HospitalInspections.org

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Based on document review and staff interview, the facility failed to develop and maintain emergency preparedness contact information in accordance with §483.73(c). Failure to develop and maintain the emergency preparedness contact information could result in the supervising agency not being notified in an emergency. The deficiency affected the contact list in the emergency preparedness plan.

Document review on 07/20/2022 starting at 2:00 PM revealed that the contact list in the emergency preparedness plan was missing contact information for the State Licensing and Certification Agency.

Interview with the director of facilities and support services at the time of observation acknowledged the deficiency, and indicated he was unaware of the requirement.

Interview with the CEO, director of compliance and risk management, and the director of facilities and support services at the time of exit acknowledged the deficiency.
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Based on observation and staff interview, the facility failed to provide locked doors within the means of egress in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain door locks within a means of egress could result in delayed egress during an emergency, resulting in injury or death. The deficiencies could impact all patients, staff, and visitors within the facility. The findings were:

1) Observation on 07/20/2022 at 10:12 AM of the cross-corridor doors adjacent to the med-surg nurses station revealed that hardware for both doors was provided with a keyed cylinder lock, which would prevent access to the identified path of egress leading towards the ICU. Interview with staff at the nurses station revealed that no one was able to locate a key for the lock.

2) Observation on 07/20/2022 at 10:22 AM in the lock up rooms revealed that two (2) keyed cylinder locks were provided at each door serving rooms ED-1, ED-2, and the anti-room accessing the suite.

3) Observation on 07/20/2022 at 11:42 AM at the interior and exterior doors of the emergency department entry vestibule revealed that the emergency egress breakaway doors were provided with thumb actuated deadbolt locks. Further observation revealed that the emergency breakaway feature would not function when the deadbolts were in the locked position.

4) Observation on 07/20/2022 at 12:25 AM at the interior doors of the main entry vestibule revealed that the emergency egress breakaway doors were provided with a thumb actuated deadbolt lock. Further observation revealed that the emergency breakaway feature would not function when the deadbolts were in the locked position.

Interview with the director of facilities and support services at the time of observation acknowledged the deficiency, and indicated he was unaware of the requirement.

Interview with the CEO, director of compliance and risk management, and the director of facilities and support services at the time of exit acknowledged the deficiency.

REF: NFPA 101, Sections 19.2.2.2.5, 19.2.2.2.5.2, 19.2.2.2.6
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Based on document review and staff interview, the facility failed to test battery-powered emergency lighting in accordance with the 2012 NFPA 101, Life Safety Code. Failure to test battery-powered lighting as required could result in system failure during an emergency. The deficiency may cause harm to staff, patients, and visitors during an emergency. The findings were:

1) Document review on 07/20/2022 starting at 2:00 PM revealed that the monthly 30-second test of batter-powered emergency lighting was not performed during the months of 03/22 and 10/21.

2) Document review on 07/20/2022 starting at 2:00 PM revealed that the annual 90-minute test of battery-powered emergency lighting had identified an inoperable fixture during the test performed on 10/21. However, no documentation was available to demonstrate that the inoperable fixture had been repaired or replaced. Field testing of the identified fixture failed when the test button was pressed by the surveyor.

Interview with the director of facilities and support services at the time of observation acknowledged the deficiency, and indicated he was aware of the requirement.

Interview with the CEO, director of compliance and risk management, and the director of facilities and support services at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Section 7.9.3.1.1(1) and 7.9.3.1.2(5)
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Based on observation and staff interview, the facility failed to maintain fire doors in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain fire doors could contribute to the spread of smoke and fire during an emergency, resulting in injury or death. The deficiencies could impact all patients, staff, and visitors within the facility. The findings were:

1) Observation on 07/20/2022 at 10:32 AM of the fire-rated cross-corridor doors located adjacent to the east elevators revealed that the left leaf, when facing the elevators, failed to latch in the closed position when released from the fully-opened position.

2) Observation on 07/20/2022 at 11:51 AM of the fire-rated cross-corridor doors located in radiology revealed that the doors would not close and latch when released from the fully-opened position.

