HospitalInspections.org

Based on observation and interview, the facility failed to implement the emergency power system requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code in accordance with 42 CFR 483.73(e)(2). This deficient practice could affect all occupants.

Findings include:

Based on records review with the Maintenance Mechanic and the Facilities Coordinator on 07/28/21 at 12:37 p.m., the generator testing form lacked the load time, cool down time, transfer time, and load percentage required by LSC and NFPA 110. Based on interview at the time of record review, the Facilities Coordinator agreed the generator documentation was missing required information.

This finding was reviewed with the Maintenance Mechanic, Facilities Coordinator, and the Director of Operations during the exit conference.

Based on observation and interview, the facility failed to ensure 2 of 2 Hazardous room corridor doors in the EVS hall were not obstructed from closing. This deficient practice could affect staff in EVS hall.

Findings include:

Based on an observation during a tour of the facility with the Maintenance Mechanic and the Facilities Coordinator on 07/28/21 at 2:27 p.m., the EVS linen storage room and utility storage room contained combustible supplies, linen, and was greater than 50 square feet making this a hazardous area. The doors to the storage rooms were self-closing but the doors were propped open with a door wedge. Based on interview at the time of observation, the Facilities Coordinator agreed the storage rooms contained large amount of combustible storage, were larger than 50 square feet, and the corridor doors to the rooms were propped open.

This finding was reviewed with the Maintenance Mechanic, Facilities Coordinator, and the Director of Operations during the exit conference.

Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm systems was installed in accordance with 19.3.4.1. LSC 9.6.1.3 requires a fire alarm system to be installed, tested, and maintained in accordance with NFPA 70, National Electrical Code and NFPA 72, National Fire Alarm Code. NFPA 72, 17.7.4.1 requires in spaces served by air handling systems, detectors shall not be located where air flow prevents operation of the detectors. This deficient practice could affect all occupants.

Findings include:

Based on an observation during a tour of the facility with the Maintenance Mechanic and the Facilities Coordinator on 07/28/21 between 12:00 p.m. and 4:00 p.m., the following locations had a smoke detectors next to an air supply/return where air flow would prevent proper operation of the detectors:
a) ADL kitchen.
b) Men's locker room.
c) Shipping and Receiving hall.
d) Imaging Prep room.
Due to the direct flow of air from the supply/return the detectors showed signs of dust acclimation. Based on interview at the time of observation, the Maintenance Mechanic and the Facilities Coordinator agreed there were smoke detectors in the direct airflow from a supply/return in the aforementioned locations.

The findings were reviewed with the Maintenance Mechanic, Facilities Coordinator, and the Director of Operations during the exit conference.

Based on record review and interview, the facility failed to provide 1 of 1 written emergency fire safety plan that incorporated all items listed in NFPA 101, Section 19.7.2.2.
1. Use of alarms.
2. Transmission of alarms to fire department.
3. Emergency phone call to fire department
4. Response to alarms.
5. Isolation of fire.
6. Evacuation of immediate area.
7. Evacuation of smoke compartment.
8. Preparation of floors and building for evacuation.
9. Extinguishment of fire.
This deficient practice affects all patients, staff, and visitors in the event of an emergency.

Findings include:

Based on records review with the Facilities Coordinator and the Director of Operations on 07/28/21 at 10:37 a.m., the provided facility's fire safety plan did not address the following items:
a) Extinguishment of fire. The fire safety plan did not indicate how use a fire extinguisher and did not address the types of fire extinguishers in the building.
b) Evacuation of smoke compartment. The fire safety plan did not address partial evacuation by moving patients beyond a smoke or fire barrier.
c) Emergency phone call to fire department. The facility did not address calling the fire department upon discover of a fire or activation of the fire alarm system.
Based on interview at the time of record review, the Facilities Coordinator and Facilities Coordinator agreed the fire safety plan was missing the aforementioned required information.

This finding was reviewed with the Maintenance Mechanic, Facilities Coordinator, and the Director of Operations during the exit conference.

Based on record review and interview, the facility failed to include all required information for 12 of 12 generator monthly load tests. Chapter 6.4.4.2 of NFPA 99 requires a written record of inspection, performance, exercising period, and repairs for the generator to be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice could affect all occupants.

Findings include:

Based on records review with the Facilities Coordinator and the Maintenance Mechanic on 07/28/21 at 10:37 a.m., the monthly generator load test documentation failed to indicate the total time under load, cool down time, transfer time, and load percentage. Based on an interview at the time of record review, the Maintenance Director stated the load time is 45 minutes, cool down time is 15 minutes, transfer time is 2-3 seconds, and load percentage between 25% to 30%, but this information was not recorded on the monthly test form.

This finding was reviewed with the Maintenance Mechanic, Facilities Coordinator, and the Director of Operations during the exit conference.

Based on observation and interview, the facility failed to ensure 1 of 1 flexible cords were not used as a substitute for fixed wiring according to 9.1.2. LSC 9.1.2 requires electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code. NFPA 70, 2011 Edition, Article 400.8 requires that, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice affects staff only.

Findings include:

Based on an observation during a tour of the facility with the Maintenance Mechanic and the Facilities Coordinator on 07/28/21 between 1:00 p.m. and 4:00 p.m., a surge protector was found powering a microwave in the lab breakroom and a refrigerator in the shipping receiving staff lounge. Based on interview at the time of observation, the Maintenance Mechanic and the Facilities Coordinator agreed surge protectors were powering high-amperage devices

The findings were reviewed with the Maintenance Mechanic, Facilities Coordinator, and the Director of Operations during the exit conference.

Based on record review and interview, the facility failed to provide 1 of 1 established procedures for operating room emergencies. This deficient practice affects 2 patients using the operating rooms.

Findings include:

Based on records review with the Facilities Coordinator and the Lead O.R. Nurse on 07/28/21 at 4:01 p.m., the facility was unable to provide written procedures for operating room emergencies that includes alarm activation, evacuation, equipment shutdown, control operations, control of chemical spills, and extinguishment of drapery, clothing and equipment fires. Based on interview at the time of observation, the Lead O.R. Nurse stated written procedures for operating room emergencies could not be located.

This finding was reviewed with the Maintenance Mechanic, Facilities Coordinator, and the Director of Operations during the exit conference.