HospitalInspections.org

Based on observations made during the survey for life safety from fire with the facility's Physical Plant Manager, it was determined that the facility failed to ensure that corridors are separated from use areas by walls constructed to provide at least 30 minutes of fire resistance at the electric room located near patient's room #313 as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.3.6.1, 19.3.6.2.1 and 19.3.6.5.

Findings include:

During the observational tour for life safety from fire, all rooms located at corridors were visited with the Physical Plant Manager (employee #5) on 4/22/10 at 1:50 pm. The storage room (located next to patient's room #313) has another room located at the back of this room (electric room). This electric room has circuit breaker panels and electrical tubing. The electrical tubing that supplies electricity to the patient care area was found passing through the wall above the door of this room over the drop ceiling of the storage room that was not sealed to prevent the passage of smoke into the storage room. Also, the wall of the storage room that separates it from the corridor has electrical tubing penetrations which will also allow smoke into the corridor through the drop ceiling.

Based on tests to doors and observations made during the survey for life safety from fire with the facility's Physical Plant Manager, it was determined that patient's doors protecting corridors at rooms #303 and #304 do not close completely (do not latch) as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.3.6.3.

Findings include:

During the tour for life safety from fire on 4/22/10 at 9:15 am, patient's sleeping room doors were tested with the Physical Plant Manager (employee #5) and it was found that patient's sleeping rooms #303 and #304 do not latch when the doors were closed, this can permit smoke, fire and noxious gases to enter the rooms in the event of a fire. All doors at the facility shall be verified at least monthly and appropriate documentation should be available upon request.

Based on tests to doors and observations made during the survey for life safety from fire with the facility's Physical Plant Manager, it was determined that smoke barriers between patient ' s rooms #304 and #305 and near the physical therapy department do not latch closed when released from their hold open devices as required by the 2000 edition of the Life Safety Code of the NFPA Sections 19.3.7.3 and 19.3.7.5.

Findings include:

During the tour for life safety from fire, patient's sleeping rooms were observed on 4/22/10 from 8:30 am till 10:30 am with the Physical Plant Manager (employee #5), it was found that the smoke barriers doors between patient ' s sleeping rooms #304 and #305 and near the physical therapy department do not latch closed when released from their hold open devices, this can permit smoke, fire and noxious gases to enter the rooms in the event of a fire.

Based on tests and observations made during the survey for life safety from fire with the facility's Physical Plant Manager, it was determined that the facility failed to ensure that emergency lighting (battery operated lamps) which provides light for a period of 90 minutes, enabling those inside to move about safely in the hallways near the patient ' s rooms, exit doors and medication preparation room as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.9.

Findings include:

1. The facility lacks emergency battery operated lamps (EBOL) for a period of 90 minutes as determined by the observational tour with the Physical Plant Manager (employee #5) on 4/22/10 from 8:30 am till 2:00 pm in the following areas:
a. In the hallways where patient ' s rooms are located.
b. In the hallway near the lunch room.
c. In the hallway near the biohazardous trash room and family member ' s waiting room.
d. In the small areas between the exit doors in the hallway and the exit doors of the stairs.
e. In the medication preparation room.
f. In the exit staircase of exit #5.
(Emergency lamps are required to ensure adequate lighting until the essential electrical system (generator) turns on or in the event that the essential electrical system fails as required since March of 2006).

Based on observations made during the survey for life safety from fire with the facility's Physical Plant Manager, it was determined that the facility failed to ensure that a written plan was found at the nursing station for staff to follow with respect to their duties in the event of an emergency as required by the 2000 edition of the Life Safety Code of the NFPA Section 18.7.1.1.

Findings include:

No evidence was found on 4/23/10 at 10:30 am that personnel have a plan or assignments with specific tasks in the event of an emergency (for example: extinguisher use, circuit breaker shut off, oxygen valve shut off, placing patients in their rooms, closing patient ' s room doors, etc). All personnel trained related to emergency procedures must be instructed related to their assignments and periodically tested for its implementation and the assignment must be posted for review by staff.

