HospitalInspections.org

The facility failed to meet the minimum construction requirement in accordance with NFPA 101, 19.1.6, Minimum Construction Requirements. This was evidenced by:

Following observation it was determined the facility is a two story, Type II(000) structure (see initial comments under tag K000). In accordance with NFPA 101, 19.1.6.2, Construction Type Limitations, a facility found to be a Type II(000) structure must be protected throughout by an automatic sprinkler system, and may be no more than two (2) stories in height.

The minimum construction requirement deficiency item was discussed during the exit conference.

It was determined through observation and record review that the facility failed to maintain the interior finish in accordance with the Life Safety Code, section 19.3.3.1. This was evidenced by:

At the time of the survey the facility failed to provide documentation that the interior finishes in the following locations met the requirement, set forth in 19.3.3.1, that the associated finish was either a Class A or B finish:

a) the main nurses station appeared to have been finished in plywood, and
b) the clean utility room by room #24 was finished in a wood paneling with an unknown rating.

The interior finish deficiency items were discussed during the survey and again during the exit conference.

It was determined by observation during the course of the survey that the facility failed to maintain the corridor doors in accordance with the Life Safety Code. This was evidenced by:

1) The corridor doors in the following locations failed to positively latch into the door frame assembly, as required by 19.3.6.3.2:
a) the south kitchen corridor door,
b) the corridor door serving room 203,
c) the corridor door serving the oxygen storage closet,
d) the corridor door for patient room #14,
e) the corridor door serving the ER,
f) the corridor door serving the Nurse Change Room,
g) the corridor door serving the Doctors' Lounge, and
h) the corridor door serving the Surgery Suite.

2) The corridor door serving Patient room #15 was found to have a gap in excess of a half of an inch on the latch side top of the door, failing to meet the requirements of 19.3.6.3.1, wherein it is stated that corridor doors shall be constructed to resist the passage of smoke.

3) The linen storage room located across from Patient room #12 had louvers, failing to meet the requirements of 19.3.6.4.

The corridor door deficiency items were discussed during the survey and again during the exit conference.

It was determined by observation during the survey that the facility failed to properly protect the hazardous areas in accordance with section 19.3.2.1 of the Life Safety Code. This was evidenced by the following:

1) The fire rated wall separating the boiler room from the remainder of the facility was found to have several unsealed wire chases and pipe penetrations.

2) The laundry room corridor door failed to be self-closing, as required.

3) The corridor door serving the kitchen storage room, a room that is greater than fifty square feet in size and housed the storage of combustibles, failed to be self-closing, as required.

4) The corridor doors serving the two (2) second floor document storage rooms, rooms that is greater than fifty square feet in size and housed the storage of combustibles, failed to:
a) be self-closing, and
b) fire-rated, as required.

5) The corridor door for the central supply room failed to fully close and positively latch into the door frame assembly when released from the fully open position, as required.

This hazardous area deficiency items were discussed during the survey and again during the exit conference.

It was determined by observation during the survey that the facility failed to provide and maintain a means of egress so arranged that exits are readily accessible at all times in accordance with the Life Safety Code. This was evidenced by the following:

The two (2) doors serving the means of egress at the main entrance of the facility were equipped with dead bolt locks. In accordance with section 19.2.2.2.4, doors in the means of egress shall not be permitted to be locked.

The means of egress deficiency items were discussed during the survey and again at the exit conference.

It was determined by observation, record review, and staff interview during the course of the survey that the facility failed to provide an acceptable written plan for the protection of all patients and for their evacuation in the event of an emergency in accordance with NFPA 101, section 19.7.2.2. This was evidenced by:

At the time of the survey the facility provided written policy and procedures for the evacuation of all patients in the event of a fire; however, the policy and procedures failed to contain the following:
a) language regarding transmission of alarm to the Fire Department,
b) language regarding staff response tot he alarm,and
c) language regarding isolation of the fire, as required.

The written policy and procedure for the evacuation of all patients in the event of a fire deficiency item was discussed during the survey and again during the exit conference.

It was determined through observation and document review during the survey, that the facility failed to perform fire drills in accordance with the Life Safety Code. This was evidenced by:

Documentation was not provided at the time of the survey to show the following drills had been completed:
a. One (1) during the second shift in the second quarter of 2012,
b. One (1) during the second shift in the first quarter of 2012, and
c. One (1) during the first shift in the first quarter of 2012.

The fire drill deficiency items were discussed during the survey and again during the exit conference.

It was determined through observation during the survey that the facility failed to maintain the laundry ventilation in accordance with the Life Safety Code and the references cited therein. This was evidenced by:

The facility failed to maintain the laundry room dryer per NFPA 54 National Fuel Gas Code. This was evidenced by:

The vent duct serving the commercial dryer in the laundry room was found to be assembled through the use of metal screws, creating areas within the duct where lint can be caught and accumulated.

The venting deficiency item was discussed during the survey and again during the exit conference.

