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Based on observations and interview during the survey, it was determined through on-going dialog with the Clinical Engineering Director and Plant Engineering Manager that the facility failed to maintain exit corridor doors resist the passage of smoke into the means of egress in the event of a hostile fire event (LSC 19/18.2.3.5, Table 19/18.3.2.1, 19/18.3.6.3, Exception 2; A19/18.3.6.3.3).
Findings include, but are not limited to:
1. On 1/12/2016, at 11:55 a.m., there was a set of double cross-corridor doors (GSDR5) that were not closing or latching properly when tested by the surveyor. It appears that there may be an air balance problem on the floor that would not allow the doors to close or latch completely.
Surveyor was accompanied by the Clinical Engineering Director and Plant Engineering Manager who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Clinical Engineering Director and Plant Engineering Manager that the facility failed to provide a one hour separation between hazardous areas and the corridor for the building.
This resulted in the potential for patients & staff to be exposed to hazardous products of fire during a hostile fire event (LSC 18/19.3.2, 8.4).
Findings include, but are not limited to:
1. On 1/11/2016, at 11:24 a.m., there was a missing automatic door closure on the Soiled Linen Door 3H334.
2. On 1/11/2016, at 2:15 p.m., there was a missing automatic door closure on the Soiled Holding Door 2N6.
Surveyor was accompanied by the Clinical Engineering Director and Plant Engineering Manager who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Clinical Engineering Director and Plant Engineering Manager that the facility failed to maintain accessible exits for the building as required by 2000 NFPA 101, 19/18.2.2.2.4.
Per exception 1 of this code reference, this condition is only allowed when the clinical needs of the patients require specialized security measures for their safety.
This resulted in the potential for panic and injury to occupants.
Findings include, but are not limited to:
1. On 1/11/2016, at 3:39 p.m., there were obscured and blocked signed exits within the HP Starker Conference Room. Exits were blocked by clothes rack and obscured by roll up blinds.
Surveyor was accompanied by the Clinical Engineering Director and Plant Engineering Manager who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Clinical Engineering Director and Plant Engineering Manager that the facility failed to maintain exit illumination on emergency power for a minimum of 90 minutes annually.
This resulted in the potential for confusion and panic by residents & staff during emergency evacuation conditions (LSC 19.2.8).
Findings include, but are not limited to:
1. On 1/12/2016, at 5:51 a.m., there was an emergency light within OR #9 that did not function when tested by the surveyor.
Surveyor was accompanied by the Clinical Engineering Director and Plant Engineering Manager who acknowledged the existence of these conditions.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Clinical Engineering Director and Plant Engineering Manager that the facility failed to provide fire drills for all staff affecting the entire building.
This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing patients to smoke and fire in the facility (LSC 19.7.1.2, A.19.7.1.2, 20.7.1.2, A.20.7.1.2).
Findings include, but are not limited to:
1. On 1/12/2016, during record review between 3:00 p.m. and 5:00 p.m., facility documentation presented to the surveyor for the Behavioral Unit showed incomplete fire drill forms for the facility.
Fire drill forms were missing items such as but not limited to the number of simulated evacuated occupants from the affected smoke compartment to an unaffected smoke compartment, specific type of fire simulated, specific location of simulated fire, staff performance during the drill and time to complete the simulated evacuation of occupants from the affected smoke compartment to the unaffected smoke compartment during the fire drill.
2. On 1/12/2016, during record review between 3:00 p.m. and 5:00 p.m., the facility had no documentation on conducting their 3rd quarter swing shift fire drill in 2014 for the Behavioral Unit.
3. On 1/12/2016, during record review between 3:00 p.m. and 5:00 p.m., facility documentation presented to the surveyor by the facility showed that fire drills for Day, Swing and Night shifts in 2014 and 2015 were not completed under varying conditions and at random times throughout the shift.
