HospitalInspections.org

Based on interview and document review, the facility failed to have policies and procedures that addressed the disposal of sewage and waste of patients and staff. This finding had the potential to affect all patients receiving services at the facility. The census was 256 patients.

Findings

On 03/13/19 a review of the facility's emergency preparedness policies and procedures did not reveal how the facility would manage the sewage and waste of patients and staff.

On 03/13/19 at 4:45 PM in an interview, Staff X and Y explained they would use an incinerator that is on the campus to take care of waste. Staff X and Y could not show this in policy.

On 03/15/19 at 12:55 PM in an interview, Staff Y and Z explained all sewage would get double bagged and put in the incinerator with the garbage. They could not show that as policy, or whether the incinerator had the capacity.

On 03/13/19 at 1:15 PM in an interview, Staff Q, R, and V said there have been plans to get rid of the incinerator.

Based on observation and interview, the facility failed to ensure penetrations to the barrier separating it from the other occupants in the building were protected in such a way as to maintain the rating. This finding had the potential to affect all patients receiving services at the facility. The census was 256 patients.

Findings:

On 03/13/19 at 7:45 AM a tour was taken of the facility with Staff T and V.

On 03/13/19 at 8:37 AM observation above the drop down ceiling of the one hour barrier revealed, as seen over the door and near smoke damper SD-136, a one foot by two foot penetration for a cable tray.

On 03/13/19 at 8:37 AM in an interview, Staff T confirmed the finding.

On 03/13/19 at 8:43 AM observation above the drop down ceiling of the one hour barrier revealed, as seen within the room next to the 8:37 AM finding, an open two inch conduit holding blue cables.

On 03/13/19 at 8:43 AM in an interview, Staff T confirmed the finding.

On 03/13/19 at 8:49 AM observation above the drop down ceiling of the one hour barrier opposite the nursing station revealed an heating, ventilation, and cooling with a top annular space and an open two inch conduit holding blue cables.

On 03/13/19 at 8:49 AM in an interview, Staff T confirmed the finding.

Based on observation and interview, the facility failed to have the exit access corridor to the northwest stair free of obstructions, combustible or otherwise, in accordance with 19.2.1 and therefore 7.1.10.1, NFPA 101, 2012 edition. This finding had the potential to affect all patients receiving services at the facility. The census was 256 patients.

Findings:

On 03/11/19 at 12:48 PM a tour was taken of the second floor of the main building with Staff Q, R and S.

On 03/11/19 at 2:01 PM the exit access corridor to the northwest exit stair by air handlers 18 and 19 revealed multiple boxes of air filters (at least 11 boxes) were placed there.

On 03/11/19 at 2:01 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure each path of egress was marked in accordance with 7.10, NFPA 101, 2012 edition. This finding had the potential to affect all patients receiving services at the facility. The census was 256 patients.

Findings:

On 03/12/19 at 9:06 AM a tour of the ground floor of the main building resumed with Staff Q, R and S.

On 03/12/19 at 11:12 AM observation of the path near bay 16 of the cath lab care unit revealed there wasn't an exit sign near the double doors.

On 03/12/19 at 11:12 AM in an interview, Staff Q confirmed the finding.

On 03/12/19 at 11:38 AM a tour was taken of the third floor of the women's pavilion with Staff Q, R, and S. At 11:48 AM observation of the neonatal intensive care unit did not reveal an exit sign to an exit access door to the south and west of the unit which was obscured by multiple curtains for patient care areas.

On 03/12/19 at 11:48 AM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure penetrations to the barrier protecting stair 5 was protected in such a way as to maintain the rating, and to ensure double doors in said barrier self closed and latched. This finding had the potential to affect all patients receiving services at the facility. The census was 256 patients.

Findings:

On 03/12/19 at 9:06 AM a tour of the ground floor of the main building resumed with Staff Q, R and S.

On 03/12/19 at 9:09 AM observation above the drop down ceiling of the two hour barrier revealed, as seen from the corridor leading to the exit access to stair 5, over the double doors (90-l-c), a one inch open conduit holding a coaxial cable and another open conduit holding red and grey cables.

On 03/12/19 at 9:09 AM in an interview, Staff Q confirmed the finding.

On 03/12/19 at 9:28 AM observation of double doors M-GE-5 in a two hour barrier revealed the self closing and latching hardware did not close and latch the doors when tested.