Based on the review of written documents related to conducted fire drills during the survey for life safety from fire with the facility's Physical Plant Manager, it was determined that the facility failed to ensure that fire drills are conducted under varying conditions related to initial fire location, early rate of growth in the fire severity and smoke generation as required by LSC 2000 section 5.5.

Findings include:

1. Written documents about conducted fire drills for the hospital were reviewed with the Physical Plant Manager (employee #5) on 4/22/10 at 3:35 pm and provided evidence that fire drill documentation does not include evidence that they are performed under varying conditions related to:
a. Initial fire location.
b. Early rate of growth in the fire severity.
c. Smoke generation.
LSC 2000 section 5.5 has eight "Design Fire Scenarios" that should be considered to comply with the above. Fire drills provide opportunities to improve on tasks during emergency and hurried events and should be used to constantly improve.

Based on observations made during the survey for life safety from fire with the facility's Physical Plant Manager, it was determined that the facility failed to ensure that smoke detectors are available in a maintenance closet and housekeeping closet of the kitchen, oxygen storage room, lack of fire alarm system documentation related to sensitivity tests and the fire alarms does not automatically notify the alarm to an approved central station in accordance with the applicable requirements of NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Findings include:

1. Smoke detectors connected to the fire alarm panel are needed in the following areas as observed with the Physical Plant Manager (employee #5) on 4/22/10 from 8:30 am till 3:00 pm:
a. The maintenance closet used by physical plant employees to store equipment and paint at exit #5.
b. The housekeeping closet at the kitchen.
c. In the oxygen storage room.

2. The facility has an outside company that services the fire alarm system and they provide the facility with a certification once a year as evidenced on 4/23/10 at 1:30 pm with the Physical Plant Manger (employee #5), however no evidence was found of the smoke detectors ' sensitivity tests.

3. The fire alarm system of the facility lacks annunciation to an approved central station as reviewed on 4/23/10 at 1:40 pm with the Physical Plant Manager (employee #5). The fire alarm system must be arranged to transmit an alarm automatically via a central station to alert the municipal fire department and fire brigade.

Based on observations made during the survey for life safety from fire with the facility's Physical Plant Manager, it was determined that the facility failed to ensure that portable fire extinguisher are available in required areas, in sufficient numbers and with appropriate instructions as required by the 2000 edition of the Life Safety Code of the NFPA Section 9.7.4.1 and NFPA 10.

Findings include:

1. During observations made of the hospital with the Physical Plant Manager (employee #5) on 4/23/10 from 8:30 am till 3:30 pm, the following was determined related to fire extinguishers:
a. Fire extinguishers located in the hallways of the patient care area are separated by more than 80 feet from each other.
b. Fire extinguishers are located in locked rooms such as the biohazardous waste room.
c. The fire extinguisher at the patient ' s lunch room was at the back of the room even though the microwave was located near the front of the room close to the door.
d. The instruction labels on the fire extinguishers related to their use is only in "English" and not in "Spanish" the predominant language spoken in Puerto Rico.

Based on observations made during the survey for life safety from fire with the facility's Physical Plant Manager, it was determined that the facility failed to ensure that a fire extinguishing sprinkler is located above the fryer in the off-site contracted kitchen as required by the 2000 edition of the Life Safety Code of the NFPA Section 18.3.2.6 and NFPA 96.

Findings include:

During observations made of the off-site contracted kitchen with the facility's Physical Plant Manager (employee #5) on 4/23/10 at 9:00 am, a double fryer was found near the stoves without coverage of a fire extinguishing sprinkler.

Based on observations made during the survey for life safety from fire with the facility's Physical Plant Manger, it was determined that the facility failed to monitor means of egress at exit staircases #3 and #5 related to rocks and dirt on steps and water at the internal stairs in accordance with the 2000 edition of the Life Safety Code of the NFPA Section 7.1.10.1.

