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Based on record review, observation and interview; the facility failed to ensure 3 of 7 means of egress were continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. This deficient practice could affect patients, staff and visitors in the post-anesthesia care unit (PACU) and staff in the sterile processing unit.

Findings include:

During a tour of the facility with the Chief Operations Officer on 11/20/19 from 9:00 a.m. to 12:00 p.m. the following conditions were found:
a) At 9:30 a.m. the two West exit doors from the PACU did not open without excessive force. Based on interview at the time of observation, the Chief Operations Officer did not know when or how often the doors are exercised to ensure reliable operation. Additionally, she agreed that the doors would impede evacuation from the PACU.
b) At 9:57 a.m. the exit door from the sterile processing room was blocked by a cart of surgical implements. Based on interview at the time of observation, the Chief Operations Officer agreed that the cart obstructed the means of egress.

Based on observation and interview, the facility failed to ensure 1 of 1 electrical equipment room door was only held open by a release device complying with LSC 7.2.1.8.2 that automatically closes such doors upon activation of the fire alarm system. This deficient practice could affect all staff only.

Findings include:

During a tour of the facility with the Chief Operations Officer on 11/20/19 at 10:40 a.m. the door to the Automatic Transfer Switch room which was in a Fire Barrier with a 1-hour Fire Resistance Rating, was found propped open with a metal wedge. Based on interview at the time of observation, the Chief Operations Officer confirmed the wedge hold open device did not release with the fire alarm.

Based on observation, the facility failed to protect 1 of 10 corridors in accordance with LSC Section 19.2.3.4(4). LSC 19.2.3.4(4) states that projections into the required width shall be permitted for wheeled equipment, provided that all of the following conditions are met:
(a) The wheeled equipment does not reduce the clear unobstructed corridor width to less than 60 in.(1525 mm).
(b) The health care occupancy fire safety plan and training program address the relocation of the wheeled equipment during a fire or similar emergency.
(c)*The wheeled equipment is limited to the following:
i. Equipment in use and carts in use
ii. Medical emergency equipment not in use
iii. Patient lift and transport equipment
This deficient practice could affect staff and up to 5 patients in the operating rooms.

Findings include:

During a tour of the facility with the Chief Operations Officer on 11/20/19 at 9:51 a.m., boxes of surgical deliveries were stacked in the corridor outside of the operating room locker rooms. Based on interview at the time of observation, the OR manager agreed that the deliveries were not wheeled and obstructed the path of egress.

Based on observation and interview, the facility failed to ensure 13 of 14 battery-operated emergency lights annual testing was properly documented in accordance with LSC 19.2.9.1. Section 19.2.9.1 states that emergency lighting shall be provided in accordance with Section 7.9. Section 7.9.3.1.1 (1) requires 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, (3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered and (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect all occupants in the facility.

Findings include:

During record review with the Chief Operations Officer on 11/19/19 at 12:32 p.m., Battery Operated Emergency Light Test Logs did not provide itemized testing documentation by location or device number. Additionally, the documentation did not indicate correct testing parameters. Monthly testing was to be 3 or 30 seconds in duration, and annual testing was to be 90 seconds or 1.5 hours in duration. Based on interview at the time of record review, the Chief Operations Officer agreed that the documentation was not itemized and the testing parameters was not specific.

Based on record review, observation, and interview, the facility failed to maintain emergency lighting in 5 of 5 operating rooms where general anesthesia is administered in accordance with NFPA 99. NFPA 99, Health Care Facilities Code, 2012 Edition, Section 6.3.2.2.11.1 states one or more battery-powered lighting units shall be provided within locations where deep sedation and general anesthesia is administered. The lighting level of each unit shall be sufficient to terminate procedures intended to be performed within the operating room. The sensor for units shall be wired to the branch circuit(s) serving general lighting within the room. Units shall be capable of providing lighting for 90 minutes and shall be tested monthly for 30 seconds and annually for 30 minutes. Section 3.3.17 defines battery-powered lighting units as individual unit equipment for backup illumination consisting of a rechargeable battery, battery-charging means, provisions for one or more lamps mounted on the equipment, or with terminals for remote lamps, or both, and relaying device arranged to energize the lamps automatically upon failure of the supply to the unit equipment. This deficient practice could affect 5 patients and staff in operating rooms where general anesthesia or life support equipment is used.

