HospitalInspections.org

Based on a review of the facility records and interview with the staff, it was determined the facility failed to ensure the emergency lighting was tested as required. This could delay or deny safe exiting from the facility in an emergency.

The findings include:

There was no documentation at the time of the survey to show the emergency lights were being tested for 90 minutes once a year. The staff stated they were not performing these tests.

1. Lee Center for Rehabilitation and Wellness (0716),

2. Regional Cancer Center (0316),

3. Advanced Heart Group (0816),

4. The Sanctuary Outpatient Center (0416),

5. Wound Care Center (1116), and

6. Sleep Disorder Center (1016).

Based on record review, observations, documentation, and interviews with facility staff during the survey, the facility could not clearly substantiate the annual fire alarm system had been tested or maintained in accordance with NFPA 72 or NFPA 101 (2000) Edition.

The findings include:

During the record review process at Coastal Cardiology (1516), the facility could not substantiate, per the provided Fire Alarm System Annual report, that the deficiencies cited on June 18, 2010 had been repaired or corrected. The report stated: a) batteries outdated inside Nac panel; b) batteries inside Nac panel have low Ah.; and c) tamper switch at back flow Building Side (West Side) Failed to activate a supervisory signal and is corroded.

Based on a review of the facility records and interview with the staff, it was determined the facility failed to test the smoke detectors as frequently as required. This in the event of a malfunction could delay or deny the required early warning of an unsafe environment or fire.

The findings include:

There was no documentation at the time of the survey to show the smoke detectors were tested for sensitivity in the last two years. This was observed at:

1. Lee Center for Rehabilitation and Wellness (0716),

2. Regional Cancer Center (0316),

3. Advanced Heart Group (0816),

4. The Sanctuary Outpatient Center (0416),

5. Riverwalk Professional Center (0516), and

6. Sleep Disorder Center (1016).

Based on observations made during tour of the facility and interview with the staff, it was determined the facility failed to ensure the fire alarm system was installed in accordance with NFPA 101 & 72, providing supervision to all sprinkler system control valves that can impair the system.

The findings include:

The Outside Stem and Yoke Valve on the sprinkler system at The Wound Care Center (1116) did not have a tamper switch installed on it. This would allow the sprinkler system to be shut down and the fire alarm panel would not notify that the sprinkler is inoperable.

Based on staff interviews, record review, and observations during the facility survey, it was determined the facility failed to maintain the sprinkler system in reliable operating condition, test the system as frequently as required, and to have sprinkler heads the proper characteristics for the intended application in accordance with NFPA 25 (2002 Edition) 5.4.1.3 " Inspection, Testing and Maintenance of Water-Based Fire Protection Systems" and NFPA 13 (2002 Edition) "Installation of Sprinkler Systems."

The findings include:

1.During the Healthpark Hospital (0216) tour, it was observed by the Inspector and the facility Administrative Staff that the 2nd Floor corridor at the Cath Lab expansion area contained a mix of standard-response fusible link 155/165 degree and quick-response bulb type 155/165 degree sprinkler heads without the required seperation.

2. It was further observed during the Healthpark (0216) tour, that a number of sprinkler heads throughout the facility were debris and dust laden, rusted or corroded and were missing escutcheons. The observed areas (from 3/21-22/2011) included: Cardiac Cath Lab #A ( loaded and escutcheons missing); EP Lab ( 2 heads loaded); Cath Lab #B (loaded); Doctors Dictation area Cath Lab (loaded); Med Records Cath Lab (loaded); OB Special Care Unit 2nd Floor Rooms @ 2213,2206, and 2204 (loaded);

3. It was observed at The Heart Group (1416) at the Nurses Station an escutcheon was loose creating an open penetration and that three (3) of the lobby heads were loaded with debris/dust.

4. There was no available documentation at Coastal Cardiology (1516) on 3/23/11, to verify the quarterly sprinkler inspections had been conducted.

5. There was no documentation to show the required quarterly inspection of the sprinkler system was being performed at The Wound Care Center (1116). This was due in February.

6. The Advanced Heart Center (0816) was observed to have a (FDC) Fire Department Connection on the exterior of the building. The required caps that protect the threads were missing.

Based on record review and staff interviews it was observed the UL 300 Range Hood System was not in compliance with NFPA 101 (2000 Edition) and NFPA 96.

The findings include:

During the document review process at The Children's Rehab Center (1216) on 3/22/11, it was determined the facility had no available evidence that an annual or semiannual Range Hood Inspection had been conducted since November 2008 by the contractor for the UL 300 system.

Based on a review of the facility records, it was determined the facility failed to ensure the facility boiler for heating water was inspected as frequently as required, in accordance with Florida Statute 554.1101. Exceeding the time interval between inspections renders the equipment unreliable.

The findings include:

A review of the boiler inspection report revealed the boiler was last inspected 1/21/10, and certified for a one year period. The certification for the boiler expired on 1/21/11.