On 03/12/19 at 9:28 AM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure doors to hazardous areas self closed in accordance with 21.3.2, NFPA 101, 2012 edition. This finding had the potential to affect all patients receiving services at the facility. The census was 256 patients.

Findings:

On 03/13/19 at 7:45 AM a tour was taken of the facility with Staff T and V.

On 03/13/19 at 9:10 AM observation of the door to the soiled utility room 1918 revealed it did not self close and latch.

On 03/13/19 at 9:10 AM in an interview, Staff T confirmed the finding.

Based on observation and interview, the facility failed to ensure doors to hazardous areas self closed in accordance with 39.3.2, NFPA 101, 2012 edition. This finding had the potential to affect all patients receiving services at the facility. The census was 256 patients.

Findings:

On 03/13/19 at 1:55 PM a tour was taken of the facility with Staff QS.

On 03/13/19 at 2:07 PM observation of the soiled utility room revealed it had sprinklers. The observation revealed the door was not self closing.

On 03/13/19 at 2:07 PM in an interview, Staff QS confirmed the finding.

Based on document review and interview, the facility failed to inspect its fire alarm system in accordance with 14.4.5 and 14.4.5.3 of NFPA 72, 2010 edition. This finding had the potential to affect all patients receiving services at the facility. The census was 256 patients.


Findings:

On 03/15/19 a review of the facility's life safety code documentation was completed. The review did not reveal where the fire alarm system had been inspected in 2018.

On 03/15/19 at 9:16 AM in an interview, Staff QR explained the alarm system had failed the third quarter of 2017, and new one was installed in May 2018, but had not been tested.

The life safety code documentation review did not reveal any evidence of smoke detector sensitivity testing.

On 03/15/19 at 9:16 AM in an interview, Staff QR confirmed the finding.

Based on document review and interview, the facility failed to maintain its fire alarm system in accordance with NFPA 72, 2010 edition.This finding had the potential to affect all patients receiving services at the facility. The census was 256 patients.

Findings:

On 03/15/19 a review of the facility's life safety code documentation was completed.

The review revealed its fire alarm system underwent an annual inspection on 02/11/19. A review of that inspection report revealed the batteries in the fire alarm control panel had failed.

On 03/15/19 at 11:46 AM in an interview, Staff QS confirmed the finding and explained the batteries had not yet been replaced and tested.

Based on document review and interview, the facility failed to provide evidence of smoke detector sensitivity testing in accordance with 14.4.5.3, NFPA 72, 2010 edition. This finding had the potential to affect all patients receiving services at the facility. The census was 256 patients.

Findings:

On 03/15/19 a review of the facility's life safety code documentation was completed. The review did not reveal any evidence of smoke detector sensitivity testing.

On 03/15/19 at 8:40 AM in an interview, Staff V confirmed the findings stating the test reports were inaccessible because they didn't have the password.

Based on observation, document review, and interview, the facility failed to inspect and test all components of the fire alarm system in accordance with 14.4.5 and all components were inventoried in accordance with 14.6.2.4, NFPA 72, 2010 edition. This finding had the potential to affect all patients receiving services at the facility. The census was 256 patients.

Findings:

On 03/15/19 at 11:15 AM a strobe only alarm device was observed in the women's locker room on the second floor of second floor of the women's pavilion.

On 03/15/19 at 11:15 AM in an interview, Staff Q confirmed the observation.

On 03/15/19 at 11:07 AM a strobe only and a horn/strobe device was observed in the breastfeeding center.

On 03/15/19 at 11:07 AM in an interview, Staff V confirmed the observation.

On 03/15/19 a review of the facility's life safety code documentation was completed. The review revealed the facility's fire alarm system was inspected and tested on 01/31/19. The review revealed the strobe device observed in the women's locker room was listed as both a horn and strobe, and the strobe only and horn/strobe device found in the breastfeeding center was not listed at all.

On 03/15/19 at 11:15 AM in an interview, Staff Q confirmed the finding.

Based on document review and interview, the facility failed to ensure gauges were inspected monthly in accordance with NFPA 25, 2011 edition, 5.2.4.1 and table 5.1.1.2 and control valves were inspected monthly in accordance with 13.3.2.1.1 and table 13.3.2.1.1. This finding had the potential to affect all patients receiving services at the facility. The census was 256 patients.

Findings

On 03/15/19 a review of the facility's life safety code documentation was completed on 03/15/19. The review did not reveal where the sprinkler system control valves and gauges were inspected monthly.

