HospitalInspections.org

Based on the observation of all fire barrier doors on 02/10/2016 the facility failed to maintain fire barrier doors with a suitable means of closing the doors and providing fire protection rating. Findings include:

The right fire door did not latch upon activation of the fire alarm system near room 116 on the east corridor hall.

The deficiency impacted 2 of 5 smoke compartments.
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Based on observation of hazardous areas on 02/10/2016 the facility failed to maintain hazardous areas separation from other spaces by smoke-resisting partitions and self closing doors. Findings include:

The X-Ray Film Storage Room was observed with combustible storage and to be approximately 65 square feet. The door was not equipped with a self closing device.

The deficiency impacted 1 of 5 smoke compartments.
_______________
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Based on observation of all fire barriers on 02/09/2016 the facility failed to maintain fire barriers that would limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. Findings include:

The fire barrier in the X-Ray corridor near the hospital entrance was observed with a unsealed penetration around a group wires.

The deficiency affected 2 of 5 smoke compartments.
_______________

2000 NFPA 101, 19.2.2.5 and 7.2.4.3 Openings in fire barriers shall be constructed to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other.
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Based on observation of all exit signs on 02/10/2016 the facility failed to maintain exit signs per code. Findings include:

The exit signs in the CT Scan hallway and the exit sign at the administrations office exit was not continuously illuminated.

The deficiency impacted 2 of 5 smoke compartments.
______________
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Based on observation of the fire drill documentation on 02/10/2016 the facility failed to conduct fire drills per code. Findings include:

The 2-10 and the 3-11 shifts were not conducting fire drills at unexpected times (the times varied within one (1) hour on each quarter).

The deficiency impacted 5 of 5 smoke compartments.
_________________
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Based on observation of the automatic sprinkler system on 02/09/2016 the facility failed to maintain free of external loads by materials either resting on the pipe or hung from the pipe. Findings include:

Groups of blue computer wires was observed resting on the sprinkler branch lines in the ceiling above the x-ray waiting area.

The deficiency impacted 1 of 5 smoke compartments.
__________

NFPA 25, 2-2.2* Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
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Based on observation of all fire extinguishers on 02/09/2016 the facility failed to maintain one (1) fire extinguisher per code. Findings include:

The fire extinguishers located at the Nurses Station, Dinning Room and OR Suite was mounted at approximately 6'-0" above finished floor.

The deficiency affected 3 of 5 smoke compartments.
_______________

1998 NFPA 10, 1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 31/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).
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Based on observation on 02/09/2016 the facility failed to maintain smoking regulations per code. Findings include:

Excessive amounts of cigarette butts was observed on the grounds around the E.R. entrance and the oxygen storage area.
_________________
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Based on observation on 02/09/2016 the facility failed to maintain the cooking facilities per code. Findings include:

The placard for the K fire extinghuisher was observed missing near the portable fire extinguisher in the cooking area.

The deficiency affected 1of 5 smoke compartments.
_______________

1998 NFPA 96, 7-2.1.1 A placard identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system shall be conspicuously placed near each portable fire extinguisher in the cooking area.
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Based on documentation provide on 02/10/2016, the facility failed to maintain the piped in medical gas system per the codes in which this system was installed.

Per documentation provided by maintenance staff, from the medical gas company there were several deficiencies written during the last inspection on 08/26/2015 that have not been corrected as of this survey date. These deficiencies include, but are not limited to:
1. Oxygen outlet leaking
2. Vacuum outlet leaking
3. Missing labels
4. Any other items that would have been required at the time of installation of this system.
_________

Review of 2000 NFPA 101, 4.2.3 Systems Effectiveness.
Systems utilized to achieve the goals of Section 4.1 shall be effective in mitigating the hazard or condition for which they are being used, shall be reliable, shall be maintained to the level at which they were designed to operate, and shall remain operational.

