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Based on document review, interview and observation, the facility failed to maintain the battery back up emergency lighting. This was evidenced by the failure to provide emergency lights and receptacles in one area, and by no documentation for testing and maintenance of the emergency lights. This affected 6 of 6 smoke compartments on the 1st floor, 1 of 2 smoke compartments on the 2nd floor and 1 of 1 smoke compartments in the basement. This has the potential to delay egress from the facility in the event of an emergency.

NFPA 101, Life Safety Code, 2000 Edition
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performers a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During document review on March 27, 2012, the documentation for the testing and maintenance of the battery operated (bullfrog type) emergency lights was requested. The facility failed to provide documentation for monthly and annual testing for the emergency lights. During record review on 7/13/12, there were no records for monthly testing for the emergency lights prior to 3/27/12.

During the facility tour on 7/13/12, the GI lab area was observed. The facility has discontinued use of the GI lab area until completion of the electrical project that will provide emergency lighting in all areas in the event of a power failure. A waiver was requested until 12/31/12, for time to obtain OSHPD approvals and completion of the electrical project. The electrical project includes wiring for emergency outlets and emergency battery back up lights in all anesthetizing areas. Refer to the deficiency K147.

Based on document review and interview, the facility failed to maintain, the dampers, as evidenced by the failure to inspect and maintain all dampers and repair dampers when they failed. This affected 6 of 6 smoke compartments on the 1st floor, 2 of 2 smoke compartments on the 2nd floor and the basement. This could result in the spread of smoke and flames from one smoke compartment to another.


NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 edition
3-4.7 Maintenance. At least every 4 years, fusible links (where
applicable) shall be removed; all dampers shall be operated to
verify that they fully close; the latch, if provided, shall be
checked; and moving parts shall be lubricated as necessary.

Findings:

On March 29, 2012, at 1:45 p.m., the Fire Damper Report, dated 6/5/2007, was reviewed during the recertification survey. The facility failed to provide a current maintenance and inspection report and failed to complete all repairs identified by the vendor during the 6/5/07 inspection.
Not all damper locations were identified throughout the facility, on the report form.

On 7/13/12, at 1:56 p.m., the Fire Damper Inspection Report, dated 7/4/12 and 7/5/12, was reviewed and staff was interviewed. The report indicated a list of the dampers that failed this inspection.

During an interview at 1:58 p.m., the Plant Operations Director was asked if the dampers had been repaired. He stated they have not been repaired, that they have to be replaced. He explained that the dampers have to be ordered and that this takes awhile.

The facility requested a time limited wavier to allow for time to obtain dampers and parts to make the repairs. The waiver was requested until 9/30/12.

Based on record review and interview, the facility failed to maintain the medical air system in accordance with NFPA 99, Health Care Facilities. This was evidenced by the failure to repair identified problems with the medical air system. This affects the Neo Natal Intensive Care Unit, and Post Partum Unit. This failure could result in potential harm to patients.

Findings:

During record review on 7/13/12, the survey report for the 3/29/12 recertification survey was reviewed. The report indicated that an interview on 3/29/12, at 10 a.m., with the facility IOR (inspector of Record), Facilities Staff 1 and the OSHPD (Office of Statewide Health Planning and Development) representative, reported the repairs to the medical air system had not started. The IOR stated they were waiting for the plans to be returned with OSHPD approval. The facility will then obtain permits from the city to perform the required work to the medical air system.

On July 13, 2012, at 3:05 p.m., during an interview, the Compliance Officer stated the project is in progress. He reported that the facility had requested a wavier for time to complete the upgrades to the medical gas system. He reported that the project is in compliance with the timeline laid out in the waiver request. The project is scheduled to be completed around 9/30/12.

Based on document review and interview the facility failed to maintain the emergency generator in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. This was evidenced by no remote annunciator for the emergency generator. This affected the entire hospital.

NFPA 110 Standard for Emergency and Standby Power Systems, 1999 Edition
3-5.6 Remote Controls and Alarms
3-5.6.1 A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2 (d). This remote alarm shall be located outside of the EPS (Emergency Power Supply) service room at a work site readily observable by personnel.

Findings:

During document review, the recertification survey for March 30, 2012, was reviewed. The survey report indicated that during an interview at 9:17 a.m., Facilities Staff 1 stated that there was no remote annunciator for the emergency generator.

On July 13, 2012, during an interview, the Plant Operations Director and the Compliance Officer reported that the facility had requested a wavier for the installation of the remote annunciator panel in a continuously monitored location. The Compliance Officer stated that the project is on track with the time line included in the waiver request. The project should be completed by 12/31/12.

Based on observation, record review and interview, the facility failed to maintain the building electrical wiring and equipment in accordance with NFPA 99, Health Care Facilities. This was evidenced by no emergency outlets and emergency lighting in one anesthetizing area. This had the potential for injury to patients in the event of a fire or a loss of electrical power. This affected one of six smoke compartments.

NFPA 101:
19.3.2.3 Anesthetizing Locations. Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA Health Care Facilities 1999 Edition
3-3.2.1.2 All Patient Care Areas
(a) Wiring, Regular Voltage.
5. Wiring in Anesthetizing Locations.
e. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

Findings:

During document review on 7/13/12, the recertification survey from 3/29/12 was reviewed. The record indicated that on 3/27/12, during a tour of the facility, the GI Lab failed to have emergency lighting or power. During an interview, the GI Lab nurse was asked if the room had emergency power or lighting. She reported there was no emergency power or lighting and that if the power goes out it is "pitch black in here."

During the facility tour on 7/13/12, the GI lab area was observed. The facility has discontinued use of the GI lab area until completion of the electrical project that will provide emergency lighting and power in the event of a power failure. A waiver was requested until 12/31/12, for time to obtain OSHPD approvals and completion of the electrical project. The electrical project includes wiring for emergency outlets and emergency battery back up lights in all anesthetizing areas. Refer to the deficiency K46.