Findings include:

1. Exit staircase #3 was observed on 4/23/10 at 12:15 pm with dampness seeping through the walls that caused the walls, handrails and steps to be wet and slippery. The slipperiness of the stairs and handrails is an impediment to the use of this staircase. "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".

2. Exit staircase #5 was observed on 4/22/10 at 11:15 am with rocks and dirt on the steps. "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".

Based on observations made during the survey for life safety from fire with the facility's Physical Plant Manger, it was determined that the facility failed to ensure that medical gas storage is in accordance with NFPA 99 Section 4.3.1.1.

Findings include:

1. When oxygen cylinders are stored in the facility the area where they are stored must be an appropriate area as stated in the National Fire Protection Association (NFPA) 99, 1999 edition, section 4-3.1.1.2. However, during the observational tour of the entire facility on 4/22/10 from 8:30 am till 3:30 pm with the facility's Physical Plant Manager (employee #5), type H and Type E oxygen cylinders were found in a closet located in the hallway between patient's rooms #313 and #314 that do not meet minimum requirements related to:
a. The room does not have a smoke detector.
b. The room does not have an extractor.
c. The door does not have a door closer.
d. An electrical receptacle is lower than five feet in height (measured from the floor).
e. The walls of this room does not connect to the ceiling above.

Based on observations during the survey for Life safety from fire with the facility's Physical Plant Manager, it was found that this facility does not comply with other Life Safety Code requirements not in CMS-2786-S related to procedures to follow in the event of a fire in the kitchen, safety officer needs training and fire hoses and fire extinguishers need signage when not visible from the hallway.

Findings include:

1. Life safety training was requested of the Physical Plant Manager (employee #5) on 4/23/10 at 1:45 pm. In order to perform life safety duties according to state law #117 from 11/7/99, the safety officer (in this facility the Physical Plant Manager) must have the following training and education that were not provided:
a. Fire prevention and control.
b. How to deal with emergencies and disasters.
c. How to handle dangerous materials and substances.
d. Knowledge related to laws, codes and federal and state regulations for health care facilities and safety.

2. The facility has fire hoses and fire extinguishers that are located in areas that are not visible from the hallway as observed with the facility's Physical Plant Manager (employee #5) on 4/22/10 from 8:30 am till 3:30 pm. A sign in the hallway that can be seen from both directions of the hallway are needed near the fire hoses and fire extinguishers to ensure that they can be found by anyone in the even of a fire.

3. Cooking personnel (employee #24) at the off-site contracted kitchen failed to know exact procedures to following in the event of a fire as determined on 4/23/10 at 9:30 am.

4. Fire extinguisher documentation was reviewed with the facility's Physical Plant Manager (employee #5) on 4/23/10 from 10:30 am and provided evidence of a monthly check list, but did not include what is performed to test them.

Based on observations and documents reviewed during the survey for life safety from fire with the facility's Physical Plant Manager, it was determined that the facility failed to test electrical receptacles that are supplied by the essential electrical system at least twice a year in accordance with NFPA 99 Section 7-6.2.1.2.

Findings include:

Written evidence reviewed on 4/23/10 at 11:05 am with the Physical Plant Manager (employee #5) related to preventive maintenance to the receptacles indicates that they are testing the receptacles supplied by the generator once a year. However, receptacles that are supplied by the essential electrical system (generator) supply power to critical care equipment (cardiac monitors and other life support equipment). Equipment or wiring faults can cause abnormal temperature increases, these abnormal temperatures may cause fire and explosions. Areas where other life support equipment are plugged into the essential electrical receptacles are required to be tested in intervals not exceeding six months because even brief interruptions of power can cause malfunctions of some equipment and appliances. The six month and annual tests must be performed by a qualified electrician and the varied tests that are performed must be documented and handed to the facility.