HospitalInspections.org

Based on observation, staff interview, and record review, the facility staff failed to provide continuously maintained exit ways free of all obstructions or impediments continuous to a public way such as a parking lot. This deficient practice affects four of thirteen exit discharge areas. This deficient practice has the potential to affect all patients, staff and visitors in the facility. Failure to ensure exterior exit ways comply with LSC requirements could delay evacuation out of the building in the event of a fire or other emergency. The facility census was 4.


1. Observation on 03/09/17, during the facility tour, showed the following hallway exit discharge areas led to a grass covered yard that required residents, staff, and visitors to traverse grass to reach the parking lot:

-designated exits #10, #11, #12, and #13 exterior doors on the north side of the building continuing 80 feet to the parking lot

Record review of the facility layout showed the exit discharge areas designated for resident use.

During an interview on 3/10/17 at 12:00 P.M., the Maintenance Lead said the building had a gravel walkway but it eroded and and grew over with grass.


The National Fire Protection Association 101, Life Safety Code 2012 Edition, section 7.7 states:


7.7 Discharge from Exits.

7.7.1* Exit Termination. Exits shall terminate directly, at a
public way or at an exterior exit discharge, unless otherwise
provided in 7.7.1.2 through 7.7.1.4.

Based on observation and facility staff interview, facility staff failed to provide emergency lighting inside two of two medication rooms This deficient practice has the potential to affect all patients, staff and visitors. Failure to provide emergency lighting could prevent proper illumination of required areas in the event of power loss. The facility census was 4.

1. Observations on 03/09/17, during the Life Safety Code (LCS) tour, showed the light fixtures in the medication room controlled by a light switch.

During an interview on 3/10/17 at 11:59 A.M., the Maintenance Lead said the medication room lights always had light switches and were installed during the building construction.

NFPA 101, 2012 edition, Section 7.9.2.7 states: "7.9.2.7 The emergency lighting system shall be either continuously in operation or shall be capable of repeated automatic
operation without manual intervention."

NFPA 99, 2012 edition, section 6.4.2.2.4.2 states:

"6.4.2.2.4.2 The critical branch shall supply power for task illumination,
fixed equipment, select receptacles, and select power
circuits serving the following areas and functions related to patient
care:
(1) Critical care areas that utilize anesthetizing gases, task illumination,
select receptacles, and fixed equipment
(2) Isolated power systems in special environments
(3) Task illumination and select receptacles in the following:
(a) Patient care rooms, including infant nurseries, selected
acute nursing areas, psychiatric bed areas (omit receptacles),
and ward treatment rooms
(b) Medication preparation areas
(c) Pharmacy dispensing areas
(d) Nurses ' stations (unless adequately lighted by corridor
luminaires)
(4) Additional specialized patient care task illumination and
receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7)*Telephone equipment rooms and closets
(8) Task illumination, select receptacles, and select power circuits
for the following areas:
(a) General care beds with at least one duplex receptacle
per patient bedroom, and task illumination as required
by the governing body of the health care facility
(b) Angiographic labs
(c) Cardiac catheterization labs
(d) Coronary care units
(e) Hemodialysis rooms or areas
(f) Emergency room treatment areas (select)
(g) Human physiology labs
(h) Intensive care units
(i) Postoperative recovery rooms (select)
(9) Additional task illumination, receptacles, and select power
circuits needed for effective facility operation, including
single-phase fractional horsepower motors, which are permitted
to be connected to the critical branch"

Based on observation and facility staff interview, facility staff failed to ensure cooking facilities are separated from the corridor. One of two doors to the combined kitchen/cafeteria was open to the corridor. Failure to ensure the kitchen was separated from the corridor increases the risk of delaying exiting from the building by not controlling the passage of smoke and products of combustion from the designated exit corridor in the event of a fire. This deficient practice has the potential to affect all patients, staff and visitors. The facility census was 4.

Observation on 3/09/17, during the building tour, showed the cafeteria door open to the corridor. Observation showed the cafeteria was open to the kitchen through one dirty tray pass thru window and one serving pass thru window. Observation showed the open cafeteria corridor door exposed the kitchen space to the corridor. Additional observation showed the kitchen oven/stove was gas fired.

During an interview on 3/10/17 at 11:55 A.M., the Maintenance Lead said the cafeteria door never had a closing device installed on it.