On 03/15/19 at 11:32 AM in an interview, Staff Q explained the control valves above the drop down ceiling were not inspected monthly, and did not have documentation to confirm the remaining control valves and gauges were inspected monthly.

Based on document review and interview, the facility failed to ensure gauges were inspected monthly in accordance with NFPA 25, 2011 edition, 5.2.4.1 and table 5.1.1.2 and control valves were inspected monthly in accordance with 13.3.2.1.1 and table 13.3.2.1.1. This finding had the potential to affect all patients receiving services at the facility. The census was 256 patients.

Findings:

On 03/15/19 a review of the facility's life safety code documentation was completed on 03/15/19. The review did not reveal where the sprinkler system control valves and gauges were inspected monthly.

On 03/15/19 at 8:40 AM in an interview, Staff V confirmed the finding.

Based on document review and interview, the facility failed to ensure gauges were inspected monthly in accordance with NFPA 25, 2011 edition, 5.2.4.1 and table 5.1.1.2 and control valves were inspected monthly in accordance with 13.3.2.1.1 and table 13.3.2.1.1. This finding had the potential to affect all patients receiving services at the facility. The census was 256 patients.

Findings:

On 03/15/19 a review of the facility's life safety code documentation was completed. The review did not reveal where the sprinkler system control valves and gauges were inspected monthly.

On 03/15/19 at 11:46 AM in an interview, Staff QS confirmed the finding.

Based on document review and interview, the facility failed to ensure gauges were inspected monthly in accordance with NFPA 25, 2011 edition, 5.2.4.1 and table 5.1.1.2 and control valves were inspected monthly in accordance with 13.3.2.1.1 and table 13.3.2.1.1. This finding had the potential to affect all patients receiving services at the facility. The census was 256 patients.

Findings:

On 03/15/19 a review of the facility's life safety code documentation was completed. The review did not reveal where the sprinkler system control valves and gauges were inspected monthly.

On 03/15/19 at 8:40 AM in an interview, Staff V confirmed the finding.

On 03/13/19 at 10:55 AM a tour was taken of the facility with Staff QR. During the tour, missing sprinkler escutcheon plates were found on sprinklers in the traction room, supply closet in the employee break room, and in the front office.

On 03/13/19 at 11:12 AM in an interview, Staff LQ confirmed the observations.

Based on observation and interview, the facility failed to ensure doors that opened on the corridor that could self close and latch did so. This finding had the potential to affect all patients receiving services at the facility. The census was 256 patients.

Findings:

On 03/11/19 at 10:20 AM a tour was taken of the third floor of the main building with Staff Q, R and S.

On 03/11/19 at 10:24 AM observation of patient rooms 362 and 356 revealed the doors opened onto the corridor and had self closing hardware that did not close and latch the doors.

On 03/11/19 at 10:24 AM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure penetrations to its smoke barriers were protected in such a way as to maintain the rating. This finding had the potential to affect all patients receiving services at the facility. The census was 256 patients.

Findings:

On 03/11/19 at 12:48 PM a tour was taken of the second floor of the main building with Staff Q, R and S.

On 03/11/19 at 12:48 PM observation above the drop down ceiling of the one hour barrier near door 42403 (near stair 4) revealed an open two inch conduit with multi-colored cables traveling through it.

On 03/11/19 at 12:48 PM in an interview, Staff Q confirmed the finding.

On 03/11/19 at 1:36 PM observation above the drop down ceiling of the one hour barrier across from a rehab office and near smoke damper sd57-9 revealed a two inch open conduit with cables running through it.

On 03/11/19 at 1:36 PM in an interview, Staff Q confirmed the finding.

On 03/11/19 at 2:49 PM observation above the drop down ceiling of the one hour barrier revealed, over the double doors by 2039j, a one inch open conduit holding a tourqoise cable and another one inch conduit holding a black cable.

On 03/11/19 at 2:49 PM in an interview, Staff Q confirmed the finding.

On 03/11/19 at 2:55 PM a tour was taken of the first floor of the main building with Staff Q, R and S.

On 03/11/19 at 5:23 PM observation above the drop down ceiling of the one hour barrier near 1016 revealed, as seen near the exit sign, an open one inch penetration.

On 03/11/19 at 5:23 PM in an interview, Staff Q confirmed the finding.

On 03/12/19 at 8:01 AM the tour of the first floor of the main building resumed with Staff Q, R and S.