Findings include:

During record review with the Chief Operations Officer on 11/19/19 at 12:32 p.m., Battery Operated Emergency Light Test Logs did not provide itemized testing documentation by location or device number. Documentation provided, documented testing by operating room number, not by specific battery operated emergency light. Based on interview at the time of record review, an employee of the electrical contractor, who conducted the testing, stated that each operating room had more than 1 battery operated emergency light. Additionally, the documentation did not indicate correct testing parameters. Monthly testing was to be 3 or 30 seconds in duration, and annual testing was to be 90 seconds or 1.5 hours in duration. Based on interview at the time of record review, the Chief Operations Officer agreed that the documentation was not itemized and the testing parameters was not specific.

1) Based on record review, observation and interview; the facility failed to ensure 1 of 1 kitchen fire suppression system was inspected semiannually. NFPA 96, 2011 Edition, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, Section 11.2.1 states Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices. Hood exhaust plenums, and the exhaust ducts shall be made by properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction at lease every six months. This deficient practice could affect staff and visitors in the kitchen.

Findings include:

Based on review of the vendor documentation with the Chief Operations Officer on 11/19/19 at 12:47 p.m. documentation indicated the kitchen hood suppression system was inspected on 04/03/19, and then on 11/07/19. Based on interview at the time of record review, the Chief Operations Officer agreed that the inspections were greater than six months apart.

2) Based on record review, observation and interview; the facility failed to ensure 1 of 1 kitchen exhaust systems was inspected semiannually. NFPA 96, 2011 Edition, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, Section 11.4 states the entire exhaust system shall be inspected for grease buildup by a properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction and in accordance with Table 11.4. Table 11.4, Schedule for Inspection for Grease Buildup, requires systems serving moderate volume cooking operations shall be inspected semiannually. NFPA 96, 11.6.1 states, upon inspection, if the exhaust system is found to be contaminated with deposits from grease laden vapors, the contaminated portions of the exhaust system shall be cleaned by a properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction. Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to remove combustible contaminants prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned, it shall not be coated with powder or other substance. When an exhaust cleaning service is used, a certificate showing the name of the servicing company, the name of the person performing the work, and the date of inspection or cleaning shall be maintained on the premises. This deficient practice could affect staff and visitors in the kitchen.

Findings include:

Based on review of the vendor documentation with the Chief Operations Officer on 11/19/19 at 12:47 p.m. documentation indicated the kitchen hood ventilation system was inspected on 02/05/19, and then on 11/11/19. Based on interview at the time of record review, the Chief Operations Officer agreed that the inspections were greater than six months apart.

Based on observation and interview, the facility failed to ensure materials used as an interior finish in the lobby and on the walls of 3 of 3 Data Rooms had a flame spread rating of Class A or Class B in accordance with 19.3.3.1. LSC 10.2.3.4 states products required to be tested in accordance with ASTM E 84, Standard Test Method for Surface Burning Characteristics of Building Materials or ANSI/UL 723, Standard for Test for Surface Burning Characteristics of Building Materials shall be grouped in the following classes in accordance with their flame spread and smoke development.
(a) Class A Interior Wall and Ceiling Finish. Flame spread 0-25; smoke development 0-450. Includes any material classified at 25 or less on the flame spread test scale and 450 or less on the smoke test scale. Any element thereof, when so tested, shall not continue to propagate fire.
(b) Class B Interior Wall and Ceiling Finish. Flame spread 26-75; smoke development 0-450. Includes any material classified at more than 25 but not more than 75 on the flame spread test scale and 450 or less on the smoke test scale.
(c) Class C Interior Wall and Ceiling Finish. Flame spread 76-200; smoke development 0-450. Includes any material classified at more than 75 but not more than 200 on the flame spread test scale and 450 or less on the smoke test scale. This deficient practice could affect all building occupants.

