HospitalInspections.org

Based on observations and interviews it was determined that the facility failed to maintain integrity of smoke separations. This resulted in the potential for smoke to spread to other areas of the facility, causing the exposure of residents & staff to hazardous products of fire (LSC 18.3.6.1, .2, .5). Findings include, but are not limited to:

1. On March 9, 2011 at 12:25 pm, an unsealed ceiling penetration was found near a fire sprinkler pipe in the OR Recovery.

Based on observations, record review and interviews it was determined that the facility failed to maintain exit corridor doors to resist the passage of smoke in accordance with NFPA 80. This resulted in the potential for passage of smoke into the means of egress in the event of a hostile fire event (LSC 18.2.3.5, Table 18.3.2.1, 18.3.6.3, 4.6.12.1). Findings include, but are not limited to:

1. On March 9, 2011 at 11:53 am, there was a door prop on an office at the outpatient registration.

2. On March 9, 2011 at 12:34 pm, there was a door prop on the housekeeping door in LDRP.

3. On March 9, 2011 at 12:40 pm, the 1999 edition of NFPA 80 was not available on site for maintenance, testing, & inspecting of fire doors.

4. On March 9, 2011 at 12:40 pm, records indicated that the Pharmacy Fire Door was past due for annual inspection. The last recorded inspection was on August 3, 2009.

Based on observations, interview and record review it was determined that the facility failed to properly identify exits. This resulted in the potential for panic and confusion during an evacuation (LSC 18.7.1.1). Findings include, but are not limited to:

1. On March 9, 2011 at 11:51 am, the exit sign next to the gift shop indicated an incorrect orientation directing occupants through a narrow door.

Based on observations, interviews and record review it was determined that the facility failed to maintain emergency action plan current & readily available. This resulted in the potential for limited staff effectiveness during emergency conditions (LSC 18.7.1.1). Findings include, but are not limited to:

1. On March 9, 2011 at 1:46 pm, a review of the facility's disaster manual revealed the following deficiencies: there was no procedure for defend in place, the fire safety plan indicated to evacuate residents in rooms adjoining the fire area if they were in danger of fire or smoke and referenced to "see pg. 11" (pg. 11 is staff staging leader), and there was no directions to notify OSFM of a fire in the facility.

Based on record reviews and interviews it was determined that the facility failed to provide fire drills for all staff. This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing residents to smoke and fire in the facility (LSC 18.7.1.2, A.18.7.1.2). Findings include, but are not limited to:

1. On March 9, 2011 at 12:40 pm, records indicated that the swing shift did not perform a fire drill during the second quarter of 2010.

2. On March 9, 2011 at 12:40 pm, records indicated that the fire drill forms were not being filled out completely and many drills were listed as coded during the day.

3. On March 9, 2011 at 12:40 pm, records indicated that a roster was not kept to record which staff members were participating in fire drills and in-service training.

Based on observations, record review and interviews it was determined that the facility failed to install fire alarm system in accordance with NFPA 72. This resulted in the potential for system and device failure during fire emergencies (LSC 18.3.4, 9.6). Findings include, but are not limited to:

1. On March 9, 2011 at 10:53 am, there was no smoke detector installed above the main fire alarm control panel.

2. On March 9, 2011 at 11:03 am, a fire alarm junction box at the main fire sprinkler riser was not painted red.

3. On March 9, 2011 at 11:33 am, the fire alarm pull station mounted next to the Respiratory Therapy room was mounted higher than 54-inches.

4. On March 9, 2011 at 11:37 am, there was no smoke detector at the Ward Clerk Nurse's Station.

5. On March 9, 2011 at 11:40 am, the fire alarm pull station mounted next to room 136 was found to be mounted higher than the adopted standards.

6. On March 9, 2011 at 11:51 am, the fire alarm pull stations located by the display case and outpatient registration areas were found to be mounted higher than the adopted standards and were not at an exit.

7. On March 9, 2011 at 12:01 pm, the fire alarm pull stations located in the kitchen and at the ED entrance were found to be mounted higher than adopted standards.

8. On March 9, 2011 at 12:07 pm, the fire alarm pull station located in the ED was found to be mounted higher than 54-inches.

9. On March 9, 2011 at 12:15 pm, the fire alarm pull station located in the basement of the ED was found to be mounted higher than the adopted standards.

10. On March 9, 2011 at 1:07 pm, there was a fire alarm strobe in the OR.

Based on observations, record review and interviews it was determined that the facility failed to test and maintain fire alarm in accordance with NFPA 72. This resulted in the potential for system and device failure during fire emergencies (LSC 4.6.12.1, 9.6.1.4, NFPA 70, NFPA 72). Findings include, but are not limited to:

1. On March 9, 2011 at 12:40 pm, it was found that the 1999 edition of NFPA 72 standard used for maintaining the fire alarm system was not available on site.

