HospitalInspections.org

Based on observation the facility failed to ensure that all hazardous storage areas for soiled laundry and medical records were in areas protected by one hour separation or sprinkler protection. The facility census was three.
Findings included:
1. Observation on 3/28/11 of the storage area for soiled laundry showed a room with two large wheeled containers (one with four bags of soiled laundry) in a room with a drop in ceiling. The ceiling was missing 12 ceiling tiles and was open to the ceiling area above and also open to ceiling areas above other areas or rooms in this section of the hospital. There were no smoke detectors or sprinklers in this section of the hospital which was adjacent to the dining area.
2. Observation on 3/30/11 of the medical records storage area within the hospital showed two rooms with medical records. Neither area had smoke detector coverage or sprinklers. Upon entry to the area the room to the right had approximately 18 boxes of medical records in storage. A room to the left had four shelves of medical records for patients and it was noted that six ceiling tiles had stains from apparent water damage in the past and five ceiling tiles were missing from the ceiling assembly.
3. With the missing ceiling tiles the areas would not provide a one hour separation from other areas and did not have the alternative sprinkler protection with the ability to limit the spread of smoke or fire.

Based on record review and interview the facility failed to ensure that the night shift of the facility received fire drills quarterly. The facility census was three.
Findings included:
1. Review of the fire drills for the facility showed that fire drills had occurred from 9:30 AM to 4:30 PM during the period of 9/29/10 to 3/19/11. There were no records of fire drills occurring from 11:00 PM to 7:00 AM.
2. During an interview on 3/30/11 at 10:25 AM Staff M (director of engineering) stated that there had been no night shift fire drills done and further defined that the nursing staff work three shifts and that the night shift would be from 11:00 PM to 7:00 AM. It was uncertain when the last drill had been done for the night shift.

Based on interview and record review the facility failed to ensure that the sprinkler system was tested quarterly for the flow alarm (inspector's test). The facility census was three.
Findings included:
1. During an interview on 3/30/11 at 10:10 AM Staff M (director of engineering) stated that a test of the sprinkler system was done annually and the only other test done was of the anti-freeze system for two components of the system.
2. Record review of the sprinkler inspection form and the tag on the sprinkler main control indicated that the outside contractor last tested the system on 11/18/10. The inspection date previous to that was 2009. There were no records to indicate the sprinkler system had been inspected quarterly for the year of 2010.
3. Chapter 9-2.6 of the 1998 edition of the National Fire Protection Association (NFPA) code 25 states that a main drain test shall be conducted annually at each water based fire protection system riser to determine whether there has been a change in the condition of the water supply piping and control valves.
Chapter 9-2.7 states that all water flow alarms shall be tested quarterly in accordance with the manufacturer's instructions.
Chapter 9-2.3 states that all system valves shall be protected from physical damage and shall be accessible.
Chapter 9-2.8 states that gauges shall be inspected monthly to verify that they are in good condition and that normal pressure is being maintained.
Chapter 9-2.8.2 states that gauges shall be replaced every five years or tested every five years by comparison with a calibrated gauge.
9-3.2.3 states that all valves shall be inspected weekly.
Chapter 9-3.4.1 states that each control valve shall be operated annually through its full range and returned to its normal position.
Chapter 9-3.4.3 states that valve supervisory switches shall be tested semiannually.

Based on observation the facility failed to individually secure all compressed medical gasses for 12 of 12 tanks of oxygen used as a reserve supply for the facility. The facility census was three.
Findings included:
1. Observation on 3/29/11 of the outside storage area for an oxygen supply revealed 12 large tanks identified as a reserve supply for the facility. There was one chain across all 12 tanks securing them to the wall. There were no other stands or fastenings individually securing each tank in place.

2. Chapter 5.1.3.3.2 of the 2002 edition of the Code NFPA (National Fire Protection Association) 99 for Health Care Facilities states that locations for central supply systems and the storage of medical gases shall meet the following requirements:
(7) be provided with racks, chains, or other fastenings to individually secure all cylinders, whether connected, unconnected, full, or empty, from falling.

Based on observation and interview the facility failed to ensure that the generator received a monthly test under load. The facility census was three.
Findings included:
1. Review of the records provided for the generator showed no records for a test of the generator under load (transfer of facility power from utility company to generator).
2. During an interview on 3/29/11 at 9:45 AM Staff M (Director of engineering) stated that there are no known records for a test of the generator under load for the facility and the generator company (contracted provider for maintenance) provides service to the generator twice per year. The last service by the generator company was on 7/13/10 and the next scheduled service was delayed so that an additional load bank test (artificial load above normal facility requirements) could also be done and was scheduled for April.