It was determined by observation and staff interview during the survey that the facility failed to prohibit combustible furnishings/decorations unless they are flame-retardant, in accordance with Life Safety Code section 19.7.5.4. This was evidenced by the following:

Decorations of a combustible nature and without associated documentation to show that they were inherently flame retardant or treated to be flame resistant were located in the following areas:
a) in the large dining room (hay bale, faux leaves, wooden pumpkin), and
b) in the copy room (wreath).
Note: These items were removed from the facility by the end of the survey.

Each of the above deficiency items were discussed during the survey and again during the exit conference.

It was determined by observation and staff interview during the survey that the facility failed to prohibit combustible draperies and other loose hanging fabrics unless they are flame-retardant, in accordance with Life Safety Code section 19.7.5.1. This was evidenced by the following:

Draperies of a combustible nature and without associated documentation to show that they were inherently flame retardant or treated to be flame resistant were located in the following areas:
a) in the large dining room,
b) in the CEO's office, and
c) in the finance office.

Each of the above deficiency items were discussed during the survey and again during the exit conference.

Through observation and staff interview during the survey it was determined that the facility failed to maintain the anesthetizing locations per NFPA 99. This was evidenced by:

1) The Operating room did not contain exhaust capabilities in case of a fire in the operating room. Although the room was equipped with a constantly running exhaust fan, this fan was found to be located approximately one foot above the finished surface of the floor. Due to the nature of smoke and the heated products of combustion to rise, it has been deemed that this arrangement is not adequate to remove smoke and the products of combustion.

2) The air handler serving the Operating room does not shut down with the activation of the fire alarm system, nor is the staff aware of a duct detector within the supply system for this handlers that would shut down supply to this location in the event smoke is detected, preventing the recirculation of smoke and the products of combustion.

Note: Per NFPA 99, 1999 Edition 5-4.1.3 "Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system."

3) The facility failed to provide Waste Anesthetic Gas Disposal (WAGD) in the Operating room. In accordance with NFPA 99 (1999), 4-4.3.2 and 4-3.3.2.3(a), WAGD must be provided at " all locations where nitrous oxide or other halogenated anesthetic agents are likely to be used. "

4) The facility failed to provide battery backed-up lighting in the Operating room, as required.

The anesthetizing location deficiency items were discussed during the survey and again during the exit conference.

It was determined through observation and through staff interview during the course of the survey that the facility failed to maintain the emergency backup generator in accordance with NFPA 101, Life Safety Code and NFPA 110, Standard for Emergency and Standby Power Systems. This was evidenced by the following:

The facility failed to provide a remote manual stop station for the generator, as required by NFPA 110, 2000 edition, 3-5.5.6.

The generator deficiency item was discussed during the survey and again during the exit conference.

It was determined by record review and staff interview during the course of the survey that the facility failed to properly maintain and test the emergency power source in accordance with (1999) NFPA 99 Health Care Facilities, section 3-4, and referenced NFPA 110, Standard for Emergency and Standby Power Systems, chapter 6. This was evidenced by the following:

The facility failed to provide documentation at the time of the survey to reflect that the weekly inspections of the generator, as required by NFPA 99, section 3-4 and NFPA 110, section 6-4, had taken place.

The emergency power supply system deficiency item was discussed during the survey and again during the exit conference.

It was determined through observation, staff interview, and document review that the facility failed to install and maintain the essential electrical system in accordance with the Life Safety Code and NFPA 99, Healthcare Facilities. This was evidenced by:

The essential electrical system throughout the hospital failed to be divided in accordance with NFPA 99, having items belonging on particular branches intermingled throughout the system and items not allowed to be on the Life Safety and Critical branches found thereon. The facility failed to provide a separate transfer switch for each of these branches, as required by NFPA 99, section 3-4.2.2.

The essential electrical system deficiency items were discussed during the survey and again during the exit conference.

It was determined by observation during the course of the survey that the facility failed to provide and maintain the electrical systems in accordance with the NFPA 70, National Electric Code.

The facility utilized an extension cord as a substitute for the fixed wiring of the structure in the PAX room.

The electrical system deficiency items were discussed during the survey and again during the exit conference.

It was determined by observation, staff interview, and through record review during the course of the survey that the facility failed to provide an acceptable fire watch policy in the event the automatic fire sprinkler system is out of service for more than 4 hours in a 24-hour period. This was evidenced by the following:

At the time of the survey the facility provided a policy and documentation enacting the policy regarding the requirement set forth in NFPA 101, 9.7.6.1, wherein it states that when a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the building shall be evacuated or an approved fire watch system is provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service. The documentation failed to reflect that the affected area must be inspected, at a minimum, every fifteen minutes (the document provided required a thrity-minute inspection).
Note: In accordance with the Colorado Department of Public Health and Environment, Health Facilities and Emergency Medical Service Division's (Authority Having Jurisdiction) policy manual in regards to Life Safety Code Fire Watch Requirements (enacted in January of 2010), a full inspection of the affected areas within this facility shall take place at a minimum of every fifteen minutes.

The fire watch policy deficiency item was discussed during the survey and again during the exit conference.