Based on observations and interview it was determined that the facility failed to ensure that there was complete sprinkler coverage in accordance with NFPA 13 for all portions of the building. This resulted in the potential for sprinkler failure and for uncontrolled fire progression in the event of a fire (LSC 18.3.5.1, NFPA 13 5-6.3.3, .4, NFPA 25). Findings include, but are not limited to:

1. On March 9, 2011 at 10:30 am, there were intermixed types of fire sprinkler heads (quick response and standard) found to be installed at the Administration reception desk and Marketing.

2. On March 9, 2011 at 10:50 am, the air compressor serving the dry fire sprinkler system was found to have a shutoff switch installed.

3. On March 9, 2011 at 11:53 am, a light was found to be blocking the spray pattern of a fire sprinkler head outside the outpatient entrance.

4. On March 9, 2011 at 12:30 pm, the LDRP closets in room 206 did not have fire sprinkler coverage.

Based on observations, record review and interviews it was determined that the facility failed to ensure that sprinkler system is continuously maintained & in reliable operating condition. This resulted in the potential for system failure during fire emergencies (LSC 4.6.12.1, NFPA 13 3-2.91, .2, .3, NFPA 25 9.6.2.1, .2 & 8.17.4.6). Findings include, but are not limited to:

1. On March 9, 2011 at 10:56 am, painted fire sprinkler heads were found by the Data Room at the water fountain in the corridor.

2. On March 9, 2011 at 11:02 am, there were no spare sidewall fire sprinkler heads.

3. On March 9, 2011 at 11:16 am, there was a painted fire sprinkler head found in the corridor by room 121.

4. On March 9, 2011 at 12:00 pm, a fire sprinkler head was found to be obstructed in the walk in cooler.

5. On March 9, 2011 at 12:40 pm, it was found that the 1999 edition of NFPA 25 was not available on site for the maintenance of the fire sprinkler system.

6. On March 9, 2011 at 12:40 pm, it was found that the fire sprinkler contractor did not complete a forward flow test of the system including a graph of pressure and gallons per minute for the system demand and available water when annual maintenance was performed on November 5, 2010.

Based on observations and interview it was determined that the facility failed to maintain fire extinguishers. This resulted in the potential for fires to progress beyond incipient stage (LSC 18.3.5.6, 4.6.12.1, 9.7.4.1, NFPA 10). Findings include, but are not limited to:

1. On March 9, 2011 at 11:43 am, two fire extinguishers were found to be mounted higher than 60-inches by Physical Therapy in the main hall.

2. On March 9, 2011 at 12:16 pm, the fire extinguisher mounted in the Transfer Switch Room was found to be higher than 60-inches.

3. On March 9, 2011 at 12:29 pm, a fire extinguisher in the LDRP area was found to be mounted higher than 60-inches.

4. On March 9, 2011 at 12:40 pm, it was found that the 1998 edition of NFPA 10 was not available on site for the maintenance of fire extinguishers.

Based on observations, record review and interviews it was determined that the facility failed to ensure that exit egress remained clear & unobstructed to the constructed clear width with no projections exceeding 6" up to 80" above the floor. This resulted in the potential for impeding full instant use of the exit system in case of fire or other emergency (LSC 7.1.10, S&C). Findings include, but are not limited to:

1. On March 9, 2011 at 11:12 am, chairs, a scale and lifts were found to be stored within the 8-foot corridor width by rooms 121 and 123.

2. On March 9, 2011 at 11:30 am, a recliner was found to be stored in the corridor by room 116.

Based upon observations and interviews it was determined that the facility failed to ensure that no storage of highly flammable character existed in the corridors. This resulted in the potential for excessive fire spread (LSC 18.7.5.5, Exhibit 18.23). Findings include, but are not limited to:

1. On March 9, 2011 at 11:14 am, a linen cart exceeding 32-gallons in size was found by room 120.

2. On March 9, 2011 at 11:29 am, there was a linen cart exceeding 32-gallons in size by room 116.

Based on observations, record review and interviews it was determined that the facility failed to provide safe storage for compressed gas (for light switch in oxygen storage room/ref. NFPA 99, A-4-3.1.1.2(a)2 #4). This resulted in the potential for damage to electrical switches and receptacles during the movement of oxygen tanks (LSC 18.3.2.4, 4.3.1.1.2). Findings include, but are not limited to:

1. On March 9, 2011 at 12:29 pm, an oxygen tank was found to be unsecured in the Mammogram area.

2. On March 9, 2011 at 12:38 pm, the med gas room was found not labeled and cylinders were improperly secured.

Based on observations, record review and interviews it was determined that the facility failed to provide proper labeling for compressed gas. This resulted in the potential for harm to patients if the incorrect zone was shut down (NFPA 99, Ch. 4). Findings include, but are not limited to:

1. On March 9, 2011 at 12:03 pm, a medical gas valve was found without a label for the zone that it was serving at the ED corridor.