Day shift fire drills were conducted between 11:15 a.m. and 1:36 p.m.; Swing shift fire drills were conducted between 3:25 p.m. and 4:15 p.m.; and Night shift drills were conducted between 5:30 a.m. and 6:15 a.m. which demonstrates that fire drills were conducted in a manner that created a pattern, instead of on different days and times and involving different locations and simulated circumstances.
4. On 1/13/2016, during record review between 11:00 a.m. and 12:00 p.m., facility documentation presented to the surveyor for the ASC showed incomplete fire drill forms for the facility.
Fire drill forms were missing items such as but not limited to the number of simulated evacuated occupants from the affected smoke compartment to an unaffected smoke compartment, specific type of fire simulated, specific location of simulated fire, Staff Performance during the drill and time to complete the simulated evacuation of occupants from the affected smoke compartment to the unaffected smoke compartment during the fire drill.
Surveyor was accompanied by the Clinical Engineering Director and Plant Engineering Manager who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Clinical Engineering Director and Plant Engineering Manager that the facility failed to test and maintain fire alarm in accordance with NFPA 72 for the entire building.
This resulted in the potential for system and device failure during fire emergencies (LSC 4.6.12.1, 9.6.1.4, NFPA 70, NFPA 72).
Findings include, but are not limited to:
1. On 1/8/2016, at 10:03 a.m., there was a smoke detector within the West Tower Elevator Service Penthouse on the roof that was broken and melted and shall be replaced.
2. On 1/11/2016, at 3:39 p.m., there were (2) blocked/obstructed fire alarm pull stations within the HP Starker Conference Room by clothes racks.
Surveyor was accompanied by the Clinical Engineering Director and Plant Engineering Manager who acknowledged the existence of these conditions.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Clinical Engineering Director and Plant Engineering Manager that the facility failed to ensure the sprinkler system was continuously maintained & in reliable operating condition.
This resulted in the potential for system failure during fire emergencies (LSC 4.6.12.1, NFPA 13 3-2.91, .2, .3, NFPA 25 9.6.2.1, .2 & 8.17.4.6).
Findings include, but are not limited to:
1. On 1/12/2016, during record review between 3:00 p.m. and 5:00 p.m., the facility did not provide documentation on weekly and monthly testing and maintenance on the sprinkler system for the Behavioral Unit.
2. On 1/12/2016, during record review between 3:00 p.m. and 5:00 p.m., there was not a current record of the required 5 yr. IIIC test for the fire sprinkler system within the Behavioral Unit. Surveyor was not able to determine the date of the last 5 yr. IIIC test.
3. On 1/12/2016, at 3:13 p.m., there was a damaged automatic sprinkler head within The Behavioral Unit Shower Rm. #113A
4. On 1/12/2016, at 3:46 p.m., there was a missing escutcheon plate on the fire sprinkler head within The Behavioral Unit Room #182.
5. On 1/13/2016, at 10:22 a.m., the gauges on the fire sprinkler riser within the ASC were dated 2008 and had not been recalibrated or replaced. Gauges were due to be replaced or recalibrated since 2013.
Surveyor was accompanied by the Clinical Engineering Director and Plant Engineering Manager who acknowledged the existence of these conditions.

Based on record review and interview during the survey, it was determined through on-going dialog with the Clinical Engineering Director and Plant Engineering Manager that the facility failed to maintain fire extinguishers in accordance with adopted standards for all extinguishers of the facility.
This resulted in the potential for fires to progress beyond incipient stage (LSC 19.3.5.6, 20.3.5.2, 4.6.12.1, 9.7.4.1, NFPA 10).
Findings include, but are not limited to:
1. On 1/12/2016, during record review between 3:00 p.m. and 5:00 p.m., the Behavioral Unit could not provide the previous fire extinguisher tags for the years 2014 and 2015. Staff mentioned that they were told that they did not have to retain the previous fire extinguisher tags.
2. On 1/13/2016, during record review between 11:00 a.m. and 12:00 p.m., the ASC could not provide the previous fire extinguisher tags for the years 2014 and 2015. Staff mentioned that they were told that they did not have to retain the previous fire extinguisher tags.