3) Observation on 07/20/2022 at 12:00 PM in the lab IT room revealed that the fire-rated door would not close and latch when released from the fully-opened position.

Interview with the director of facilities and support services at the time of observation acknowledged the deficiency, and indicated he was aware of the requirement.

Interview with the CEO, director of compliance and risk management, and the director of facilities and support services at the time of exit acknowledged the deficiency.

REF: NFPA 101, Sections 8.3.3.1
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Based on observation and staff interview, the facility failed to protect hazardous areas in accordance with the 2012 NFPA 101, Life Safety Code. Failure to protect hazardous areas as required could contribute to the spread of fire, and lead to injury or death. The deficiencies could impact all patients, staff, and visitors in the areas identified. The findings were:

1) Observation on 07/20/2022 at 10:20 AM of the med-surg sitz bath room revealed that the space was being utilized as a storage room. Further observation revealed that the space was approximately 65 sq. ft., and was sprinklered, but the door to the corridor was not provided with a self-closing or automatic-closing device.

2) Observation on 07/20/2022 at 10:43 AM of the med-surg clean linen room revealed that the space was utilized for the storage of large quantities of combustible materials, and was sprinklered, but the door to the corridor was not provided with a self-closing or automatic-closing device.

3) Observation on 07/20/2022 at 10:56 AM of the short stay patient room 201 revealed that the room was being utilized for storage, and was sprinklered, but the door to the corridor was not provided with a self-closing or automatic-closing device.

Interview with the director of facilities and support services at the time of observation acknowledged the deficiency, and indicated he was aware of the requirement.

Interview with the CEO, director of compliance and risk management, and the director of facilities and support services at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Section 19.3.2.1.3
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Based on observation and staff interview, the facility failed to protect cooking equipment in accordance with the 2012 NFPA 101, Life Safety Code, and the 2011 NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. Failure to properly protect cooking equipment could lead to equipment damage or improper protection by fire suppression systems, resulting in injury or death during an emergency. The deficiency affected the kitchen and all staff within. The findings were:

Observation on 07/20/2022 at 12:06 PM in the kitchen revealed a wheeled gas-fired deep fryer located beneath the grease hood and fire suppression system. Further observation revealed that no means was provided to ensure that the cooktop is returned to the approved location beneath the fire suppression system after being moved for service or cleaning.

Interview with the director of facilities and support services at the time of observation acknowledged the deficiency, and indicated he was not aware of the requirement.

Interview with the CEO, director of compliance and risk management, and the director of facilities and support services at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Sections 19.3.2.5.5 and 9.2.3
2011 NFPA 96, Section 12.1.2.3
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Based on document review and staff interview, the facility failed to test and maintain fire alarm systems in accordance with the 2012 NFPA 101, Life Safety Code, and the 2010 NFPA 72, National Fire Alarm and Signaling Code. Failure to maintain fire alarm systems as required could result in system failure or malfunction during an emergency. The deficiencies could impact all patients, staff, and visitors. The findings were:

Document review on 07/20/2022 starting at 2:00 PM revealed that the facility did not have documentation to demonstrate that the following testing had been performed:

1. Monthly activation of the fire alarm system
2. Annual annunciator panel testing
3. Semi-annual testing of sealed lead acid batteries for the fire alarm system
4. Semi-annual battery load voltage testing
5. Annual alarm notification device testing
6. Annual testing of the manual fire alarm boxes
7. Annual testing of all heat detectors
8. Annual testing of all smoke damper operation
9. Annual smoke detector smoke entry testing
10. Bi-annaul smoke detector sensitivity testing
11. Quarterly water flow alarm device testing
12. Quarterly supervisory signal device testing

Interview with the director of facilities and support services at the time of observation acknowledged the deficiency, and indicated he was aware of the requirement.