Based on observations, record review and interviews it was determined that the facility failed to properly maintain the generator. This resulted in the potential for the lack of emergency electrical power (LSC 4.6.12.1, NFPA 110, NFPA 99, 3.4.4.1, 6.4.2) Findings include, but are not limited to:

1. On March 9, 2011 at 12:16 pm, the generator annunciator was not located at a constantly attended location.

2. On March 9, 2011 at 12:17 pm, there was no battery-powered emergency lights found at the Transfer Switch and Control Panel.

3. On March 9, 2011 at 12:18 pm, the diesel tank serving the generator was found to have a vent that measured less than 12-feet above grade.

4. On March 9, 2011 at 12:40 pm, the facility did not have access to the 1999 edition of NFPA 110 on site for the proper maintenance of the generator.

Based on observations, record review and interviews it was determined that the facility failed to ensure that electrical wiring & equipment was used/maintained and in accordance with NFPA 70. This resulted in the potential for injury to residents & staff (NFPA 70 550.13 (B), 9.1.2, NEC 110-3.8). Findings include, but are not limited to:

1. On March 9, 2011 at 10:45 am, relocatable power taps were being used in lieu of permanent wiring in the Training Room and Offices throughout the facility per interview with the Maintenance Director.

2. On March 9, 2011 at 11:22 am, a microwave rated for household use was found in the Family Room by room 126.

3. On March 9, 2011 at 11:25 am, a relocatable power tap was found in the pharmacy.

4. On March 9, 2011 at 11:32 am, multiple relocatable power taps were connected in the Respiratory Therapy Office.

5. On March 9, 2011 at 11:34 am, the oxygen storage room across from the Respiratory Therapy room contained electrical fixtures within 60-inches of the floor and had no sign indicating that it was an oxygen storage room.

6. On March 9, 2011 at 11:35 am, room 111 in the ICU contained a relocatable power tap that was not approved for patient use.

7. On March 9, 2011 at 11:38 am, the oxygen storage by room 120 contained electrical fixtures within 60-inches of the floor.

8. On March 9, 2011 at 12:10 pm, a relocatable power tap was found at a computer in the ED.

9. On March 9, 2011 at 12:08 pm, a 3-to-1 electrical outlet adapter was found at the ED desk.

10. On March 9, 2011 at 11:45 am, a household-rated microwave was found in Conference Room and the IT Room.

11. On March 9, 2011 at 12:23 pm, an extension cord was found to be serving the television in the Doctor's Lounge by the ORs.

12. On March 9, 2011 at 12:24 pm, a relocatable power tap and household-rated microwave were found in the Doctor's Lounge by the ORs.

13. On March 9, 2011 at 12:25 pm, a non-patient-rated relocatable power tap was found in the OR Recovery Room.

14. On March 9, 2011 at 12:27 pm, a household-rated microwave was found in Mammogram & LDRP Nourishment.

15. On March 9, 2011 at 1:07 pm, a non-patient-rated relocatable power tap was found in the OR.

Based on record review and interviews it was determined that the facility failed to have a plan to address either a planned or unplanned fire sprinkler system shutdown that identified their procedures to follow when the fire sprinkler system was unavailable. This potentially prevents early notification of smoke &/or fire that delays evacuation of residents/patients & staff to a safe refuge. Findings include, but are not limited to:

1. On March 9, 2011 at 12:40 pm, records indicated that OSFM was not notified that the facility was on fire watch for the fire sprinkler system.

Based on record review and interviews it was determined that the facility failed to have a plan to address either a planned or unplanned fire alarm system shutdown that identified their procedures to follow when the fire alarm system was unavailable. This potentially prevents early notification of smoke &/or fire that delays evacuation of residents/patients & staff to a safe refuge. Findings include, but are not limited to:

1. On March 9, 2011 at 12:40 pm, records indicated that OSFM was not notified when the facility was in fire watch for the fire alarm system.

Based on observations and interviews it was determined that the facility failed to install alcohol gel hand sanitizing dispensing stations away from sources of ignition and a minimum of 4' spacing between dispensers. This resulted in the potential for injury to residents and staff (LSC 18.3.2.7, CFR 403.744, 418.100, 460.72, 482.41, 483.70, 486.623, 485.623). Findings include, but are not limited to:

1. On March 9, 2011 at 11:18 am, an alcohol hand gel dispenser was found to be adjacent to an electrical switch by room 120.

2. On March 9, 2011 at 12:10 pm, an alcohol hand gel dispenser was found to be adjacent to an electrical device in the emergency department.