Surveyor was accompanied by the Clinical Engineering Director and Plant Engineering Manager who acknowledged the existence of these conditions.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Clinical Engineering Director and Plant Engineering Manager that the facility failed to ensure safe smoking practices by patients, staff and visitors in the facility in accordance with facility policies and life safety regulations.
This resulted in the potential for exposing patients, staff and visitors to a fire and/or smoke environment (LSC 19/18.7.4).
Findings include, but are not limited to:
1. On 1/8/2016, at 4:58 p.m., the facility Smoking Policy presented to the surveyors mentioned that the entire campus of the hospital was no smoking. During the surveyor tour on the exterior of the building, the surveyor discovered an area that had been used for smoking and smoking materials were being discarded into an unknown substance.
The area were the smoking materials were found was outside of the Main Cafeteria on the north east side of the building and behind a support column.
Surveyor was accompanied by the Clinical Engineering Director and Plant Engineering Manager who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Clinical Engineering Director and Plant Engineering Manager that the facility failed to provide safe storage for compressed gas for the facility.
This resulted in the potential for injury to staff and patients from a damaged compressed gas cylinder releasing unexpectedly. (LSC 18/19.3.2.4, NFPA 99 4.3.1.1.2).
Findings include, but were not limited to:
1. On 1/11/2016, at 11:38 a.m., there were (3) compressed gas oxygen cylinders being stored within the Hallway of Cardio Pulmonary outside of Door 2H226 and 2H218.
2. On 1/11/2016, at 12:05 p.m., there was 1-compressed gas cylinder that was not properly secured by evidence of the cylinder standing in a free non-restrained fashion that would allow the cylinder to fall and strike other cylinders or walls within Patient Rm. 2305 during a seismic event.
3. On 1/12/2016, at 8:47 a.m., there was 1-compressed gas cylinder that was not properly secured by evidence of the cylinder standing in a free non-restrained fashion that would allow the cylinder to fall and strike other cylinders or walls within Room G520 during a seismic event.
4. On 1/12/8/2016, at 12:03 p.m., there were (6) compressed gas oxygen cylinders being stored in an alcove behind a curtain within the elevator lobby on Floor 2 South, Floor 2 Center and Floor 2 Southwest. The alcove was not adjacent to the Nurse's Stations and were open to the corridor.
Surveyor was accompanied by the Clinical Engineering Director and Plant Engineering Manager who acknowledged the existence of these conditions.

Based on observations and interviews it was determined through on-going dialog with the Clinical Engineering Director and Plant Engineering Manager that the facility failed to provide safe storage for compressed gas.
This resulted in the potential for damage to electrical switches and receptacles during the movement of oxygen tanks (LSC 19/18.3.2.4, NFPA 99 4.3.1.1.2).
Findings include, but were not limited to:
1. On 1/12/2016, at 12:27 p.m., there were (4) compressed gas oxygen cylinders being stored within a Cath Lab Recovery Treatment Space that was not properly separated from the other patient treatment spaces and had electrical outlets and switches within 60" of the finish floor.
2. On 1/8/2016, at 2:16 p.m., there were (2) compressed gas oxygen cylinders being stored within Patient Rm. 3305 that had electrical outlets and switches within 60" of the finish floor. Surveyor interviewed staff within the Sleep Lab and staff mentioned that the room had been converted into a storage room and that patients had not used the room for over and year.
3. On 1/11/2016, at 2:50 p.m., there were (2) compressed gas oxygen cylinders being stored within Storage Rm. 2W022 that had electrical outlets and switches within 60" of the finish floor.
Surveyor was accompanied by the Clinical Engineering Director and Plant Engineering Manager who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Clinical Engineering Director and Plant Engineering Manager that the facility failed to ensure that piped in medical gas systems comply with NFPA 99.
This resulted in the potential for injury to patients during medical procedures.