Findings include:

During a facility tour with the Chief Operations Officer on 11/20/19 between 9:00 a.m. and 12:00 p.m. the lobby was found to have wood paneling on the walls. Based on interview, the Chief Operations Officer stated she could not provide documentation regarding the flame spread of the paneling. Additionally, she stated that the paneling had previously been treated with flame retardant, however could not provide documentation regarding the type, or the date of application. Then, three data rooms were found to have oriented strand board (OSB) on the walls behind the telecommunications equipment. The wood had been painted over. Based on interview at the time of observation, the Chief Operations Officer stated that she could not provide documentation regarding the flame spread of the oriented strand board.

Based on record review and interview, the facility failed to maintain 1 of 1 fire alarm systems in accordance with NFPA 72, as required by LSC 101 Sections 19.3.4.5.1 and 9.6. NFPA 72, Section 14.3.1 states that unless otherwise permitted by 14.3.2, visual inspections shall be performed in accordance with the schedules in Table 14.3.1, or more often if required by the authority having jurisdiction. Table 14.3.1 states that the following must be visually inspected semi-annually:
a. Control unit trouble signals
b. Remote annunciators
c. Initiating devices (e.g. duct detectors, manual fire alarm boxes, heat detectors, smoke detectors, etc.)
d. Notification appliances
e. Magnetic hold-open devices
This deficient practice could affect all building occupants.

Findings include:

During record review with the Chief Operations Officer on 11/19/19 at 11:30 a.m., no documentation could be provided regarding a visual semi-annual fire alarm system inspection. Based on interview at the time of record review, the Chief Operations Officer agreed that visual semi-annually inspections of the fire-alarm system were not completed on a semi-annual basis.

Based on observation, and interview, the facility failed to protect 1 of 1 Fire Pump Room in accordance with NFPA 20, Standard for the Installation of Stationary Pumps for Fire Protection (2010). Section
4.12.2.1 states that access to the fire pump room shall be pre-planned with the fire department and Section 4.12.2.1.1 states that Fire pump rooms not directly accessible from the outside shall be accessible through an enclosed passageway from an enclosed stairway or exterior exit. The enclosed passageway shall have a minimum 2-hour fire-resistance rating. This deficient finding affects all building occupants.

Findings include:

During a tour of the facility with the Chief Operations Officer on 11/20/19 at 10:25 a.m. it was found that the Fire Pump Room was located in an isolated room protected by a Fire Wall with a 2-Hour Fire Resistance Rating. However, the Pump Room was not accessible from the outside, and was not accessible through an enclosed passageway from an enclosed stairway or exterior exit. Entry to the Fire Pump Room was only possible through a Supply Room with combustible storage. Based on interview at the time of observation, the Chief Operations Officer confirmed the supply room was the only access to the Fire Pump Room.

1) Based on record review and interview, the facility failed to document sprinkler system inspections in accordance with NFPA 25. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.4.1 states gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained. Section 5.1.2 states valves and fire department connections shall be inspected, tested, and maintained in accordance with Chapter 13. Section 13.1.1.2 states Table 13.1.1.2 shall be utilized for inspection, testing and maintenance of valves, valve components and trim. Section 4.3.1 states records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request. This deficient practice could affect all patients, staff, and visitors.

Findings include:

Based on review of the fire sprinkler vendor documentation for the most recent twelve month period with the Chief Operations Officer during record review from 10:00 a.m. to 2:15 p.m. on 11/19/19 the following was found:
a) Monthly wet sprinkler system gauge inspection documentation for 10 months of the most recent 12 month period was not available for review. In addition, monthly inspection documentation for all sprinkler system control valves for 10 months of the most recent 12 month period was not available for review.
b) Gauge and valve inspection documentation was not itemized for 2 of 2 months. Based on record review, the facility had four sprinkler zones. Documentation stated "Gauges: Passed and Valves: Passed" Based on interview at the time of record review, the Chief Operations Officer agreed that the documentation for 10 of the most recent 12 months was not available, as it was not recorded, and agreed that documentation for the most recent 2 months, which were recorded, was not itemized.