Based on observation the facility failed to ensure that all hazardous storage areas for soiled laundry and medical records were in areas protected by one hour separation or sprinkler protection. The facility census was three.
Findings included:
1. Observation on 3/28/11 of the storage area for soiled laundry showed a room with two large wheeled containers (one with four bags of soiled laundry) in a room with a drop in ceiling. The ceiling was missing 12 ceiling tiles and was open to the ceiling area above and also open to ceiling areas above other areas or rooms in this section of the hospital. There were no smoke detectors or sprinklers in this section of the hospital which was adjacent to the dining area.
2. Observation on 3/30/11 of the medical records storage area within the hospital showed two rooms with medical records. Neither area had smoke detector coverage or sprinklers. Upon entry to the area the room to the right had approximately 18 boxes of medical records in storage. A room to the left had four shelves of medical records for patients and it was noted that six ceiling tiles had stains from apparent water damage in the past and five ceiling tiles were missing from the ceiling assembly.
3. With the missing ceiling tiles the areas would not provide a one hour separation from other areas and did not have the alternative sprinkler protection with the ability to limit the spread of smoke or fire.

Based on record review and interview the facility failed to ensure that the night shift of the facility received fire drills quarterly. The facility census was three.
Findings included:
1. Review of the fire drills for the facility showed that fire drills had occurred from 9:30 AM to 4:30 PM during the period of 9/29/10 to 3/19/11. There were no records of fire drills occurring from 11:00 PM to 7:00 AM.
2. During an interview on 3/30/11 at 10:25 AM Staff M (director of engineering) stated that there had been no night shift fire drills done and further defined that the nursing staff work three shifts and that the night shift would be from 11:00 PM to 7:00 AM. It was uncertain when the last drill had been done for the night shift.

Based on interview and record review the facility failed to ensure that the sprinkler system was tested quarterly for the flow alarm (inspector's test). The facility census was three.
Findings included:
1. During an interview on 3/30/11 at 10:10 AM Staff M (director of engineering) stated that a test of the sprinkler system was done annually and the only other test done was of the anti-freeze system for two components of the system.
2. Record review of the sprinkler inspection form and the tag on the sprinkler main control indicated that the outside contractor last tested the system on 11/18/10. The inspection date previous to that was 2009. There were no records to indicate the sprinkler system had been inspected quarterly for the year of 2010.
3. Chapter 9-2.6 of the 1998 edition of the National Fire Protection Association (NFPA) code 25 states that a main drain test shall be conducted annually at each water based fire protection system riser to determine whether there has been a change in the condition of the water supply piping and control valves.
Chapter 9-2.7 states that all water flow alarms shall be tested quarterly in accordance with the manufacturer's instructions.
Chapter 9-2.3 states that all system valves shall be protected from physical damage and shall be accessible.
Chapter 9-2.8 states that gauges shall be inspected monthly to verify that they are in good condition and that normal pressure is being maintained.
Chapter 9-2.8.2 states that gauges shall be replaced every five years or tested every five years by comparison with a calibrated gauge.
9-3.2.3 states that all valves shall be inspected weekly.
Chapter 9-3.4.1 states that each control valve shall be operated annually through its full range and returned to its normal position.
Chapter 9-3.4.3 states that valve supervisory switches shall be tested semiannually.

Based on observation the facility failed to individually secure all compressed medical gasses for 12 of 12 tanks of oxygen used as a reserve supply for the facility. The facility census was three.
Findings included:
1. Observation on 3/29/11 of the outside storage area for an oxygen supply revealed 12 large tanks identified as a reserve supply for the facility. There was one chain across all 12 tanks securing them to the wall. There were no other stands or fastenings individually securing each tank in place.

2. Chapter 5.1.3.3.2 of the 2002 edition of the Code NFPA (National Fire Protection Association) 99 for Health Care Facilities states that locations for central supply systems and the storage of medical gases shall meet the following requirements:
(7) be provided with racks, chains, or other fastenings to individually secure all cylinders, whether connected, unconnected, full, or empty, from falling.

Based on observation and interview the facility failed to ensure that the generator received a monthly test under load. The facility census was three.
Findings included:
1. Review of the records provided for the generator showed no records for a test of the generator under load (transfer of facility power from utility company to generator).
2. During an interview on 3/29/11 at 9:45 AM Staff M (Director of engineering) stated that there are no known records for a test of the generator under load for the facility and the generator company (contracted provider for maintenance) provides service to the generator twice per year. The last service by the generator company was on 7/13/10 and the next scheduled service was delayed so that an additional load bank test (artificial load above normal facility requirements) could also be done and was scheduled for April.