and for their evacuation in the event of an emergency in accordance with the Life Safety Code. At a minimum a written health care occupancy fire safety plan shall provide for the following:

1. Use of Alarms
2. Transmission of alarms to fire department
3. Response to Alarms
4. Isolation of the Fire
5. Evacuation of the immediate area
6. Evacuation of smoke compartment
7. Preparation of floors and building for evacuation
8. Extinguishment of fire

This could lead to the inability of staff to safely evacuated residents and visitors in the event of an emergency. This finding was acknowledged by the Plant Operator.

The findings include but are not limited to:

1. There is no documentation of annual review of the Disaster Plan.
2. The plan exists in fragmented form in several documents, some of which are quite dated. Plan needs to be updated to incorporate all the topics necessary for all emergency responses and evacuation in a manner whereby staff can readily access this information.

Based upon a review of the facility fire drill records and staff interview with the Maintenance Manager during the record review portion of the facility survey of 03/31/2015, between the hours of 0945 and 1200, it was discovered that the facility has failed to conduct fire drills for staff. This could result in staff ' s failure to provide for the safety of patients and visitors through a failure to respond to a fire emergency in accordance with the facility ' s published fire procedures. These findings were acknowledged by the Maintenance Manager.

The findings are as follows:

1. Swing Shift - missing 2nd & 3rd Quarters 2014.
2. Night Shift - missing 3rd Quarter 2014.

Based upon staff interview, observation and record review during the survey of the facility on 03/31/2015, between the hours of 0945 and 1200, while accompanied by the Maintenance Manager, it was discovered that the facility has failed to maintain the automatic fire sprinkler system in a reliable operating condition as required by NFPA 25. This could result in a failure of the proper operation of the automatic fire sprinkler system with the potential of fire spreading unchecked, placing patients, visitors and staff at risk. This finding was acknowledged by the Maintenance Manager.

The findings include but are not limited to:

1. The AFSS is overdue for 5 year testing (last completed 05/2007).

During the survey tour of 04/01/2015, between the hours of 1030 and 1130, while accompanied by the Surgery Supervisor and the Maintenance Manager, through record review, observation and staff interview, it was discovered that the facility has failed to protect medical gas administration areas in accordance with NFPA 99. This could result in ignition of flammable gases or oxidizers, placing staff and patients at risk. These findings were acknowledged by the Surgery Supervisor and the Maintenance Manager.

The findings include but are not limited to:

1. The hospital's ORs utilizing general anesthesia routinely falls below 35%.

2. The OR written policy on humidity does not address the low end humidity level.

During the survey tour of 03/31/2015, between the hours of 1230 and 1630, while accompanied by the Maintenance Manager, through observation and staff interview, it was discovered that the facility failed to maintain their emergency generator in accordance with the requirements of National Fire Protection Association (NFPA) Standard 110. This could compromise the ability of the emergency power supply to be shut down safely in the event of a generator malfunction, placing staff at risk. These findings were acknowledged by the Maintenance Manager.

The findings are as follows:
1. Generator(s) are lacking a Remote Stop Switch (per NFPA 110 3-5.5.6)