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Based on observation, the facility failed to ensure doors in the path of egress did not require the use of a key, a tool, or special knowledge or effort for operation from the egress side in accordance with NFPA 101-2012, Section 7.2.1.5.3, 7.2.1.5.10, and 7.2.1.6. Facilities can only lock doors and gates in the case of clinical need such as a special care unit.

Findings include:

1. During an observation on 3/11/24 at 11:20 a.m., the marked exit doors leaving the ER area, going to the materials hall were found to be maglocked, with an electronic badge-in device. Egress from the door was with an electronic device using a card to unlock the doors and enter. The system is set up as an "access-controlled" egress special locking arrangement. The motion detector was not a part of the system.

Whatever type of special locking arrangement they want to utilize throughout the facility, either delayed egress, or access-controlled egress, the facility must then apply all the features the code requires in NFPA 101-2012 Section 7.2.1.6. The locked doors in the lighted path of egress must also unlock and be open to occupants in the event the sprinkler or fire detection systems are activated.

2. During an observation on 3/11/24 at 11:22 a.m., the area in the materials corridor leading to imaging had marked exit signs leading to magnetically locked doors. This was set up as an "access-controlled" egress special locking arrangement. The motion detector was not a part of the system.

Based on interview and observation, the facility failed to provide emergency lighting per NFPA 110 Standard for Emergency and Standby Power Systems 2010 Edition, Section 7.3.1.

Findings include:

1. During an observation on 3/11/24 at 10:25, the generator was inspected. There was a "frog-eye" emergency light observed in the room housing the generator. It was not apparent if the light was backed by battery power as required.

In an interview through email, staff member A stated, the electrician told them that the light was only hard wired to the generator, it was not a battery power backed light.

Based on observation, the facility failed to maintain emergency lighting provided to occupants of the building in accordance with NFPA 101 Life Safety Code, 2012 Edition, Section 4.6.12.3.

Findings include:

1. During an observation on 3/11/23 at 1:40 p.m., the "frog-eye" emergency lights in the occupancy were tested and failed to work.

In this new business occupancy, emergency lighting is not required by the code due to none of the following three conditions existing:
1. The building is three or more stories in height.
2. The occupancy is subject to 50 or more occupants above or below the level of exit discharge.
3. The occupancy is subject to 300 or more total occupants.

However, Section 4.6.12.3, states any life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

Based on observation, the facility failed to ensure a photo-luminescent sign was installed in accordance with NFPA 101 2012 Edition, Section 7.10.7.2.

Findings include:

1. During an observation on 3/11/24 at 11:35 a.m., there was a photo-luminescent exit sign at the imaging entrance. There was no continuous illumination near the face of the sign by a reliable light source to ensure "charging" of the sign in case of a power outage or an emergency.

Based on an observation, the facility failed to ensure accessibility to a manual fire alarm box in accordance with NFPA 101, 2012 Edition, Section 9.6.2.7

Findings include:

1. During an observation on 3/11/24 at 11:12 a.m., the ambulance entrance was inspected. A fire alarm pull station near the exit door was blocked from instant access.

2. During an observation on 3/11/24 at 12:14 p.m., the pre-op exit door was inspected. There was a pull station near the door which was blocked from instance access.

Based on an observation the facility:

a) failed to ensure a sprinkler head was installed clear of a ceiling mounted fixture in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.6.5.2 and Table 8.6.5.1.2,

b) failed to sprinkle the entire facility in accordance with NFPA 101, Life Safety Code, 2012 Edition, Section 19.3.5.1.

Findings Include:

1. During an observation on 3/11/24 at 12:05 p.m., infusion bay 4 was inspected. A ceiling mounted rail system for privacy curtains was observed, obstructing a sprinkler head. The head was within 12 inches of the rail, and the rail was lower than the deflector on the sprinkler head.

2. During an observation on 3/11/24 at 12:07 p.m., the med records area was inspected. A new wall had been built recently which left an alcove without sprinkler coverage in the area.

Based on observation, record review, the facility failed to test or replace gauges on the sprinkler system every five years, in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Sections 13.2.7.1 and 13.2.7.2,

Findings include:

1. Review of the facility's sprinkler reports and through observation on 3/11/24 at 12:30 p.m., the standpipe gauges had not been changed or recalibrated since December of 2018.

Based on observation, the facility failed to maintain sprinkler heads free of foreign materials per NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.1.1.1.

Findings include:

1. During an observation on 3/11/24 at 11:40 a.m., the soiled utility room by the OR was inspected. There was a large piece of material stuck to and hanging off the sprinkler head in the room.

Based on observation, the facility failed to maintain access to portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.3.1.