On 03/12/19 at 8:01 AM observation above the drop down ceiling of the one hour barrier revealed, as seen over and near the west leaf of the double doors perpendicular to storage room 1126, a drain pipe with an annular space.

On 03/12/19 at 8:01 AM in an interview, Staff Q confirmed the finding.

On 03/12/19 at 8:24 AM observation above the drop down ceiling of the one hour smoke barrier revealed, as seen from the corridor and to the right of the door to room 1140.1Q, a two inch conduit open to air and holding a blue cable.

On 03/12/19 at 8:24 AM in an interview, Staff Q confirmed the finding.

On 03/12/19 at 8:35 AM observation above the drop down ceiling of the one hour barrier, revealed, as seen from the retail pharmacist office, blue wires traveling through a penetration.

On 03/12/19 at 8:35 AM in an interview, Staff Q confirmed the finding.

On 03/12/19 at 8:48 AM observation above the drop down ceiling of the one hour barrier, revealed, as seen from room two in the surgical step down unit, dried unrated foam within a penetration.

On 03/12/19 at 8:48 AM in an interview, Staff Q confirmed the finding.

On 03/12/19 at 8:55 AM observation above the drop down ceiling of the one hour barrier, as seen from the room five in the surgical step down unit, three polygonal shaped cuts into the dry wall.

On 03/12/19 at 8:55 AM in an interview, Staff Q confirmed the finding.

On 03/12/19 at 9:06 AM a tour of the ground floor of the main building resumed with Staff Q, R and S.

On 03/12/19 at 9:55 AM observation above the drop down ceiling of the two hour barrier revealed, as seen from the east side of the double doors in corridor GE0007 and over the left leaf, a flex conduit with an annular space and a one inch open conduit.

On 03/12/19 at 9:55 AM in an interview, Staff Q confirmed the finding.

On 03/12/19 at 10:10 AM observation above the drop down ceiling of the one hour barrier revealed, as seen over the double doors GE027, an open one inch conduit holding two white cables.

On 03/12/19 at 10:10 AM in an interview, Staff Q confirmed the finding.

On 03/12/19 at 11:38 AM a tour was taken of the third floor of the women's pavilion with Staff Q, R, and S.

On 03/12/19 at 11:51 AM observation above the drop down ceiling of the one hour barrier revealed, as seen above door 3w370.7b, an open half inch conduit holding blue and orange cables.

On 03/12/19 at 11:51 AM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure doors in smoke barriers with self closing and latching hardware closed and latched the doors.This finding had the potential to affect all patients receiving services at the facility. The census was 256 patients.

Findings:

On 03/11/19 at 10:20 AM a tour was taken of the third floor of the main building with Staff Q, R and S.

On 03/11/19 at 11:02 AM observation of the double doors m-3c-19 revealed they did not coordinate to close and latch unless release in a certain order.

On 03/11/19 at 11:02 AM in an interview, Staff Q confirmed the finding.

On 03/11/19 at 12:48 PM a tour was taken of the second floor of the main building with Staff Q, R and S.

On 03/11/19 at 1:21 PM observation of double doors 2171 (in the southeast area of the pre/post operative suite) revealed the self closing and latching hardware did not close and latch the doors when tested.

On 03/11/19 1:21 PM in an interview, Staff Q confirmed the finding.

On 03/11/19 at 2:55 PM a tour was taken of the first floor of the main building with Staff Q, R and S.

On 03/11/19 at 4:50 PM observation of a rated automated sliding door in the one hour barrier between the cafeteria and the corridor revealed a marketing banner stand was on the doors path of travel.

On 03/11/19 at 4:50 PM in an interview, Staff Q confirmed the finding.

On 03/12/19 at 8:01 AM the tour of the first floor of the main building resumed with Staff Q, R and S.

On 03/12/19 at 8:14 AM observation of the double doors in the one hour barrier east of the surgical step down unit and south of the step down unit revealed the self closing and latching hardware did not close and latch the doors when tested.

On 03/12/19 at 8:14 AM in an interview, Staff Q confirmed the finding.

On 03/12/19 at 9:06 AM a tour of the ground floor of the main building resumed with Staff Q, R and S.

On 03/12/19 at 10:48 AM observation of the double doors (GE027) in the one hour barrier revealed the self closing and latching hardware did not close and latch the doors when tested.