NFPA 101, 2012 edition, Section 19.3.2.5.5 states:

"19.3.2.5.5* Where cooking facilities are protected in accordance
with 9.2.3, the presence of the cooking equipment shall
not cause the room or space housing the equipment to be
classified as a hazardous area with respect to the requirements
of 19.3.2.1, and the room or space shall not be permitted to be
open to the corridor."

Based on record review and facility staff interview, facility staff did not ensure all devices connected to the fire alarm system were inspected and tested per NFPA 72, National Fire Alarm and Signaling Code, 2010 edition. This deficient practice has the potential to affect all patients, staff and visitors. Failure to inspect/test all components connected to the fire alarm system could delay emergency services response and evacuation out of the building in the event of a fire or other emergency. The facility census was 4.

Record review of the annual fire alarm inspection dated 10/10/2016 did not show inspections and connection function tests for the following:

-Air handler unit shutdown
-fire and smoke dampers
-magnetic hold open devices
-post indicator valve electronic supervision
-smoke detector sensitivity testing
-semi annual fire alarm testing

Record review of the annual fire alarm inspections for 2016 did not show smoke detector sensitivity testing for the facility smoke detectors.

During an interview on 3/10/2017 at 12:05 P.M., the Maintenance Lead said he believed the fire alarm inspection company did the inspections per code requirements.

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, Table 14.3.1, Table 14.4.2.2, Table 14.4.5, sections 14.4.5, 14.4.5.3.1 through section 14.4.5.4 for additional testing information.

Based on facility staff interview and record review, facility staff failed to inspect the wet sprinkler systems per NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition. This deficient practice has the potential to affect all patients, staff and visitors. Failure to inspect/test all components of the sprinkler system could prevent or delay activation of the sprinkler system in the event of a fire. The facility census was 4.

Record review on 03/09/2017 did not show the following inspections:

- annual backflow prevention devices serving the sprinkler system

- quarterly testing for the wet sprinkler system

During an interview on 03/10/2017 at 12:10 P.M., the Maintenance Lead said no quarterly sprinkler inspections or annual backflow inspections were available prior to June 20th, 2016 when the current Maintenance Lead started working at the facility.

Refer to NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition, Chapters 5 and 13 for additional information.

13.6 Backflow Prevention Assemblies.

13.6.1 Inspection. Inspection of backflow prevention assemblies
shall be as described in 13.6.1.1 through 13.6.1.2.2.

Based on observation and facility staff interview, facility staff failed to ensure corridor doors closed and latched without being blocked when 12 corridor doors had doorstops attached to the corridor door. This deficient practice has the potential to affect all patients, staff and visitors. Failure to ensure corridor doors were not blocked from closing and latching has the potential to prevent or delay evacuation out of the building in the event of a fire or other emergency by allowing smoke, fumes and the products of fire from entering the exit corridors in the event of a fire. The facility census was 4.

Observation on 3/08-09/2017, during the building tour, showed the following doors equipped with doorstops:

-two doors in Plant Operations
-one kitchen door
-three sets of corridor double door sets(two sets in cafeteria corridor and one in the emergency room)
-two doors in physical therapy
-one ultra sound room door

During an interview on 3/10/2017 at 12:02 P.M., the Maintenance Lead said he did not know when the doorstops were installed in the building.

19.3.6.3.10* Doors shall not be held open by devices other
than those that release when the door is pushed or pulled.

Based on observation and facility staff interview, facility staff failed to ensure transfer grills were not installed in corridors. This deficient practice has the potential to affect all patients, staff and visitors. Failure to ensure transfer grills were not installed in corridors has the potential to prevent or delay evacuation out of the building in the event of a fire or other emergency by allowing smoke, fumes and the products of fire from entering the exit corridors in the event of a fire. The facility census was 4.

Observation on 3/08-09/2017, during the building tour, showed the following transfer grills:

-Electrical closet between the cafeteria/kitchen

-Electrical room near the infusion room

During an interview on 3/10/2017 at 11:57 A.M., the Maintenance Lead said the transfer grills in the electrical rooms were installed during the hospital construction.

NFPA 101, 2012 edition, Section 19.3.6.4 states:

"19.3.6.4 Transfer Grilles.
19.3.6.4.1 Transfer grilles, regardless of whether they are
protected by fusible link-operated dampers, shall not be used
in corridor walls or doors."

Based on observation and facility staff interview, the facility staff failed to ensure the building ventilation system was installed according to NFPA 90B, Standard for the Installation of Warm Heating and Air-Conditioning and Ventilating Systems, 2012 edition and NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems, 2012 edition. The census was 4.