Findings include:

1. During an observation on 3/11/24 at 1:31 p.m., the entry vestibule was inspected. The portable extinguisher in the room was found to be blocked from immediate access by items placed in the vestibule.

Based on observation, the facility failed to maintain a corridor door resistant to the passage of smoke in accordance with NFPA 101, 2012 Edition, Section 19.3.6.3.1 and 19.3.6.3.2.

Findings include:

1. During an observation on 3/11/24 at 11:55 a.m., Surgical supply room in the OR area was inspected. The corridor door was found to have four holes through the door where the door handle and latch were changed out at some point, leaving holes through the door.

Based on record review, the facility failed to ensure the fire safety plan and subsequent drills documented all requirements listed in the the code for responding to a fire drill per NFPA 101. 2012 Edition, section 19.7.1.2.

Findings include:

1. Review of the facility fire drills going back a year reflected the facility lacked documentation in regards to all the elements required by code for the fire safety plan, specifically, the facility was not training staff to make a simulated emergency call to the fire department or 911. Even thouigh the system dialer will alert the monitoring agency, the code requires staff to still call 911 and report about the alarm.

Based on observation, the facility failed to keep soiled linen receptacles greater than 32 gallons in an area protected as hazardous in accordance with NFPA 101, 2012 Edition, Section 19.7.5.7.1.

Findings include:

1. During an observation on 3/11/24 at 11:30 a.m., the materials hallway was inspected. There were two large rolling bins for linens left outside a protected room in the corridor. The largest size allowed to be unattended in the corridor is 32 gallons, one is allowed for garbage, and one is allowed for soiled laundry.

Based on observation, the facility failed to maintain the electrical system in accordance with NFPA 70 National Electric Code, 2011 Edition, Article 110-12(B).

Findings include:

1. During an observation on 3/11/24 at 10:28 a.m., the area outside of receiving was inspected. There was an outlet cover missing on the red outlet near the door.

Based on record review, the facility failed to maintain documentation of inspections on all Patient-Care Related Electrical Equipment (PCREE). The deficient practice affected all smoke compartments.

Findings include:

1. Review of facility records on 3/11/24 reflected a lack of documentation for the electric beds in the facility having been electrically tested for continuity, resistance, leakage, physical integrity, etc.