Based on interview and document review, the facility failed to implement fire drills wherein the fire alarm signal was transmitted in accordance with 19.7.1.4, NFPA 101, 2012 edition, and, given the responses on the evaluation forms, failed to ensure facility personnel were familiar with the signals and emergency actions required during a fire drill. This finding had the potential to affect all patients receiving services at the facility. The census was 256 patients.


Findings:

On 03/15/19 a review of the facility's life safety code documentation was completed.

The reviewed revealed on 06/23/19 at 01:30 AM a fire drill was conducted, but did not include a transmission of the fire alarm signal.

On 03/15/19 at 9:53 AM in an interview, Staff V confirmed the findings.

A review of the fire drills' evaluation forms revealed for the drill conducted on 01/27/18 at 1:48 PM, on 05/18/18 at 9:06 PM, and on 11/14/18 at 7:13 PM the critique for staff knowledge on whether they knew the location of area of refuge was marked n/a.

For the other nine drills conducted during the year, the line was checked for yes that staff did know the location of the area of refuge.

A review of the evaluation forms revealed a section for fire alarm operations. The fire alarm operations section asked the author to assess whether the pull station functioned properly, the visual and audio devices functioned properly, the doors closed and properly latched, the overhead page was audible, and the system reset without difficulties.

The 04/26/18 evaluation form had n/a checked for pull station functioned properly and doors closed and properly latched. The 05/18/18 evaluation form had n/a checked for pull station functioned properly, and the 06/23/18 evaluation form had all five lines checked as n/a.

A review of the facility's fire drill policy was completed on 03/15/19. The review did not reveal what the correct answers should be for staff knowledge of the location of area of refuge and the fire alarm operations section: yes, no, or n/a.

On 03/13/18 at 8:13 AM in an interview, Staff V confirmed the finding.

Based on interview and document review, the facility failed to implement fire drills wherein the fire alarm signal was transmitted in accordance with 19.7.1.4, NFPA 101, 2012 edition. This finding had the potential to affect all patients receiving services at the facility. The census was 256 patients.

Findings:

On 03/15/19 a review of the facility's life safety code documentation was completed. The review revealed the fire drills completed on 05/22/18 at 9:00 PM, 06/04/18 at 12:20 AM, 09/03/18 at 1:20 AM, and 12/06/18 at 12:20 AM did not include a transmission of the fire alarm signal.

On 03/15/19 at 9:53 AM in an interview, Staff V confirmed the findings

Based on observation and interview, the facility failed to ensure portable space heating devices were not present in patient care areas. This finding had the potential to affect all patients receiving services at the facility. The census was 256 patients.

Findings:

On 03/11/19 at 10:20 AM a tour was taken of the third floor of the main building with Staff Q, R and S.

On 03/11/19 at 10:30 AM observation of the physician area of the western nursing station revealed a portable space heater under the desk.

On 03/11/19 at 10:30 AM in an interview, Staff Q confirmed the finding.

Based on document review and interview, the facility failed to maintain its generator in accordance with 8.3.1, NFPA 110, 2010 edition.This finding had the potential to affect all patients receiving services at the facility. The census was 256 patients.

Findings:

On 03/15/19 a review of the facility's generator life safety code documentation was completed on 03/15/19. The review did not reveal any weekly inspections of the generator.

On 03/15/19 at 8:35 AM in an interview, Staff T confirmed the finding and said, "I don't do anything with the generator."

Based on observation and interview, the facility failed to ensure each area that stored oxygen cylinders had a sign in accordance with 11.3.4, NFPA 99, 2012 edition. This finding had the potential to affect all patients receiving services at the facility. The census was 256 patients.

Findings:

On 03/13/19 at 1:55 PM a tour was taken of the facility with Staff QS.

On 03/13/19 at 2:20 PM the clean utility room was observed to have oxygen tanks stored within and the observation did not reveal an oxygen sign on the outside.

On 03/13/19 at 2:20 PM in an interview, Staff QS confirmed the finding.

Based on observation and interview, the facility failed to ensure each area that stored oxygen cylinders had a sign in accordance with 11.3.4, NFPA 99, 2012 edition. This finding had the potential to affect all patients receiving services at the facility. The census was 256 patients.

Findings:

On 03/13/19 at 7:45 AM a tour was taken of the facility with Staff T and V.

On 03/13/19 at 9:03 AM observation of storage room 1913 revealed oxygen tanks stored within. The observation did not reveal a sign outside the room in accordance with 11.3.4, NFPA 99, 2012 edition.

On 03/13/19 in an interview, Staff T confirmed the finding.