HospitalInspections.org

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #15), it was determined that the facility failed to ensure that emergency lighting (battery operated lamps) which provides light for a period of 90 minutes, enabling those inside to move about safely in an emergency are provided throughout the hallways of the hospital, waiting area of the emergency room and outside staircases as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.9.

Findings include:

1. The facility lacks emergency battery operated lamps (EBOL) for a period of 90 minutes as determined by the observational tour with the facility's Engineer (employee #15) from 9/13/11 through 9/15/11 from 8:30 am till 4:00 pm in the following areas:
a. Throughout the hallways (means of egress) of the entire facility (floors one through eight).
b. The waiting area of the Emergency Room.
c. The hallway from the hospital to the emergency room.
d. At the outside staircases of the hospital (all landings).
(Emergency lamps are required to ensure adequate lighting until the essential electrical system (generator) turns on or in the event that the essential electrical system fails as required since March 13 of 2006).

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #15), it was determined that the facility failed to ensure that smoke detectors are available at all required areas and the fire alarm system lacks annunciation to an approved central station as required by the applicable requirements of NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Findings include:

1. Smoke detectors connected to the fire alarm panel are needed in the following areas as observed with the facility's Engineer (employee #15) from 9/13/11 through 9/15/11 from 8:30 am till 4:00 pm:
a. In the triage room of the emergency room.
b. In the treatment room (with a large refrigerator) located next to the triage area of the Emergency Room.
c. In the pantry of the pediatric emergency room (microwave and refrigerator).

2. The fire alarm system lacks annunciation to an approved central station as reviewed on 9/15/11 at 1:00 pm with the facility's Engineer (employee #15). The fire alarm system must be arranged to transmit an alarm automatically via a central station to alert the municipal fire department and fire brigade. The facility's Engineer (Employee #15) stated during an interview on 9/15/11 at 1:10 pm that the company that is on site making the final repairs to the fire alarm system will install the connection needed for the central station once the entire system is finished.

Based on observations made during the survey for life safety from fire of the medical record department and interview, it was determined that the facility failed to ensure that portable fire extinguisher are available in the medical record department related to size and location as required in the 2000 edition of the Life Safety Code of the NFPA Section 9.7.4.1 and NFPA 10.

Findings include:

1. The medical record department was visited on 9/15/11 at 2:00 pm and it was found that the lower floor of this department has two large water fire extinguishers. They were found to be approximately 30 pounds. The medical record supervisor (employee #21) stated on 9/15/11 at 2:20 pm that she could not lift them because they were too heavy.

2. The medical record department was visited on 9/15/11 at 2:00 pm and it was found that the top floor has only one fire extinguisher for this entire floor. Another fire extinguisher is needed near the back rooms to cover that area.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #15), it was determined that the facility failed to ensure that the automatic fire suppression system above the stoves are appropriately designed and maintained as required by the 2000 edition of the Life Safety Code of the NFPA Section 9.2.3, 19.3.2.6 and NFPA 96.

Findings include:

1. The automatic fire suppression system above the stoves was observed on 9/14/11 at 9:45 am with the facility's Engineer (employee #15) and failed to provide evidence of the following:
a. Fuel source is automatically disconnected when the fire suppression system is activated.
b. Verification that activation of the fire suppression system activates the facility's fire alarm.
c. The kitchen's hood exhaust system six month maintenance was requested, however no evidence was found of the updated required hood/duct exhaust fan inspection by a properly trained, qualified and certified company or person in accordance with the manufacturer's exhaust system inspection schedule. This certification should be posted on the side of the hood system visible for inspection.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #15) and review of fire department endorsement and letter from an Architect and interview, it was determined that the facility failed to monitor means of egress at the outside metal staircase "External staircase #5" and the back exit door of the lower floor of the medical record department to ensure that they are maintained free from all obstructions in accordance with the 2000 edition of the Life Safety Code of the NFPA Section 7.1.10.1.

Findings include:

1. The back exit door of the lower floor of the medical record department was visited on 9/15/11 at 2:00 pm and provided evidence that it was locked closed. The medical record supervisor (employee #21) stated during an interview on 9/15/11 at 2:05 pm that she did not know when was the last time that the door was opened. "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".