Actual NFPA Standard: NFPA 99, Health Care Facilities Code (2012)
3.3.137 Patient-Care-Related Electrical Equipment.
Electrical equipment appliance that is intended to be used for diagnostic, therapeutic, or monitoring purposes in a patient care vicinity.
10.3 Testing Requirements - Fixed and Portable.
10.3.1* Physical Integrity. The physical integrity of the power cord assembly composed of the power cord, attachment plug, and cord-strain relief shall be confirmed by visual inspection.
10.3.2* Resistance.
10.3.2.1 For appliances that are used in the patient care vicinity, the resistance between the appliance chassis, or any exposed conductive surface of the appliance, and the ground pin of the attachment plug shall be less than 0.50 ohm under the following conditions:
(1) The cord shall be flexed at its connection to the attachment plug or connector.
(2) The cord shall be flexed at its connection to the strain relief on the chassis.
10.3.2.2 The requirement of 10.3.2.1 shall not apply to accessible metal parts that achieve separation from main parts by double insulation or metallic screening or that are unlikely to become energized (e.g., escutcheons or nameplates, small screws).
10.3.3* Leakage Current Tests.
10.3.3.1 General.
10.3.3.1.1 The requirements in 10.3.3.2 through 10.3.3.4 shall apply to all tests.
10.3.3.1.2 Tests shall be performed with the power switch ON and OFF.
10.3.3.2 Resistance Test. The resistance tests of 10.3.3.3 shall be conducted before undertaking any leakage current measurements.
10.3.3.3* Techniques of Measurement. The test shall not be made on the load side of an isolated power system or separable isolation transformer.
10.3.3.4* Leakage Current Limits. The leakage current limits in 10.3.4 and 10.3.5 shall be followed.
10.3.4 Leakage Current - Fixed Equipment.
10.3.4.1 Permanently wired appliances in the patient care vicinity shall be tested prior to installation while the equipment is temporarily insulated from ground.
10.3.4.2 The leakage current flowing through the ground conductor of the power supply connection to ground of permanently wired appliances installed in general or critical care areas
shall not exceed 10.0 mA (ac or dc) with all grounds lifted.
10.3.5 Touch Current - Portable Equipment.
10.3.5.1* Touch Current Limits. The touch current for cord connected equipment shall not exceed 100 ?A with the ground wire intact (if a ground wire is provided) with normal polarity and shall not exceed 500 ?A with the ground wire disconnected.
10.3.5.2 If multiple devices are connected together and one power cord supplies power, the leakage current shall be measured as an assembly.
10.3.5.3 When multiple devices are connected together and more than one power cord supplies power, the devices shall be separated into groups according to their power supply cord, and the leakage current shall be measured independently for each group as an assembly.
10.3.5.4 Touch Leakage Test Procedure. Measurements shall be made using the circuit, as illustrated in Figure 10.3.5.4, with the appliance ground broken in two modes of appliance operation as follows:
(1) Power plug connected normally with the appliance on
(2) Power plug connected normally with the appliance off (if equipped with an on/off switch)
10.3.5.4.1 If the appliance has fixed redundant grounding (e.g., permanently fastened to the grounding system), the touch leakage current test shall be conducted with the redundant
grounding intact.
10.3.5.4.2 Test shall be made with Switch A in Figure 10.3.5.4 closed.
10.3.6* Lead Leakage Current Tests and Limits - Portable Equipment.
10.3.6.1 The leakage current between all patient leads connected together and ground shall be measured with the power plug connected normally and the device on.
10.3.6.2 An acceptable test configuration shall be as illustrated in Figure 10.3.5.4.
10.3.6.3 The leakage current shall not exceed 100 ?A for ground wire closed and 500 ?A ac for ground wire open.
10.5.2.1 Testing Intervals.
10.5.2.1.1 The facility shall establish policies and protocols for the type of test and intervals of testing for patient care-related electrical equipment.
10.5.2.1.2 All patient care-related electrical equipment used in patient care rooms shall be tested in accordance with 10.3.5.4 or 10.3.6 before being put into service for the first time and after any repair or modification that might have compromised electrical safety.
10.5.2.5* System Demonstration. Any system consisting of several electric appliances shall be demonstrated to comply with this code as a complete system.
10.5.3 Servicing and Maintenance of Equipment.
10.5.3.1 The manufacturer of the appliance shall furnish documents containing at least a technical description, instructions for use, and a means of contacting the manufacturer.
10.5.3.1.1 The documents specified in 10.5.3.1 shall include the following, where applicable:
(1) Illustrations that show the location of controls
(2) Explanation of the function of each control
(3) Illustrations of proper connection to the patient or other equipment, or both
(4) Step-by-step procedures for testing and proper use of the appliance
(5) Safety considerations in use and servicing of the appliance
(6) Precautions to be taken if the appliance is used on a patient simultaneously with other electric appliances
(7) Schematics, wiring diagrams, mechanical layouts, parts
lists, and other pertinent data for the appliance
(8) Instructions for cleaning, disinfection, or sterilization
(9) Utility supply requirements (electrical, gas, ventilation, heating, cooling, and so forth)
(10) Explanation of figures, symbols, and abbreviations on
the appliance
(11) Technical performance specifications
(12) Instructions for unpacking, inspection, installation, adjustment,
and alignment
(13) Preventive and corrective maintenance and repair
procedures
10.5.3.1.2 Service manuals, instructions, and procedures provided by the manufacturer shall be considered in the development of a program for maintenance of equipment.
10.5.6 Record Keeping - Patient Care Appliances.
10.5.6.1 Instruction Manuals.
10.5.6.1.1 A permanent file of instruction and maintenance manuals shall be maintained and be accessible.
10.5.6.1.2 The file of manuals shall be in the custody of the engineering group responsible for the maintenance of the appliance.
10.5.6.1.3 Duplicate instruction and maintenance manuals shall be available to the user.
10.5.6.1.4 Any safety labels and condensed operating instructions on an appliance shall be maintained in legible condition.
10.5.6.2* Documentation.
10.5.6.2.1 A record shall be maintained of the tests required by this chapter and associated repairs or modifications.
10.5.6.2.2 At a minimum, the record shall contain all of the following:
(1) Date
(2) Unique identification of the equipment tested
(3) Indication of which items have met or have failed to meet the performance requirements of 10.5.6.2
10.5.6.3 Test Logs. A log of test results and repairs shall be maintained and kept for a period of time in accordance with a health care facility's record retention policy.
10.5.8 Qualification and Training of Personnel.
10.5.8.1* Personnel concerned for the application or maintenance of electric appliances shall be trained on the risks associated with their use.
10.5.8.1.1 The health care facilities shall provide programs of continuing education for its personnel.
10.5.8.1.2 Continuing education programs shall include periodic review of manufacturers' safety guidelines and usage requirements for electrosurgical units and similar appliances.
10.5.8.2 Personnel involved in the use of energy-delivering devices including, but not limited to, electrosurgical, surgical laser, and fiberoptic devices shall receive periodic training in fire suppression.
10.5.8.3 Equipment shall be serviced by qualified personnel only.