2) Based on observation and interview, the facility failed to ensure the spray pattern for sprinklers were not obstructed in 1 of 1 storage rooms in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, and NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, as required by LSC 19.3.5.1. NFPA 25 Section 5.2.1.2 states the minimum clearance required by the installation standard shall be maintained below all sprinkler deflectors. Section 5.2.1.3 states stock, furnishings, or equipment closer to the sprinkler deflector than permitted by the clearance rules of the installation standard shall be corrected. NFPA 13, 2011 edition, Section 8.5.5.1 states sprinklers shall be located so as to minimize obstructions to discharge as defined in 8.5.5.2 and 8.5.5.3 or additional sprinklers shall be provided to ensure adequate coverage of the hazard. Sections 8.5.5.2 and 8.5.5.3 do not permit continuous or noncontinuous obstructions less than or equal to 18 inches below the sprinkler deflector or in a horizontal plane less than 18 inches below the sprinkler deflector that prevent the spray pattern from fully developing. This deficient practice could affect staff only.

Findings include:

During a facility tour with the Chief Operations Officer on 11/20/19 at 9:35 a.m. storage was found within 18 inches of a sprinkler in the Radiology storage room. The storage was measured to be 18 inches from the base of the concealed sprinkler cover plate. Based on interview at the time of observation, the Chief Operations Officer stated that the sprinkler, when activated, drops 1.5 inches, resulting in only 16.5 inches to the obstruction. This was confirmed by the Chief Operations Officer, who agreed with the measurement, at the time of observation.

3) Based on observation and interview, the facility failed to maintain the ceiling construction in one area throughout the facility. The ceiling tiles trap hot air and gases around the sprinkler and cause the sprinkler to operate at a specified temperature. NFPA 13, 2010 edition, 8.5.4.11 states the distance between the sprinkler deflector and the ceiling above shall be selected based on the type of sprinkler and the type of construction. This deficient practice could affect all staff and visitors in the kitchen.

Findings include:

During a tour of the facility with the Chief Operations Officer on 11/20/19 at 9:46 a.m. a 4 inch by 4 inch penetration was found in the suspended ceiling lay-in panels around conduits in the kitchen. This was confirmed by the Chief Operations Officer at the time of observation.

Based on observation and interview, the facility failed to maintain 1 of 1 fire extinguisher in the Sterile Processing room in accordance with NFPA 10, Standard for Portable Fire Extinguisher (2010). NFPA 10, Section 6.1.3.1 states that fire extinguishers shall be conspicously located where they are redily accessible and immediately available in the event of a fire. Section 6.1.3.3.1 states that fire extinguishers shall not be obstructed or obscured from view. This deficient practice affects staff only.

Findings include:

During a facilty tour with the Chief Operations Officer on 11/20/19 at 9:17 a.m. a fire extinguisher in the Sterile Processing room was blocked by a surgical cart. Based on interview at the time of observation, the Chief Operations Officer agreed the fire extinguisher was not readily accessible.

Based on observation and interview, the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 2 of 2 smoke barrier walls were protected to maintain the smoke resistance of each smoke barrier. LSC Section 19.3.7.3 requires smoke barriers to be constructed in accordance with LSC Section 8.5. 8.5.6.3 states that where a smoke barrier is also constructed as a fire barrier, the penetrations shall be protected in accordance with the requirements of 8.3.5. 8.3.5.1 states that penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device. The fire stop system or device shall be tested in accordance with ASTM E 814, Standard Test Method for Fire Tests of Through Penetration Fire Stops, or ANSI/UL 1479, Standard for Fire Tests of Through-Penetration Firestops. This deficient practice could affect all building occupants.