Findings include but are not limited to:
1. On 1/7/2016, during record review between 8:00 a.m. and 5:30 p.m., semi-annual, annual, or bi-annual testing and maintenance on the facilities Medical Gas System was being performed by facility staff and there was no documentation showing technician competence in maintaining the Med. Gas System to the adopted NFPA 99 standards.
2. On 1/12/2016, at 12:03 p.m., there was a light burned out on the Med. Gas Panel within the Nursery on 4 Center.
Surveyor was accompanied by the Clinical Engineering Director and Plant Engineering Manager who acknowledged the existence these conditions.

Based on record review and interview during the survey, it was determined through on-going dialog with the Clinical Engineering Director and Plant Engineering Manager that the facility failed to ensure that piped-in medical gas complied with NFPA 99, 5-4.1.1.
This resulted in the potential for injury to patients during medical procedures.
Findings include, but are not limited to:
1. On 1/7/2016, during record review between 8:00 a.m. and 5:30 p.m., the humidity policy that was presented to the surveyor specified an adopted humidity range of 20% - 60%.
Facility was unable to provide any documentation on equipment that was being used within the OR's and Procedure Room's to show what the optimum relative humidity levels would be for the equipment.
Surveyor was accompanied by the Clinical Engineering Director and Plant Engineering Manager who acknowledged the existence of these conditions.

Based on record review and interview during the survey, it was determined through on-going dialog with the Clinical Engineering Director and Plant Engineering Manager that the facility failed to maintain smoke barrier fire resistance ratings when ducts penetrate smoke barriers throughout the building.
This resulted in the potential for the spread of fire/smoke to other smoke compartments (LSC 19.3.7.3).
Findings include, but are not limited to:
1. On 1/7/2016, during record review between 8:00 a.m. and 5:30 p.m., smoke and fire dampers testing and maintenance was being performed by facility staff and there was no documentation showing technician competence in maintain the dampers.
Surveyor was accompanied by the Clinical Engineering Director and Plant Engineering Manager who acknowledged the existence of these conditions.

Based on observations, record review and interviews it was determined through on-going dialog with the Clinical Engineering Director and Plant Engineering Manager that the facility failed to properly maintain the generator affecting the entire facility.
This resulted in the potential for the lack of emergency electrical power (LSC 4.6.12.1, NFPA 110, NFPA 99, 3.4.4.1, 6.4.2).
Findings include, but are not limited to:
1. On 1/6/2016, during record review between 3:00 p.m. and 5:30 p.m., monthly maintenance was being performed by multiple facility staff members and there was no documentation showing technician competence in maintaining the generator for these staff members to the adopted 1999 edition of NFPA 110 standards.
2. On 1/7/2016, during record review between 8:00 a.m. and 5:30 p.m., monthly specific gravity inspection on the generator batteries was being performed but a specific value was not being recorded when the inspection was being conducted as required by NFPA 110.
3. On 1/13/2016, at 9:32 a.m., there was no emergency task illumination within the Transfer Switch Room for the facilities generator (Door B112).
Surveyor was accompanied by the Clinical Engineering Director and Plant Engineering Manager who acknowledged the existence of these conditions.

Based on record review and interview during the survey, it was determined through on-going dialog with the Clinical Engineering Director and Plant Engineering Manager that the facility failed to provide an alternate source of power in accordance with NFPA 99 3.6, which would provide a minimum of 90 minutes of power in an outage.
This resulted in the potential for panic and confusion for staff and residents in a power outage.
Findings include, but are not limited to:
1. On 1/12/2016, during record review between 3:00 p.m. and 5:00 p.m., there was no documentation showing the required monthly 30 second test or annual 90 minute test on emergency lights within the generator enclosure or generator transfer switch for the Behavioral Unit generator.
Surveyor was accompanied by the Clinical Engineering Director and Plant Engineering Manager who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Clinical Engineering Director and Plant Engineering Manager that the facility failed to ensure that that electrical wiring & equipment was used/maintained and in accordance with NFPA 70.