Based on a review of the facility records and interview with the staff, it was determined the facility failed to ensure the emergency lighting was tested as required. This could delay or deny safe exiting from the facility in an emergency.

The findings include:

There was no documentation at the time of the survey to show the emergency lights were being tested for 90 minutes once a year. The staff stated they were not performing these tests.

1. Lee Center for Rehabilitation and Wellness (0716),

2. Regional Cancer Center (0316),

3. Advanced Heart Group (0816),

4. The Sanctuary Outpatient Center (0416),

5. Wound Care Center (1116), and

6. Sleep Disorder Center (1016).

Based on record review, observations, documentation, and interviews with facility staff during the survey, the facility could not clearly substantiate the annual fire alarm system had been tested or maintained in accordance with NFPA 72 or NFPA 101 (2000) Edition.

The findings include:

During the record review process at Coastal Cardiology (1516), the facility could not substantiate, per the provided Fire Alarm System Annual report, that the deficiencies cited on June 18, 2010 had been repaired or corrected. The report stated: a) batteries outdated inside Nac panel; b) batteries inside Nac panel have low Ah.; and c) tamper switch at back flow Building Side (West Side) Failed to activate a supervisory signal and is corroded.

Based on a review of the facility records and interview with the staff, it was determined the facility failed to test the smoke detectors as frequently as required. This in the event of a malfunction could delay or deny the required early warning of an unsafe environment or fire.

The findings include:

There was no documentation at the time of the survey to show the smoke detectors were tested for sensitivity in the last two years. This was observed at:

1. Lee Center for Rehabilitation and Wellness (0716),

2. Regional Cancer Center (0316),

3. Advanced Heart Group (0816),

4. The Sanctuary Outpatient Center (0416),

5. Riverwalk Professional Center (0516), and

6. Sleep Disorder Center (1016).

Based on observations made during tour of the facility and interview with the staff, it was determined the facility failed to ensure the fire alarm system was installed in accordance with NFPA 101 & 72, providing supervision to all sprinkler system control valves that can impair the system.

The findings include:

The Outside Stem and Yoke Valve on the sprinkler system at The Wound Care Center (1116) did not have a tamper switch installed on it. This would allow the sprinkler system to be shut down and the fire alarm panel would not notify that the sprinkler is inoperable.

Based on staff interviews, record review, and observations during the facility survey, it was determined the facility failed to maintain the sprinkler system in reliable operating condition, test the system as frequently as required, and to have sprinkler heads the proper characteristics for the intended application in accordance with NFPA 25 (2002 Edition) 5.4.1.3 " Inspection, Testing and Maintenance of Water-Based Fire Protection Systems" and NFPA 13 (2002 Edition) "Installation of Sprinkler Systems."

The findings include:

1.During the Healthpark Hospital (0216) tour, it was observed by the Inspector and the facility Administrative Staff that the 2nd Floor corridor at the Cath Lab expansion area contained a mix of standard-response fusible link 155/165 degree and quick-response bulb type 155/165 degree sprinkler heads without the required seperation.

2. It was further observed during the Healthpark (0216) tour, that a number of sprinkler heads throughout the facility were debris and dust laden, rusted or corroded and were missing escutcheons. The observed areas (from 3/21-22/2011) included: Cardiac Cath Lab #A ( loaded and escutcheons missing); EP Lab ( 2 heads loaded); Cath Lab #B (loaded); Doctors Dictation area Cath Lab (loaded); Med Records Cath Lab (loaded); OB Special Care Unit 2nd Floor Rooms @ 2213,2206, and 2204 (loaded);

3. It was observed at The Heart Group (1416) at the Nurses Station an escutcheon was loose creating an open penetration and that three (3) of the lobby heads were loaded with debris/dust.

4. There was no available documentation at Coastal Cardiology (1516) on 3/23/11, to verify the quarterly sprinkler inspections had been conducted.

5. There was no documentation to show the required quarterly inspection of the sprinkler system was being performed at The Wound Care Center (1116). This was due in February.

6. The Advanced Heart Center (0816) was observed to have a (FDC) Fire Department Connection on the exterior of the building. The required caps that protect the threads were missing.

Based on record review and staff interviews it was observed the UL 300 Range Hood System was not in compliance with NFPA 101 (2000 Edition) and NFPA 96.

The findings include:

During the document review process at The Children's Rehab Center (1216) on 3/22/11, it was determined the facility had no available evidence that an annual or semiannual Range Hood Inspection had been conducted since November 2008 by the contractor for the UL 300 system.

Based on a review of the facility records, it was determined the facility failed to ensure the facility boiler for heating water was inspected as frequently as required, in accordance with Florida Statute 554.1101. Exceeding the time interval between inspections renders the equipment unreliable.

The findings include:

A review of the boiler inspection report revealed the boiler was last inspected 1/21/10, and certified for a one year period. The certification for the boiler expired on 1/21/11.