Interview with the CEO, director of compliance and risk management, and the director of facilities and support services at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Section 19.3.4.1
2010 NFPA 72, Sections 13.2.6.1 and 14.6.2.4 and Tables 14.3.1, 14.4.5
2011 NFPA 25, Table 5.1.1.2
2012 NFPA 90A, Section 4.4.1
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Based on observation and staff interview, the facility failed to install fire sprinkler systems in accordance with the 2012 NFPA 101, Life Safety Code, and the 2010 NFPA 13, Standard for the Installation of Sprinkler Systems. Failure to install fire sprinkler systems as required could result in system failure or malfunction during an emergency. The deficiencies could impact all patients, staff, and visitors in the area. The findings were:

1) Observation on 07/20/2022 starting at 9:40 AM in ICU room 314 revealed that ceiling-mounted booms containing electrical receptacles and medical gas ports were capable of being located less than 18 inches beneath, and obstructing, two (2) sprinkler heads within the space. This condition was also observed in ICU rooms 311, 313, and 316.

2) Observation on 07/20/2022 at 11:53 AM of x-ray room 2 revealed that ceiling-mounted imaging equipment was capable of being stored in a location that was less than 18 inches beneath, and obstructing, one or more sprinkler heads within the room.

Interview with the director of facilities and support services at the time of observation acknowledged the deficiency, and indicated he was aware of the requirement.

Interview with the CEO, director of compliance and risk management, and the director of facilities and support services at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Section 19.3.5 and 9.7
2010 NFPA 13, Section 8.6.5.1
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Based on document review and staff interview, the facility failed to test and maintain fire sprinkler systems in accordance with the 2012 NFPA 101, Life Safety Code, and the 2011 NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Failure to maintain fire sprinkler systems as required could result in system failure or malfunction during an emergency. The deficiencies could impact all patients, staff, and visitors. The findings were:

Document review on 07/20/2022 starting at 2:00 PM revealed that the facility did not have documentation to demonstrate that the following testing had been performed:

1. Annual main drain test
2. Annual backflow preventer testing
3. Gauge recalibration or replacement at five (5) year intervals

Interview with the director of facilities and support services at the time of observation acknowledged the deficiency, and indicated he was aware of the requirement.

Interview with the CEO, director of compliance and risk management, and the director of facilities and support services at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Section 19.3.5.1 and 9.7.5
2011 NFPA 25, Sections 5.3.2.1, 13.2.5, and 13.6.2.1
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Based on observation and staff interview, the facility failed to provide and maintain corridor doors in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain corridor doors as required could contribute to smoke and fire migration during an emergency, resulting in injury or death. The deficiencies could impact all patients, staff, and visitors within the areas noted. The findings were:

1) Observation on 07/20/2022 at 9:50 AM at the med-surg storage room located across the hall from room 319 revealed that the door opening to the corridor at the north side of the room contained a transfer air louver providing communication between the storage room and the corridor.

2) Observation on 07/20/2022 at 10:15 AM at the med-surg medication room revealed multiple holes in the wooden door around the perimeter of the door knob. It appeared that the door knob has been replaced multiple times without patching or repairing the previous penetrations.

3) Observation on 07/20/2022 at 11:16 AM at the respiratory storage room revealed that both doors opening to the corridors contained a transfer air louver providing communication between the storage room and the adjacent corridors.

Interview with the director of facilities and support services at the time of observation acknowledged the deficiency, and indicated he was unaware of the requirement.

Interview with the CEO, director of compliance and risk management, and the director of facilities and support services at the time of exit acknowledged the deficiency.


REF: NFPA 101, Sections 19.3.6.3.1 and 19.3.6.4.1
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Based on document review and staff interview, the facility failed to test and maintain HVAC systems in accordance with the 2012 NFPA 101, Life Safety Code, 2012 NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating systems, and 2010 NFPA 80, Standard for Fire Doors and Other Opening Protective's. Failure to test and maintain HVAC systems as required could lead to a delayed or failed response to smoke and fire events in the facility, resulting in injury or death. The deficiency could affect all patients, staff, and visitors. The findings were:

Document review on 07/20/2022 starting at 2:00 PM revealed that the facility had no record of inspection, testing, or maintenance of fire dampers throughout the facility. Fire dampers must be inspected, tested, and maintained at least once during a four (6) year period.