This resulted in the potential for injury to residents & staff (NFPA 70, 9.1.2, NEC 110-3.8).
Findings include, but are not limited to:
1. On 1/8/2016, at 11:02 a.m., there was a relocatable power tap (RPT) at the Nurse Station and stairstepper machine within Cardio Rehab that did not meet UL60601-1 listings for patient care areas.
2. On 1/8/2016, at 11:14 a.m., there was exposed wiring above a wall cabinet within the Nursery (Door 4C35). The wiring used to power a clock.
3. On 1/8/2016, at 1:25 p.m., there was a relocatable power tap at the 3rd Floor North Nurse Station that did not meet UL60601-1 listings for patient care areas.
4. On 1/8/2016, at 2:12 p.m., there was an extension cord powering a radio within the Sleep Disorder area (Door 3S23).
5. On 1/11/2016, at 2:43 p.m., there was an extension cord powering an appliance within the Phone Closet on the 2nd floor (Door 2N8).
6. On 1/11/2016, at 3:20 p.m., there was a microwave within the Medical Records area that did not appear to be a commercial grade microwave. Surveyor examined microwave and found no label to show a commercial grade and also looked up model number and could not determine if the microwave was commercial grade.
7. On 1/11/2016, at 4:18 p.m., there were open circuit breaker areas within electrical panel E1GL10C. Panel was located in Administration Area behind Door #1W006.
8. On 1/12/2016, at 5:45 a.m., there was an extension cord that was plugged into a wall outlet but not powering anything within an alcove adjacent to OR #4.
9. On 1/12/2016, at 5:47 a.m., there was a relocatable power tap (RPT) that did not meet UL 60601-1 listings for patient care areas within OR #5. The power tap was under the computer desk.
10. On 1/12/2016, at 6:02 a.m., there was a relocatable power tap (RPT) that did not meet UL 60601-1 listings for patient care areas within Cath Lab #4. The non-patient RPT had been attached to a supply table.
11. On 1/12/2016, at 6:14 a.m., there was a relocatable power tap (RPT) that was permanently mounted to the building within Cath Lab 3.
12. On 1/12/2016, at 6:14 a.m., there was a relocatable power tap (RPT) that was on the floor within Cath Lab 3.
13. On 1/12/2016, at 8:44 a.m., there was an extension cord in use within the Office 1N043.
14. On 1/12/2016, at 8:50 a.m., there was a household grade microwave within the ED Breakroom (Door GW005).
15. On 1/12/2016, at 9:17 a.m., there was an extension cord powering a power tap that was powering Monitoring Equipment within the room behind Door G514.
16. On 1/12/2016, at 11:42 a.m., there was a relocatable power tap (RPT) within Rm. #4203 and Rm. #4204 that were attached to the TV Armoire that did not meet UL60601-1 listings for patient care areas.
17. On 1/12/2016, at 2:25 p.m., there was an open circuit breaker slot within 3CL2 panel.
18. On 1/13/2016, at 1:39 p.m., there was an unprotected exterior electrical outlet adjacent to the Bicycle Rack on the North side of the facility adjacent to the ED Entrance.
Surveyor was accompanied by the Clinical Engineering Director and Plant Engineering Manager who acknowledged the existence of these conditions.

Based on the observations and interview during the survey, it was determined through on-going dialog with the Clinical Engineering Director and Plant Engineering Manager that the facility failed to install alcohol based hand rub (ABHR) dispensers away from sources of ignition for the building.
This resulted in the potential for injury to residents and staff (LSC 18/19.3.2.6, CFR 403.744, 418.100, 460.72, 482.41, 483.70, 486.623, 485.623).
Findings include, but are not limited to:
1. On 1/11/2016, at 11:22 a.m., there was an alcohol based hand rub (ABHR) dispenser installed above an electrical outlet between Door 3H330 and 3H331.
Surveyor was accompanied by the Clinical Engineering Director and Plant Engineering Manager who acknowledged the existence of these conditions.