2. During the observational tour of the hospital with the facility's Engineer (employee #15) on 9/14/11 from 9:00 am till 4:00 pm, it was found that the hospital has an outside metal staircase that was not properly maintained. The access to this staircase is from the fourth, fifth and seventh floors and it was found that these exit doors had labels on them stating "Do Not Use". The Chief Executive Officer (employee #11) was interviewed on 9/14/11 at 9:30 am and he stated that the facility has a "Conditional Endorsement" from the fire department due to their continued evaluation of this outside staircase. He stated that an Architect evaluated this outside staircase and he wrote a letter recommending that the staircase is not needed if they make a minor construction adjustment related to the travel distance from the rooms closest to this staircase. He stated that years ago the facility was cited for having dead ends on these floor and this is the reason why the outside staircase was built, but the Architect performed a study and wrote in his letter to the Joint Commission that the facility can resolve the distance issue by making a new wall and door thus reducing the distance to less than 30 feet. On 9/14/11 at 2:00 pm no evidence was found that the architects' recommendation to construct a wall and door was performed on the fourth, fifth or seventh floors. "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #15) and interview, it was determined that the facility failed to ensure that dirty linen is stored in an appropriate manner as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.7.5.5.

Findings include:

During the observational tour of the fifth floor on 9/14/11 from 1:30 pm till 2:30 pm, it was determined that personnel are using the dirty utility room to place dirty linen into four large containers, however this room is not protected as a hazardous area. The Engineer (employee #15) stated during an interview on 9/14/11 at 1:45 pm that this room is used as a holding area until personnel make their rounds and remove the dirty linen from this room. This room needs proper air extraction and the construction of this room must be verified to ensure one hour fire rating (with 3/4 hour fire-rated doors) with positive latching if it is to continue holding dirty linen. Also, collection containers can not exceed 32 gallons within any 64 square foot area. The doors to this room did not latch closed and materials inside this room were accessible to non-authorized personnel (the dirty linen shared this room with patient's commodes, Cidex OPA and other materials).

Based on observations during the survey for Life safety from fire with the facility's Engineer (employee #15) and interview, it was found that this facility does not comply with other Life Safety Code requirements not in CMS-2786-R related to standpipe maintenance, oxygen storage, paint stored in the general storage room, facility is using mult-outlet adapter, the facility is not using fire rated garbage containers, smoke barrier doors held open by two pieces of wood, no documented oxygen alarm system testing, exit plans in the laboratory department are not appropriately designed, a small storage closet near the mental health clinic is a risk for a fire and the medical record storage room on the second floor has stacks of boxes near the water heater.

Findings include:

1. When oxygen cylinders are not in use (connected to a patient), they are to be stored in an appropriate area as stated in the National Fire Protection Association (NFPA) 99, 1999 edition, section 4-3.1.1.2. However, during the observational tour of the entire facility from 9/13/11 through 9/15/11 from 8:30 am till 4:00 pm with the facility's Engineer (employee #15) type H and Type E oxygen cylinders were found in areas that do not meet minimum requirements:
a. In the respiratory therapy area of the emergency room (three type H oxygen cylinders).
b. Three type E oxygen cylinders were found in the minor surgery room of the emergency room.
c. One type H and one type E oxygen cylinder at the Neonatal Intensive Care Unit.
d. Two type H and one type E oxygen cylinders at the Intensive Care Unit.
e. Two type E oxygen cylinders were found in the crash cart room of the fifth floor.
f. One type H and one type E oxygen cylinders at the C.T scan room.

2. The nursing station at the pediatric emergency room was visited on 9/13/11 at 11:30 am and was found with a regular receptacle that had an adapter which converted two outlets into six. Multi-outlet adapters are not recommended due to the potential for them to over heat.

3. Regular garbage containers located at offices and work areas were verified from 9/13/11 through 9/15/11 from 8:30 am till 4:00 pm (emergency room and hospital) with the facility's Engineer (employee #15) and provided evidence that they are not made of fire rated material and tested as such. Rubber or plastic garbage containers that are not made of fire rated material can emit toxic fumes if they catch on fire.

4. During the observational tour of the facility on 9/13/11 at 10:30 am, it was found that the smoke barrier doors located near the emergency room from the hospital hallway on the first floor were found with two pieces of wood holding the two door leafs in the open position.