Review of 1999 NFPA 99, 4-3.5.2.3 Patient Gas Systems - Level 1.
(a) * Piping systems shall not be used for the distribution of flammable anesthetic gases.
(b) Nonflammable medical gas systems used to supply gases for respiratory therapy shall be installed in accordance with 4-3.1 of this chapter.
(c) Maintenance programs in accordance with the manufacturers ' recommendations shall be established for the medical air compressor supply system as connected in each individual installation.
(d) * The responsible authority of the facility shall establish procedures to ensure that all signal warnings are promptly evaluated and that all necessary measures are taken to reestablish the proper functions of the medical gas system.
(e) Piping systems for gases shall not be used as a grounding electrode.
(f) The facility shall have the capability and organization to implement a plan to cope with a complete loss of any medical gas system.
(g) A periodic testing procedure for nonflammable medical gas and related alarm systems shall be implemented.
(h) The test specified in 4-3.4.1.3(i) shall be conducted on the downstream portions of the medical gas piping system whenever a system is breached or whenever modifications are made or maintenance performed.
(i) * Periodic retesting of audible and visual alarm indicators shall be performed to determine that they are functioning properly, and records of the test shall be maintained until the next test.
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Based on the observation on 02/10/2016 of the emergency room the facility failed to maintain emergency lighting.

In the emergency room two battery operated emergency lights did not function when tested.

This deficiency impacted 1 of 5 smoke compartments.
__________________

1999 NFPA 110, 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.
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Based on observation on 02/09/2016 the facility failed to meet the requirements for the operation of the generator. Findings include:

During testing of the generator, when the auto-run-off switch was placed in the 'off' position, there was no alarm and detection system provided.

The deficiency affected 5 of 5 smoke compartments.
_______________
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NFPA 99.3-4.1.1.15 + Alarm Annunciator.
A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]

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Based on observation on 02/10/2016 the facility failed to maintain the electrical equipment. Findings include:

1. Above the ceiling in the drug room an electrical junction box was observed missing its cover.

2. In the laundry room a refrigerator and a clothes dryer was observed plugged into a surge protector (extension cord).

3. In the respiratory therapy office a refrigerator was observed plugged into a surge protector (extension cord).

4. The electrical panel room in the medical records office was observed with open spaces in 2 boxes.

The deficiency impacted 4 of 5 smoke compartments.
_________

1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.
1999 NFPA 70, 370-28.(c) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use.

Based on the observation of all fire barrier doors on 02/10/2016 the facility failed to maintain fire barrier doors with a suitable means of closing the doors and providing fire protection rating. Findings include:

The right fire door did not latch upon activation of the fire alarm system near room 116 on the east corridor hall.

The deficiency impacted 2 of 5 smoke compartments.
_______________
.

.
Based on observation of hazardous areas on 02/10/2016 the facility failed to maintain hazardous areas separation from other spaces by smoke-resisting partitions and self closing doors. Findings include:

The X-Ray Film Storage Room was observed with combustible storage and to be approximately 65 square feet. The door was not equipped with a self closing device.

The deficiency impacted 1 of 5 smoke compartments.
_______________
.

.
Based on observation of all fire barriers on 02/09/2016 the facility failed to maintain fire barriers that would limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. Findings include:

The fire barrier in the X-Ray corridor near the hospital entrance was observed with a unsealed penetration around a group wires.

The deficiency affected 2 of 5 smoke compartments.
_______________

2000 NFPA 101, 19.2.2.5 and 7.2.4.3 Openings in fire barriers shall be constructed to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other.
.

.
Based on observation of all exit signs on 02/10/2016 the facility failed to maintain exit signs per code. Findings include:

The exit signs in the CT Scan hallway and the exit sign at the administrations office exit was not continuously illuminated.

The deficiency impacted 2 of 5 smoke compartments.
______________
.

.
Based on observation of the fire drill documentation on 02/10/2016 the facility failed to conduct fire drills per code. Findings include:

The 2-10 and the 3-11 shifts were not conducting fire drills at unexpected times (the times varied within one (1) hour on each quarter).

The deficiency impacted 5 of 5 smoke compartments.
_________________
.

.
Based on observation of the automatic sprinkler system on 02/09/2016 the facility failed to maintain free of external loads by materials either resting on the pipe or hung from the pipe. Findings include:

Groups of blue computer wires was observed resting on the sprinkler branch lines in the ceiling above the x-ray waiting area.

The deficiency impacted 1 of 5 smoke compartments.
__________

NFPA 25, 2-2.2* Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
.