Interview with the director of facilities and support services at the time of observation acknowledged the deficiency, and indicated he was unaware of the requirement.

Interview with the CEO, director of compliance and risk management, and the director of facilities and support services at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Section 9.2.1
2012 NFPA 90A; Section 5.4.8.1
2010 NFPA 80, Section 19.4.1
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Based on document review and staff interview, the facility failed to perform monthly operational tests of the elevator firefighter's emergency operations in accordance with the 2012 NFPA 101, Life Safety code. Failure to maintain firefighter's emergency operations systems could result in injury or death during an emergency. The deficiency affected all elevators within the facility. The findings were:

Document review on 07/20/2022 starting at 2:00 PM could not establish that monthly testing of the elevator firefighter's emergency operations was being performed.

Interview with the director of facilities and support services at the time of observation acknowledged the deficiency, and indicated he was unaware of the requirement.

Interview with the CEO, director of compliance and risk management, and the director of facilities and support services at the time of exit acknowledged the deficiency.

REF: NFPA 101, Section 9.4.6
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Based on document review and staff interview, the facility failed to perform fire drills in accordance with the 2012 NFPA 101, Life Safety code. Failure to perform fire drill as required could lead to inadequate training of staff, patients, and visitors, which could result in injury or death during an emergency. The deficiency could affect all staff, patients, and visitors. The findings were:

Document review on 07/20/2022 starting at 2:00 PM revealed that the facility had no record of fire drills being performed during the past 12 months.

Interview with the director of facilities and support services at the time of observation acknowledged the deficiency, and indicated he was aware of the requirement.

Interview with the CEO, director of compliance and risk management, and the director of facilities and support services at the time of exit acknowledged the deficiency.

REF: NFPA 101, Section 19.7
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Based on document review and staff interview, the facility failed to perform annual inspection of fire-rated doors in accordance with the 2012 NFPA 101, Life Safety Code, and the 2010 NFPA 80, Standard for Fire Doors and Other Protective Openings. Failure to inspect fire-rated doors as required could result in equipment failure during an emergency, resulting in injury or death. The deficiency could impact all staff , patients, and visitors within the facility. The findings were:

Document review on 07/20/2022 starting at 2:00 PM could not establish that the facility had performed testing of all fire doors and rolling fire doors throughout the facility during the past 12 months.

Interview with the director of facilities and support services at the time of observation acknowledged the deficiency, and indicated he was aware of the requirement.

Interview with the CEO, director of compliance and risk management, and the director of facilities and support services at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Sections 18.7.6 and 4.6.12
2010 NFPA 80, Section 5.2.1 and 5.2.14.3
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Based on document review and staff interview, the facility failed to test and maintain the emergency generator in accordance with the 2012 NFPA 101, Life Safety Code, and the 2012 NFPA 99, Health Care Facilities Code. Failure to test and maintain the emergency generator as required could result in system failure during an emergency. The deficiency could affect all staff, patients, and visitors within the facility. The findings were:

1) Document review on 07/20/2022 starting at 2:00 PM revealed that documentation was available to demonstrate weekly testing requirements between the months of 09/21 and 03/22, but that no additional information was available to demonstrate consistent weekly testing throughout the year.

2) Document review on 07/20/2022 starting at 2:00 PM revealed that monthly testing documentation was available for the months of 9/21 through 02/22 only. No additional information was available to demonstrate that the required testing was being performed each month.

3) Document review on 07/20/2022 starting at 2:00 PM could not establish that the required monthly testing of the emergency generator's battery was being performed.

4) Document review on 07/20/2022 starting at 2:00 PM could not establish that the emergency generator was being tested for four (4) hours every 36 months as required.

Interview with the director of facilities and support services at the time of observation acknowledged the deficiency, and indicated he was aware of the requirement.

Interview with the CEO, director of compliance and risk management, and the director of facilities and support services at the time of exit acknowledged the deficiency.

REF: NFPA 99, Section 8.3.7.1, 8.4, 8.4.2, and 8.4.9
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