Findings include:

Based on observations with the Chief Operations Officer on 11/20/19 between 11:18 a.m. and 12:00 p.m. the following penetrations were found:
a) At 11:18 a.m. a 1 X 2 inch unsealed penetration was found between drywall above the lay-in ceiling near the east post-anesthesia care unit southeast door.
b) At 11:21 a.m. an unsealed penetration in a 2-inch stubbed out conduit was found above the lay-in ceiling tile in the corridor south east of the post-anesthesia care unit.
c) At 11:25 a.m. an unsealed penetration in a 1-inch stubbed out conduit was found above the lay-in ceiling tile in the corridor northeast of the Operating Room doors.
d) At 11:27 a.m. 2 unsealed penetration in 1-inch stubbed out conduits was found above the lay-in ceiling tile near the staff lounge.
e) At 11:33 a.m. a 3 x 12 inch unsealed penetration was found above the Sterile Processing room rolling fire door where drywall had been removed.
f) At 11:38 a.m. an unsealed penetration in a 2-inch stubbed out conduit was found above the lay-in ceiling tile near the hospitality room; a 1 x 6 inch unsealed penetration was found above the lay-in ceiling tile where drywall had been removed around a conduit near the hospitality room; a 1 x 1 inch unsealed penetration around a structural 'L' bracing above the lay-in ceiling tile near the hospitality room.
g) At 11:53 a.m. an unsealed penetration in a 2-inch stubbed out conduit was found above the lay-in ceiling tile near the inpatient hospitality room. Based on interview at the time of observations, the Chief Operations Officer confirmed penetrations were in the smoke barriers and agreed with the measurements. It was noted that findings a through e were corrected prior to the facility exit on the same date.

Based on record review, observation, and interview, the facility failed to provide a complete facility specific written fire safety plan for the protection of 18 of 18 patients to accurately address all life safety systems, plus a system addressing all items required by NFPA 101, 2012 edition, Section 19.7.2.2. LSC 4.8.2.1(3) requires evacuation procedures appropriate to the building, its occupancy, emergencies and hazards. LSC 19.7.2.2 requires a written health care occupancy fire safety plan that shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire
This deficient practice could affect all occupants in the event of an emergency.

Findings include:

Based on a review of the fire plan 11/19/19 at 10:40 a.m. with the Chief Operations Officer present, the deficiencies were identified:
a) The fire plan did not address the use of alarms or transmission of alarm to the fire department.
b) The fire plan did not identify smoke compartment doors completely. Based on observation, the facility had cross-corridor doors that were not in smoke compartment barriers. During interview at time of observation, a facility nurse with two years employment, mis-identified which cross-corridor doors would complete smoke compartment evacuation and stated she was not trained on which doors were part of smoke barriers and would offer protection.
c)The fire plan did not address the preparation of floors and building for evacuation. The plan states that access to all exits are free and unobstructed. During the subsequent tour, a portable x-ray machine was located in a means of egress.
Based on interview at the time of record review and observation, the Chief Operations Officer agreed that the fire plan was not complete.

Based on record review and interview, the facility failed to conduct at least 2 of 12 quarterly shift fire drills during the most recent 12 month time period. LSC 19.7.1.6 requires drills to be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with signals and emergency action required under varied conditions. This deficient practice affects all staff, visitors, and patients.

Findings include:

During record review with the Chief Operations Officer on 11/19/19 at 10:52 a.m., the facility provided documentation of fire drills, however it was incomplete. The facility was unable to document that all facility personnel were involved in quarterly fire drills. Based on interview at the time of record review, the Chief Operations Officer stated that the inpatient nursing staff operates on a 12 hour shift, from 7:00 a.m. to 7:00 p.m. and then from 7:00 p.m. to 7:00 a.m. There were no fire drills between 7:00 p.m. and 7:00 a.m. during the first quarter (January, February, and March) of 2019, and as of the date of survey, no fire drills between 7:00 p.m. and 7:00 p.m. for the fourth quarter (October, November, December) of 2018 or 2019. Additionally, Urgent Care staff operate from 9:00 a.m. to 9:00 p.m., and dietary and administative staff work from 7:00 a.m. to 3:30 p.m. and 8:00 a.m. to 4:30 p.m. respectively. During the second quarter (April, May, and June) and third quarter (July, August, and September) of 2019, there were no fire drills conducted between 6:30 a.m. and 10:30 p.m. Based on interview at the time of record review, the Chief Operations Officer agreed that fire drills were not conducted to ensure that all staff are trained in fire response actions. Additionally, it was found that during the first quarter fire drills, Urgent Care signed off as a unit, as opposed to individual employees. Based on inteview, the Chief Operations Officer agreed it could not be determined which employees were involved in the fire drills.