5. The facility has a large oxygen tank that supplies oxygen to the hospital located at the back of the hospital as observed on 9/14/11 at 9:20 am with the facility's Engineer (employee #15). The facility was requested evidence of periodic master alarm panel testing related to the audible and visual signals (high/low alarms for +/- 20% operating pressure), however the Engineer (employee #15) stated on 9/14/11 at 9:25 am that the system is working properly and so are the alarms, however he does not have documentation of tests performed to verify the alarms' status, but he knows that they are working because when they fill the tank with oxygen the alarms are tested.

6. The general storage room on the second floor was visited on 9/14/11 at 9:30 am with the facility's Engineer (employee #15) and was found with ten containers of paint (five gallons each). Products and materials that are flammable can not be stored in an area that is used to store facility equipment and boxes (this storage room is fully sprinklered).

7. The exit plans (for evacuation purposes) of the laboratory department were reviewed on 9/14/11 at 11:35 am and provided evidence that they do not have the locations of the fire extinguishers, pull stations or the fire hoses.

8. On 9/15/11 at 9:30 am the ambulatory Mental Health Clinic located in a building next to the hospital was visited with the facility's Engineer (employee #15). During observations of this clinic a small room located in a hallway that leads to the clinic (this small room is part of the mental health clinic) was found with a metal gate that has a two inch by two inch open space where they place a pad lock. The inside of this room was found stacked from floor to ceiling with card board boxes filled with papers. Due to the materials in this room and the open space where some one can lite a match and flick it into the room it is a potential hazard that needs attention to remove the risk of a fire.

9. The medical records department storage room on the second floor was visited on 9/15/11 at 2:00 pm and was found with boxes of medical records stack one on the top of the other next to the water heater which increases the potential for a hazard.

10. Standpipes (fire hoses) were observed during the life safety observational tour with the facility's Engineer (employee #15) from 9/13/11 through 9/15/11 from 8:30 am till 4:00 pm and the following was determined:
a. No evidence was found of the documentation of the standpipe and Hose System Inspection, Testing and maintenance in accordance with NFPA 25 chapter 6 related with: control valves, pressure regulating devices, piping, hose connections, cabinet, hose, hose storage device, alarm device, hose nozzle, pressure control device, pressure reducing valve, hydrostatic test, flow test, main drain test, hose connections and valves (all types).

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #15), it was determined that the facility failed to ensure that emergency lighting (battery operated lamps) which provides light for a period of 90 minutes, enabling those inside to move about safely in an emergency are provided throughout the hallways of the hospital, waiting area of the emergency room and outside staircases as required by the 2000 edition of the Life Safety Code of the NFPA Section 7.9.

Findings include:

1. The facility lacks emergency battery operated lamps (EBOL) for a period of 90 minutes as determined by the observational tour with the facility's Engineer (employee #15) from 9/13/11 through 9/15/11 from 8:30 am till 4:00 pm in the following areas:
a. Throughout the hallways (means of egress) of the entire facility (floors one through eight).
b. The waiting area of the Emergency Room.
c. The hallway from the hospital to the emergency room.
d. At the outside staircases of the hospital (all landings).
(Emergency lamps are required to ensure adequate lighting until the essential electrical system (generator) turns on or in the event that the essential electrical system fails as required since March 13 of 2006).

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #15), it was determined that the facility failed to ensure that smoke detectors are available at all required areas and the fire alarm system lacks annunciation to an approved central station as required by the applicable requirements of NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code).

Findings include:

1. Smoke detectors connected to the fire alarm panel are needed in the following areas as observed with the facility's Engineer (employee #15) from 9/13/11 through 9/15/11 from 8:30 am till 4:00 pm:
a. In the triage room of the emergency room.
b. In the treatment room (with a large refrigerator) located next to the triage area of the Emergency Room.
c. In the pantry of the pediatric emergency room (microwave and refrigerator).

2. The fire alarm system lacks annunciation to an approved central station as reviewed on 9/15/11 at 1:00 pm with the facility's Engineer (employee #15). The fire alarm system must be arranged to transmit an alarm automatically via a central station to alert the municipal fire department and fire brigade. The facility's Engineer (Employee #15) stated during an interview on 9/15/11 at 1:10 pm that the company that is on site making the final repairs to the fire alarm system will install the connection needed for the central station once the entire system is finished.

Based on observations made during the survey for life safety from fire of the medical record department and interview, it was determined that the facility failed to ensure that portable fire extinguisher are available in the medical record department related to size and location as required in the 2000 edition of the Life Safety Code of the NFPA Section 9.7.4.1 and NFPA 10.