.
Based on observation of all fire extinguishers on 02/09/2016 the facility failed to maintain one (1) fire extinguisher per code. Findings include:

The fire extinguishers located at the Nurses Station, Dinning Room and OR Suite was mounted at approximately 6'-0" above finished floor.

The deficiency affected 3 of 5 smoke compartments.
_______________

1998 NFPA 10, 1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 31/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).
.

.
Based on observation on 02/09/2016 the facility failed to maintain smoking regulations per code. Findings include:

Excessive amounts of cigarette butts was observed on the grounds around the E.R. entrance and the oxygen storage area.
_________________
.

.
Based on observation on 02/09/2016 the facility failed to maintain the cooking facilities per code. Findings include:

The placard for the K fire extinghuisher was observed missing near the portable fire extinguisher in the cooking area.

The deficiency affected 1of 5 smoke compartments.
_______________

1998 NFPA 96, 7-2.1.1 A placard identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system shall be conspicuously placed near each portable fire extinguisher in the cooking area.
.

.
Based on documentation provide on 02/10/2016, the facility failed to maintain the piped in medical gas system per the codes in which this system was installed.

Per documentation provided by maintenance staff, from the medical gas company there were several deficiencies written during the last inspection on 08/26/2015 that have not been corrected as of this survey date. These deficiencies include, but are not limited to:
1. Oxygen outlet leaking
2. Vacuum outlet leaking
3. Missing labels
4. Any other items that would have been required at the time of installation of this system.
_________

Review of 2000 NFPA 101, 4.2.3 Systems Effectiveness.
Systems utilized to achieve the goals of Section 4.1 shall be effective in mitigating the hazard or condition for which they are being used, shall be reliable, shall be maintained to the level at which they were designed to operate, and shall remain operational.

Review of 1999 NFPA 99, 4-3.5.2.3 Patient Gas Systems - Level 1.
(a) * Piping systems shall not be used for the distribution of flammable anesthetic gases.
(b) Nonflammable medical gas systems used to supply gases for respiratory therapy shall be installed in accordance with 4-3.1 of this chapter.
(c) Maintenance programs in accordance with the manufacturers ' recommendations shall be established for the medical air compressor supply system as connected in each individual installation.
(d) * The responsible authority of the facility shall establish procedures to ensure that all signal warnings are promptly evaluated and that all necessary measures are taken to reestablish the proper functions of the medical gas system.
(e) Piping systems for gases shall not be used as a grounding electrode.
(f) The facility shall have the capability and organization to implement a plan to cope with a complete loss of any medical gas system.
(g) A periodic testing procedure for nonflammable medical gas and related alarm systems shall be implemented.
(h) The test specified in 4-3.4.1.3(i) shall be conducted on the downstream portions of the medical gas piping system whenever a system is breached or whenever modifications are made or maintenance performed.
(i) * Periodic retesting of audible and visual alarm indicators shall be performed to determine that they are functioning properly, and records of the test shall be maintained until the next test.
.

.
Based on the observation on 02/10/2016 of the emergency room the facility failed to maintain emergency lighting.

In the emergency room two battery operated emergency lights did not function when tested.

This deficiency impacted 1 of 5 smoke compartments.
__________________

1999 NFPA 110, 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.
.

.
Based on observation on 02/09/2016 the facility failed to meet the requirements for the operation of the generator. Findings include:

During testing of the generator, when the auto-run-off switch was placed in the 'off' position, there was no alarm and detection system provided.

The deficiency affected 5 of 5 smoke compartments.
_______________
.
NFPA 99.3-4.1.1.15 + Alarm Annunciator.
A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]

.
Based on observation on 02/10/2016 the facility failed to maintain the electrical equipment. Findings include:

1. Above the ceiling in the drug room an electrical junction box was observed missing its cover.

2. In the laundry room a refrigerator and a clothes dryer was observed plugged into a surge protector (extension cord).

3. In the respiratory therapy office a refrigerator was observed plugged into a surge protector (extension cord).

4. The electrical panel room in the medical records office was observed with open spaces in 2 boxes.

The deficiency impacted 4 of 5 smoke compartments.
_________

1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.
1999 NFPA 70, 370-28.(c) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use.