Observation on 3/09/17, during the building tour, showed a stand-alone room air conditioner in the medication room. Additional observation showed the warm air exhaust flexible duct penetrated the suspended ceiling and exhausted the air into the interstitial space between the ceiling and the roof.

During an interview on 3/09/17 at 11:58 A.M., the Maintenance Lead said he does not know when or why the portable air conditioning unit was installed in the nursing unit medication room.

NFPA 101, 2012 edition, Section 19.5.2 states:

"19.5.2 Heating, Ventilating, and Air-Conditioning.
19.5.2.1 Heating, ventilating, and air-conditioning shall comply
with the provisions of Section 9.2 and shall be installed in
accordance with the manufacturer ' s specifications, unless otherwise
modified by 19.5.2.2."

9.2 Heating, Ventilating, and Air-Conditioning.
9.2.1 Air-Conditioning, Heating, Ventilating Ductwork, and
Related Equipment. Air-conditioning, heating, ventilating
ductwork, and related equipment shall be in accordance with
NFPA 90A, Standard for the Installation of Air-Conditioning and
Ventilating Systems, or NFPA 90B, Standard for the Installation of
Warm Air Heating and Air-Conditioning Systems, as applicable, unless
such installations are approved existing installations,
which shall be permitted to be continued in service.

Refer to NFPA 90A, Standard for the Installation of Air-Conditioning and
Ventilating Systems, 2012 edition, Section 4.2.4 thru 4.2.4.2 and Section 4.3.3.1 for additional information.

Based on staff interview and record review, facility staff failed to conduct fire drills for three of four quarters reviewed. This deficient practice has the potential to effect all facility residents. Failure to hold drills could effect facility staff response in a fire or other emergency. The facility census was 4.

1. Record review on 03/09/17 of the facility fire drill records, showed the following fire drills were not conducted:

-first quarter of 2016
-second quarter of 2016
-fourth quarter 2016

During an interview on 03/09/17 at 3:27 P.M., the Maintenance Lead said he started at the hospital June 20th, 2016 and conducted the third quarter fire drill July 10th, 2016. He said he started to revise the fire drill policy and procedures and the fourth quarter 2016 fire was missed. Additionally, he said the drills previous to June 20th, 2016 were unavailable.

The National Fire Protection Association 101 Life Safety Code, 2012 edition, Section 19.7.1 states:

19.7.1 Evacuation and Relocation Plan and Fire Drills.

19.7.1.4* Fire drills in health care occupancies shall include
the transmission of a fire alarm signal and simulation of emergency
fire conditions.

19.7.1.5 Infirm or bedridden patients shall not be required
to be moved during drills to safe areas or to the exterior of the
building.

19.7.1.6 Drills shall be conducted quarterly on each shift to
familiarize facility personnel (nurses, interns, maintenance
engineers, and administrative staff) with the signals and emergency
action required under varied conditions.

19.7.1.7 When drills are conducted between 9:00 p.m. and
6:00 a.m. (2100 hours and 0600 hours), a coded announcement
shall be permitted to be used instead of audible alarms.

Based on record review and facility staff interview, the facility failed to ensure that all building systems had been assigned a risk assessment category and documented. The census was 4.

1. Review of the facility documents for fire safety, building system tests, and policies showed no assessment of the which systems were critical for patient safety.

2. During an interview on 03/10/17 at 12:15 PM, the Maintenance Lead said the facility started the process of doing the risk assessments but do not have categorical risk assessments for building systems.

Based on observation and facility staff interview, the facility failed to maintain their emergency power generator in accordance with the National Fire Protection Association (NFPA) 110, 2010 edition. The generator did not have an emergency stop switch remotely located away from the generator location. This deficient practice has the potential to affect all patients, staff and visitors. Failure to install the generator in accordance with NFPA standards increases the probability the generator will not function as designed in the event of a power outage. The facility census was 4.

Observation on 3/09/2017, during the facility tour, of the facility emergency generator showed the uncovered manual stop switch located outside the generator casing on the generator.

During an interview on 3/10/17, at 12:01 P.M., the Maintenance Lead said generator was installed during the construction of the hospital in 2006 and never had a remote stop switch.

NFPA 110 "Emergency and Standby Power Systems", 2010 edition, section 5.6.5.6 states: "5.6.5.6* All installations shall have a remote manual stop station
of a type to prevent inadvertent or unintentional operation located
outside the room housing the prime mover, where so installed,
or elsewhere on the premises where the prime mover is
located outside the building.

5.6.5.6.1 The remote manual stop station shall be labeled."