Findings include:

1. The medical record department was visited on 9/15/11 at 2:00 pm and it was found that the lower floor of this department has two large water fire extinguishers. They were found to be approximately 30 pounds. The medical record supervisor (employee #21) stated on 9/15/11 at 2:20 pm that she could not lift them because they were too heavy.

2. The medical record department was visited on 9/15/11 at 2:00 pm and it was found that the top floor has only one fire extinguisher for this entire floor. Another fire extinguisher is needed near the back rooms to cover that area.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #15), it was determined that the facility failed to ensure that the automatic fire suppression system above the stoves are appropriately designed and maintained as required by the 2000 edition of the Life Safety Code of the NFPA Section 9.2.3, 19.3.2.6 and NFPA 96.

Findings include:

1. The automatic fire suppression system above the stoves was observed on 9/14/11 at 9:45 am with the facility's Engineer (employee #15) and failed to provide evidence of the following:
a. Fuel source is automatically disconnected when the fire suppression system is activated.
b. Verification that activation of the fire suppression system activates the facility's fire alarm.
c. The kitchen's hood exhaust system six month maintenance was requested, however no evidence was found of the updated required hood/duct exhaust fan inspection by a properly trained, qualified and certified company or person in accordance with the manufacturer's exhaust system inspection schedule. This certification should be posted on the side of the hood system visible for inspection.

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #15) and review of fire department endorsement and letter from an Architect and interview, it was determined that the facility failed to monitor means of egress at the outside metal staircase "External staircase #5" and the back exit door of the lower floor of the medical record department to ensure that they are maintained free from all obstructions in accordance with the 2000 edition of the Life Safety Code of the NFPA Section 7.1.10.1.

Findings include:

1. The back exit door of the lower floor of the medical record department was visited on 9/15/11 at 2:00 pm and provided evidence that it was locked closed. The medical record supervisor (employee #21) stated during an interview on 9/15/11 at 2:05 pm that she did not know when was the last time that the door was opened. "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".

2. During the observational tour of the hospital with the facility's Engineer (employee #15) on 9/14/11 from 9:00 am till 4:00 pm, it was found that the hospital has an outside metal staircase that was not properly maintained. The access to this staircase is from the fourth, fifth and seventh floors and it was found that these exit doors had labels on them stating "Do Not Use". The Chief Executive Officer (employee #11) was interviewed on 9/14/11 at 9:30 am and he stated that the facility has a "Conditional Endorsement" from the fire department due to their continued evaluation of this outside staircase. He stated that an Architect evaluated this outside staircase and he wrote a letter recommending that the staircase is not needed if they make a minor construction adjustment related to the travel distance from the rooms closest to this staircase. He stated that years ago the facility was cited for having dead ends on these floor and this is the reason why the outside staircase was built, but the Architect performed a study and wrote in his letter to the Joint Commission that the facility can resolve the distance issue by making a new wall and door thus reducing the distance to less than 30 feet. On 9/14/11 at 2:00 pm no evidence was found that the architects' recommendation to construct a wall and door was performed on the fourth, fifth or seventh floors. "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency".

Based on observations made during the survey for life safety from fire with the facility's Engineer (employee #15) and interview, it was determined that the facility failed to ensure that dirty linen is stored in an appropriate manner as required by the 2000 edition of the Life Safety Code of the NFPA Section 19.7.5.5.

Findings include:

During the observational tour of the fifth floor on 9/14/11 from 1:30 pm till 2:30 pm, it was determined that personnel are using the dirty utility room to place dirty linen into four large containers, however this room is not protected as a hazardous area. The Engineer (employee #15) stated during an interview on 9/14/11 at 1:45 pm that this room is used as a holding area until personnel make their rounds and remove the dirty linen from this room. This room needs proper air extraction and the construction of this room must be verified to ensure one hour fire rating (with 3/4 hour fire-rated doors) with positive latching if it is to continue holding dirty linen. Also, collection containers can not exceed 32 gallons within any 64 square foot area. The doors to this room did not latch closed and materials inside this room were accessible to non-authorized personnel (the dirty linen shared this room with patient's commodes, Cidex OPA and other materials).