Based on observation, records review, and interview, the facility failed to ensure 19 of 68 fire door assemblies were maintained in accordance of LSC 19.1.1.4.1.1 Communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire door assemblies. (See also Section 8.3.) LSC 8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code. NFPA 80 5.2.1 states fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ. NFPA 80, 5.2.4.1 states fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly.

NFPA 80, 5.2.4.2 states as a minimum, the following items shall be verified:
(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.
This deficient practice could affect all occupants.

Findings include:

During record review with the Chief Operations Officer on 11/19/19 at 12:16 p.m., vendor provided documentation indicated that during the annual inspection of the fire door assemblies on 10/16/19, 19 of 68 doors were found to be non-compliant. Based on interview at the time of record review, the Chief Operations Officer stated they had provided the inspection results to the facility door vendor for solutions, however was unable to provide any additional documentation regarding quotes or provided solutions.

Based on observation, record review, and interview, the facility failed to maintain 1 of 1 piped gas system in accordance with NFPA Health Care Facilities Code requirement at Section 99 5.1.14.4.8 which states that audible and visual alarm indicators shall meet the following requirements:
(1) Tested periodically to determine that they are functioning properly
(2) Records of the test shall be maintained until the next test is performed.
This deficent practice could affect all patients on piped medical gases.

Findings include:

During a facility tour with the Chief Operations Officer on 11/20/19 at 9:33 a.m. when requested, the Chief Operations Officer and staff nurses were unable to test the remote alarm panel of the piped medical gas systems and were not aware that the panel could be tested. Additionally, the Chief Operations Officer stated that the testing of the remote alarm panels should be conducted during monthly Periodic Maintenance. During document review the previous day, 11/19/19, the only documentation provided regarding testing or maintenance of piped medical gases was the annual test and inspection dated 07/02/19.

Based on record review and interview, the facility failed to ensure 1 of 1 emergency generators was allowed a 5 minute cool down period after a load test. Chapter 6.4.4.1.1.4(a) of 2012 NFPA 99 requires monthly testing of the generator serving the emergency electrical system to be in accordance with NFPA 110, the Standard for Emergency and Standby Powers Systems, Chapter 8. NFPA 110, 6.2.10 Time Delay on Engine Shutdown requires that a minimum time delay of 5 minutes shall be provided for unloaded running of the Emergency Power Supply (EPS) prior to shutdown. This delay provides additional engine cool down. This time delay shall not be required on small (15 kW or less) air-cooled prime movers. This deficient practice could affect all patients, as well as staff and visitors in the facility.

Findings include:

Based on record review with the Chief Operations Officer on 11/20/19 at 9:00 a.m., the generator log form documented the generator was tested monthly for at least 30 minutes under load, however, there was no documentation on the form that showed the generator had a cool down time following its load test. Based on interview at the time of record review, the Chief Operations Officer agreed the generator cool down was not documented. Record review indicated the facility had a 600 kW rated generator.

Based on observation and interview, the facility failed to ensure 1 of 1 MRI office flexible cords were not used as a substitute for fixed wiring. LSC 9.1.2 requires electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code. NFPA 70, 2011 Edition, Article 400.8 requires that, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice affects staff and up to 1 patient in the MRI room.

Findings include:

During a tour of the facility with the Chief Operations Officer on 11/20/19 at 9:16 a.m. a surge protector was found powering a microwave in the MRI office. Based on interview at the time of each observation, the Chief Operations Officer confirmed the improper use of a surge protector.