Based on observations during the survey for Life safety from fire with the facility's Engineer (employee #15) and interview, it was found that this facility does not comply with other Life Safety Code requirements not in CMS-2786-R related to standpipe maintenance, oxygen storage, paint stored in the general storage room, facility is using mult-outlet adapter, the facility is not using fire rated garbage containers, smoke barrier doors held open by two pieces of wood, no documented oxygen alarm system testing, exit plans in the laboratory department are not appropriately designed, a small storage closet near the mental health clinic is a risk for a fire and the medical record storage room on the second floor has stacks of boxes near the water heater.

Findings include:

1. When oxygen cylinders are not in use (connected to a patient), they are to be stored in an appropriate area as stated in the National Fire Protection Association (NFPA) 99, 1999 edition, section 4-3.1.1.2. However, during the observational tour of the entire facility from 9/13/11 through 9/15/11 from 8:30 am till 4:00 pm with the facility's Engineer (employee #15) type H and Type E oxygen cylinders were found in areas that do not meet minimum requirements:
a. In the respiratory therapy area of the emergency room (three type H oxygen cylinders).
b. Three type E oxygen cylinders were found in the minor surgery room of the emergency room.
c. One type H and one type E oxygen cylinder at the Neonatal Intensive Care Unit.
d. Two type H and one type E oxygen cylinders at the Intensive Care Unit.
e. Two type E oxygen cylinders were found in the crash cart room of the fifth floor.
f. One type H and one type E oxygen cylinders at the C.T scan room.

2. The nursing station at the pediatric emergency room was visited on 9/13/11 at 11:30 am and was found with a regular receptacle that had an adapter which converted two outlets into six. Multi-outlet adapters are not recommended due to the potential for them to over heat.

3. Regular garbage containers located at offices and work areas were verified from 9/13/11 through 9/15/11 from 8:30 am till 4:00 pm (emergency room and hospital) with the facility's Engineer (employee #15) and provided evidence that they are not made of fire rated material and tested as such. Rubber or plastic garbage containers that are not made of fire rated material can emit toxic fumes if they catch on fire.

4. During the observational tour of the facility on 9/13/11 at 10:30 am, it was found that the smoke barrier doors located near the emergency room from the hospital hallway on the first floor were found with two pieces of wood holding the two door leafs in the open position.

5. The facility has a large oxygen tank that supplies oxygen to the hospital located at the back of the hospital as observed on 9/14/11 at 9:20 am with the facility's Engineer (employee #15). The facility was requested evidence of periodic master alarm panel testing related to the audible and visual signals (high/low alarms for +/- 20% operating pressure), however the Engineer (employee #15) stated on 9/14/11 at 9:25 am that the system is working properly and so are the alarms, however he does not have documentation of tests performed to verify the alarms' status, but he knows that they are working because when they fill the tank with oxygen the alarms are tested.

6. The general storage room on the second floor was visited on 9/14/11 at 9:30 am with the facility's Engineer (employee #15) and was found with ten containers of paint (five gallons each). Products and materials that are flammable can not be stored in an area that is used to store facility equipment and boxes (this storage room is fully sprinklered).

7. The exit plans (for evacuation purposes) of the laboratory department were reviewed on 9/14/11 at 11:35 am and provided evidence that they do not have the locations of the fire extinguishers, pull stations or the fire hoses.

8. On 9/15/11 at 9:30 am the ambulatory Mental Health Clinic located in a building next to the hospital was visited with the facility's Engineer (employee #15). During observations of this clinic a small room located in a hallway that leads to the clinic (this small room is part of the mental health clinic) was found with a metal gate that has a two inch by two inch open space where they place a pad lock. The inside of this room was found stacked from floor to ceiling with card board boxes filled with papers. Due to the materials in this room and the open space where some one can lite a match and flick it into the room it is a potential hazard that needs attention to remove the risk of a fire.

9. The medical records department storage room on the second floor was visited on 9/15/11 at 2:00 pm and was found with boxes of medical records stack one on the top of the other next to the water heater which increases the potential for a hazard.

10. Standpipes (fire hoses) were observed during the life safety observational tour with the facility's Engineer (employee #15) from 9/13/11 through 9/15/11 from 8:30 am till 4:00 pm and the following was determined:
a. No evidence was found of the documentation of the standpipe and Hose System Inspection, Testing and maintenance in accordance with NFPA 25 chapter 6 related with: control valves, pressure regulating devices, piping, hose connections, cabinet, hose, hose storage device, alarm device, hose nozzle, pressure control device, pressure reducing valve, hydrostatic test, flow test, main drain test, hose connections and valves (all types).